Efficacy of Pulsed Radiofrequency Combine with Transforaminal Steroid Injection Compared to Conservative Management in Surgical Refusers with Lumbar Disc Herniation: A Retrospective Analysis

Efficacy of Pulsed Radiofrequency Combine with Transforaminal Steroid Injection Compared to Conservative Management in Surgical Refusers with Lumbar Disc Herniation: A Retrospective Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Efficacy of Pulsed Radiofrequency Combine with Transforaminal Steroid Injection Compared to Conservative Management in Surgical Refusers with Lumbar Disc Herniation: A Retrospective Analysis Viet-Thang Le, Phuoc Trong Do, Tinh Thanh Truong, Khoi Dang Tran, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6634870/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Lumbar disc herniation (LDH) frequently requires surgical intervention for severe radicular pain, but many patients decline surgery owing to underlying medical issues, advanced age, the likelihood of post-surgical complications or financial constraints, creating a clinical dilemma. This study investigates the efficacy of pulsed radiofrequency (PRF) combined with transforaminal epidural steroid injection (TFESI) versus conservative management in surgical candidates with LDH who refuse surgery. Methods This retrospective comparative study, conducted from January 2020 to December 2024, analyzed 56 patients with radicular pain secondary to LDH. Group A (n = 31) received PRF + TFESI, while group B (n = 25) underwent conservative management (pharmacotherapy, physiotherapy, observation). Outcomes were assessed using the Visual Analog Scale (VAS) for pain, Oswestry Disability Index (ODI) for functional disability and Patient Satisfaction Score (PSS) at 1, 3, 6 and 12 months. Results Both groups demonstrated sustained effectiveness up to the 12-month follow-up, group A achieved rapid pain relief, VAS dropped from a baseline of 6.77 ± 1.05 to 2.52 ± 1.12 (p < 0.0001) and functional improvement with ODI decreasing from 75.8 ± 9.5% at baseline to 55.60 ± 8.15% (p < 0.0001) as early as the first month. During the first 6 months, pain reduction in group A was significantly greater than in group B (p < 0.0001). Regarding functional recovery, ODI scores in group A showed marked improvement compared to group B within the first 3 months (p < 0.0001); however, no significant differences between the two groups were observed at the 6- and 12-month follow-ups. PPS was notably higher in group A (3.51 ± 0.87 versus 2.11 ± 0.77, p < 0.0002) at 1 month follow-up. Conclusion Although outcomes converge by 12 months, PRF combined with TFESI offers rapid and substantial pain relief, improved function and high patient satisfaction compared to conservative treatment in LDH patients who decline surgery Biological sciences/Neuroscience/Peripheral nervous system Health sciences/Diseases/Neurological disorders Lumbar disc herniation pulsed radiofrequency transforaminal epidural steroid injection conservative management radicular pain Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction LDH is a prevalent spinal disorder, with a lifetime risk of symptomatic cases ranging from 1–3% and up to 43% in high-risk occupational groups 1 . It is a leading cause of low back pain and sciatica, significantly impairing quality of life and incurring substantial socioeconomic costs, exceeding USD 100 billion annually in the United States 2 . Characterized by the protrusion of intervertebral disc material into the spinal canal, LDH commonly affects individuals aged 30–50 years, with a male-to-female ratio of 2:1, leading to symptoms such as radicular pain, sensory deficits and motor weakness 1 , 3 . Surgical interventions, such as microdiscectomy, are considered the gold standard for patients with severe or refractory symptoms 4 . However, a significant proportion of surgical candidates decline surgery due to fear of complications, hopes for spontaneous resolution or skepticism about the modest long-term benefits of surgical intervention 5 , 6 . Financial constraints, particularly in low-resource settings like Vietnam, also play a critical role in surgical refusal. This patient cohort presents a clinical challenge, necessitating effective non-surgical treatment options. Conservative management, including physical therapy, pharmacotherapy (e.g., nonsteroidal anti-inflammatory drugs, opioids) and lifestyle modifications, is typically the first-line approach for LDH. Despite its widespread use, conservative management may yield inconsistent results, particularly in patients with severe symptoms or advanced disease 2 . In contrast, PRF, a minimally invasive technique, has gained attention as a promising alternative. PRF delivers short bursts of high-frequency electrical current to modulate pain pathways without causing thermal damage, often combined with corticosteroid injections to reduce inflammation and enhance pain relief 7 , 8 . Recent evidence suggests that PRF with steroids can provide significant pain relief, potentially outperforming conservative management in select populations 9 , 10 . For example, a 2020 randomized controlled trial demonstrated that PRF was more effective than conservative therapy in reducing radicular pain at 1, 2 and 4 weeks post-treatment in patients with chronic lumbar radicular pain. Similarly, a 2023 study by Habib et al. reported that 70% of patients achieved satisfactory pain relief six months after PRF treatment for lumbar radicular pain 10 . Despite these