추간판질환에 대한 안전하고 성공적인 추간공경유 후근신경절 및 경막외차단술을 위한 유용한 지침

초록

Background: The purpose of this study is to verify some of useful and important guidelines for the safe procedures and successful outcome, both for patients and physician when planned for transforaminal dorsal root ganglion and epidural nerve block for lumbar disc disorder. Methods: Personal notes taken during first 1950 cases of during initial 4 year period (phase I) were reviewed and points that were considered important were listed and served as guidelines for following 5800 cases in recent 4 years (phase II). Results from phase II study were then compared with those from phase I. Patients who met inclusion criteria received precise C-arm guided transforaminal dorsal root ganglion and epidural blocks at the level(s) and side(s) of their documented pathologies. After correct placement of needles, contrast dye was injected to visualize the nerve roots and transforaminal dye passage to epidural space. All patents received 1∼3 injection(s), consisted of mixtue of steroid and lidocain, depending on severity, persistency of symptoms and recurrence of symptoms. Patients were then carefully monitored for 30 minutes to 2 hours after the procedures. All patients were evaluated by an independent observer and received sequential questionnaires before and after injection, documenting pain level, and patient satisfaction. Also, patients were evaluated for pain relief, recurrence of symptoms as well as the type and rate of complications, and actors related to good outcome were evaluated. Successful results were considered when greater than 75% of previous pain with function restored to the degrees of patients' previous activities. Radiation exposure was evaluated for the safety of physician performing the procedure. Minimal follow up period was 12 months. Results: Of the total 7750 patients (average age 45.9 years, range 23∼74 years), 84% (phase I), 91% (phase II) of patients showed successful results and functional restoration at one year follow-up evaluation. Seventy-one (0.92%) patients were refractory to these injections and subsequently underwent surgical interventions with good postoperative results. Recurrence rate was 32% (average onset 6.2 months) with average VAS at recurrence 4.1. Complication rates were decreased from 4.2%/injection in phase I to 0.69%/injection when strict guidelines were followed and all of these complications were mild, transient and there were no worsened cases. Also, there were no complications from physician who performed the procedures. Factors mostly related to better outcome were pre-treatment symptomduration less than 6 months, excellent early and prolonged response, no recurrence within 3 months. There were no statistical significant difference between responders and nonresponders in age, sex, level of disc herniation, or preinjection pain level. Radiation dose exposed was decreased average 5.8 mR/pt (phase I) to 1.1 mR/pt (phase II) for 1 level procedure and average 15.4 mR/pt (phase I) to 2.4 mR/pt (phase II) for 2 level procedures. Average radiation dose exposed to the physician was 1/1200 of amount exposed to the patient when safety measures were strictly followed. Conclusion: Results of this study indicates that precise C-arm guided transforminal DRG and epidural block is a safe, feasible, and effective therapeutic/prognostic, when carefully performed, nonsurgical treatment option for patients with lumbar disc in whom more conservative treatments are not effective. Thus, it should be considered in selected patients before planning surgical intervention. When such treatment is chosen for the patients, these guidelines should be appreciated to obtain successful results and to minimize complications.

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