Pulsed Radiofrequency with Steroid Injection Brings Sciatica Relief

Combined treatment outperformed treatment with steroid injections alone

Alessandro Napoli MD PhD

Researchers found that a minimally invasive procedure combined with epidural steroid injection treatment led to superior pain reduction and disability improvement over one year in patients with sciatica. The results of the study were published in Radiology. The combined treatment performed better than steroid injections alone.

Sciatica is pain that originates along the sciatic nerve. Treatments to relieve pain include nonsteroidal anti-inflammatory medications, applying heat or cold, and exercising to help minimize inflammation. When the pain is caused by a lumbar disc herniation, surgery is often the treatment option for pain relief.

 “The goal of nonoperative care is to provide the most effective means of symptom resolution, while still avoiding the need for a surgical procedure,” said the study’s lead author, Alessandro Napoli, MD, PhD, associate professor of radiology and interventional radiology at Policlinico Umberto I – Sapienza University of Rome, in Italy. “However, in many cases conventional approaches are ineffective.”

Minimally invasive interventional therapy has become increasingly popular in patients with sciatica who have become resistant to conservative treatments. Among the available options, transforaminal epidural steroid injection (TFESI) is the only interventional procedure recommended in clinical guidelines. However, the duration of benefit is usually short, and additional treatments are often necessary.

Another treatment that researchers have studied for sciatica pain relief is pulsed radiofrequency.

Napoli Radiology Interventional Sciatica TFESI

CT-guided pulsed radiofrequency (PRF) with transforaminal epidural steroid injection. A 62-year-old woman underwent PRF followed by transforaminal epidural steroid injection for sciatica due to left contained intraforaminal disk herniation at the L4-5 level. (A) A 22-gauge needle electrode with a 10-mm active tip was introduced and advanced using one 3-mm oblique axial unenhanced CT scan, which revealed that the needle tip was proximate to the target dorsal root ganglion with the lateral foraminal portal of entry. (B) Sensitive stimulation (50 Hz) PRF current with a threshold of no more than 0.2 V was used to confirm proper positioning by evoking tingling or electric pain in the dermatome that had to match the target dorsal root ganglion. Therapeutic PRF was then performed in one 10-minute session with E-dose functionality, maintaining temperature below the threshold for neural damage (42°C) and a constant voltage (45 V). Immediately after PRF administration, epidural spread of 0.3 mL of contrast material was confirmed using intermittent intraprocedural CT fluoroscopic imaging with no intravascular contrast material flow demonstration. A combination of steroid and anesthetic (1 mL lidocaine [ 20 mg/mL] and 2 mL dexamethasone [10 mg/mL]) was then injected without altering needle position to conclude the procedure.

https://doi.org/10.1148/radiol.221478 © RSNA 2023

Participants Report Better Leg Pain Reduction, Disability Improvement

For the multicenter randomized trial, researchers wanted to determine the difference in effectiveness between pulsed radiofrequency combined with TFESI versus the steroid injection alone for sciatica pain lasting 12 weeks or longer and not responsive to conservative treatment in patients with due to lumbar disc herniation.

A total of 351 participants (223 men) with sciatica were randomly assigned to receive a single CT-guided pulsed radiofrequency treatment combined with TFESI (174 patients) or TFESI alone (177 patients). Participants were recruited at two tertiary university hospitals and one spine clinic. All procedures were carried out in an outpatient clinic, took only 10 minutes and were performed without general anesthesia.

At four, 12 and 52 weeks there was greater leg pain reduction and greater disability improvement in participants who received pulsed radiofrequency combined with TFESI compared to the participants who only received the steroid injection.

“The results of our trial demonstrate that a combined treatment of pulsed radiofrequency and TFESI leads to better outcomes at one year following a single 10-minute procedure,” Dr. Napoli said.

For More Information

Access the Radiology study, “CT-guided Pulsed Radiofrequency Combined with Steroid Injection for Sciatica from Herniated Disc: A Randomized Trial.”

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