遠外側入路的經椎間孔硬脊膜上類固醇注射在椎間盤突出併腰椎神經根壓迫的病人之功效—迴溯性分析

The efficacy of far lateral approach for transforaminal epidural steroid injection in patients with HIVD with lumbar radiculopathy–a retrospective analysis

林盈均(Ying-Chun Lin)

指導教授 ： 陳祈玲

國立臺灣大學/醫學院/臨床醫學研究所/碩士(2021年)

https://doi.org/10.6342/NTU202103937

摘要

背景: 椎間盤突出合併神經根病變是常見的退化性脊椎疾患。經椎間孔硬脊膜上類固醇注射是以實證為基礎的臨床指引所推薦的其中一種用以緩解腰椎神經根病變疼痛的治療方式。已知良好的顯影劑分布與有效的疼痛控制相關，但最佳的注射方式或技術尚未被確立。
目的: 欲確定一種新式的經椎間孔硬脊膜上類固醇注射—遠外側入路的經椎間孔硬脊膜上類固醇注射，其顯影劑分布與疼痛控制的成效。
方法: 本研究迴溯性收錄在西元2010年1月到2020年8月之間，因為椎間盤突出合併腰椎神經根病變於本院疼痛科接受同一位疼痛專科醫師施作經椎間孔硬脊膜上類固醇注射的所有病人。其中，接受傳統經椎間孔硬脊膜上類固醇注射的病人被視為對照組，而接受遠外側入路的經椎間孔硬脊膜上類固醇注射的病人被視為實驗組。所有病人的基本資料、X光透視下顯影劑的分布、注射前後的疼痛數字評定量表、注射前後的止痛藥使用和併發症等均會被搜集與分析。
結果: 期間收錄143位對照組與237位實驗組，共380位病人納入分析。除了椎間盤脫出(p = 0.01)和脊椎側彎(p = 0.04)的比例不同以外，兩組其他的基本特徵都相似。實驗組有較佳的顯影劑分布(p < 0.01)，此結果經校正後依然存在(p < 0.001)。兩組均未發生鞘內腔注射，但實驗組椎間盤內注射的發生率較高(10% vs. 3%, p = 0.008)。相較於注射前，兩組的疼痛分數與止痛藥劑量均顯著下降，但兩組之間未達統計顯著差異。在中介分析中，遠外側入路的經椎間孔硬脊膜上類固醇注射與注射後一個月的疼痛控制相關。
結論: 相較於傳統注射方式，遠外側入路的經椎間孔硬脊膜上類固醇注射有較佳的顯影劑分布與注射後一個月的疼痛控制。期待未來有前瞻性研究來確認此分析的結果。

關鍵字

經椎間孔硬脊膜上類固醇注射 ； 腰椎 ； 神經根病變 ； 椎間盤突出 ； 疼痛數字評定量表 ； 顯影劑分布

並列摘要

Background: Herniated intervertebral disc (HIVD) with radiculopathy is a common degenerative spine disorder. Transforaminal epidural steroid injection (TFESI) is one of the pain relief treatments for lumbar radiculopathy recommended by evidence-based guideline. Adequate contrast distribution is correlated with better pain control, but the best approach has not been confirmed yet.
Aim: To confirm the efficacy of contrast distribution and pain relief with a new approach of TFESI, i.e. far lateral lateral recess approach (FLLR-TFESI).
Methods: Patients receiving transforaminal ESIs due to HIVD with radiculopathy between 2010 Jan. and 2020 Aug. by the same pain specialist in our pain clinic were retrospectively enrolled. While the FLLR-TFESI was taken as the experimental group, the conventional approach was viewed as the control group. The baseline characteristics, the pattern of contrast enhancement under fluoroscopic guidance, the pre- and post-procedure numeric pain rating scale (NRS) and dosage of analgesics, and the complications of these patients were collected and analyzed.
Results: A total of 380 patients were analyzed (143 in control group and 237 in experimental group). The two groups were balanced in most baseline characteristics, excepting disc extrusion (p = 0.01) and scoliosis (p = 0.04). The FLLR-TFESI have a better contrast distribution (p < 0.01), even after adjustment (p < 0.001). No intrathecal injection was noted, but higher rate of intra-disc injection was noted in FLLR-TFESI group (10% vs 3%, p = 0.008). Both groups demonstrated a significant reduction of either pain score or analgesics dosage from baseline, but no significant differences between groups were noticed. Notably, FLLR-TFESI did associated with optimal pain improvement at one month in mediation analysis.
Conclusion: The FLLR-TFESI has a better contrast enhancement and pain improvement by 1 month in comparison to conventional approach. Prospective study to confirm the study result is suggested in the future.

並列關鍵字

Transforaminal epidural steroid injection (TFESI) ； lumbar ； radiculopathy ； herniated intervertebral disc (HIVD) ； numeric rating scale (NRS) ； contrast distribution

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