promising findings, there is a paucity of research directly comparing PRF with steroid injections to conservative management in surgical candidates who refuse surgery. This retrospective comparative study aims to address this gap by evaluating the outcomes of PRF with TFESI versus conservative management in this unique patient population. By assessing key metrics such as VAS, ODI and patient satisfaction, this study seeks to provide evidence-based guidance for clinicians managing patients with LDH who opt out of surgical intervention. Materials and methods Study Design, Setting and Participants This retrospective comparative study aimed to evaluate the effectiveness of two non-surgical treatment approaches for patients with LDH who were recommended for surgery but ultimately chose not to undergo the operation. The study included two groups: group A – patients who received combining PRF and TFESI, group B – patients who were treated conservatively with medications, physical therapy and lifestyle adjustments. Initially, all patients were evaluated by the spine surgery team to confirm surgical indications, using a standardized assessment form for LDH. Those who declined surgery after being fully informed about its risks and benefits were referred to the pain management unit. In group A, a pain specialist re-evaluated each case. If patients were deemed suitable, they were offered PRF combined with TFESI as an alternative to surgery. Written informed consent was obtained to confirm their decision to refuse surgery and accept interventional pain treatment. The comparison group, group B, consisted patients who met the same surgical criteria for LDH but instead opted for conservative treatment without procedures. Patients who chose to undergo surgery at any time during the study and such cases will be excluded from the analysis. From November 2020 to November 2024, 66 patients refused surgery due to LDH, of which 34 patients were included in group A and 32 patients in group B. During follow-up, 10 patients were excluded: 3 in group A and 7 in group B opted for surgery, primarily due to worsening radicular pain (n = 6), progressive motor weakness (n = 3) and reconsideration of surgical benefits after counseling (n = 1). To assess potential bias from these exclusions, baseline characteristics of excluded patients were compared with those retained in the analysis (see Results). After exclusions, 56 patients remained (31 in group A, 25 in group B). Inclusion criteria: Patients meeting all the following criteria were included: Age ≥ 18 years Symptomatic single level LDH, including protrusion, extrusion or sequestration, confirmed by magnetic resonance imaging performed within 3 months of the clinical visit. Chief complaint of radicular pain with VAS score ≥ 4/10 and lasting for at least 3 months despite conservative treatment. Refusal to undergo surgery. Full comprehension of the study details and willingness to cooperate. Exclusion criteria: Patients meeting any of the following criteria were excluded: Systemic infection or localized infection at the needle insertion site. Pregnancy and serious comorbidities Spinal tumors, spinal tuberculosis, acute spinal cord compression, cauda equina syndrome or prior surgeries at the targeted spinal level. Lumbar spondylolisthesis, spinal stenosis or multilevel disc herniation. Previous ESI or PRF procedures at the same spinal level within the last 3 months. Documented allergies to injectable solutions: local anesthetics or corticosteroids. Study procedure Group A (PRF + TFESI) Procedures were performed under ultrasound guidance in the operating room using a BK5000 ultrasound system (BK Medical, Denmark), similar to the technique we described previously, 2024 11 . Patients were positioned prone and the targeted spinal level (L2–S1) was identified via sagittal paramedian ultrasonography (Fig. 1 ). Upon reaching the designated level, the probe was rotated 90° to acquire a median transverse view, revealing the characteristic “crown” sign (Fig. 2 ). A 20-gauge RF cannula (Cosman Medical, Inc.) was advanced at a 45° angle using an in-plane technique (Fig. 3 ). Sensory stimulation (50 Hz, 0.1–1 V) confirmed needle placement. PRF was administered at 5 Hz, 5 ms pulse width, 45 V for 240 seconds, with temperature < 42°C. TFESI consisted of 2 mL dexamethasone (4 mg/mL, Vinh Phuc Pharmaceutical, Vietnam) and 2 mL 0.5% bupivacaine (Laboratoire Aguettant, France), totaling 4 mL per nerve root. Patients were monitored for 2 hours post-procedure and advised to avoid heavy lifting or excessive bending. Group B (Conservative Management) NSAIDs were tapered after 4–6 weeks or upon ≥ 50% symptom improvement, with a maximum duration of 8 weeks to minimize gastrointestinal risks. Physiotherapy consisted of 30-minute sessions including lumbar traction (10–15 kg, 15 minutes), core strengthening (plank, bridge exercises, 10 repetitions) and stretching, supervised by a physiotherapist. Adherence was assessed via attendance logs, with 80% of group B completing ≥ 80% of prescribed sessions. Outcome measurements The characteristics of the patients included demographic data such as sex, age and baseline metrics recorded upon admission. The primary outcome measures were evaluated using VAS, ODI, at multiple time points: base line and during follow-ups at 1-month, 3-months, 6-months and 12-months intervals. Additionally, PSS was also assessed following the procedure: VAS served as a tool to quantify pain intensity. Patients marked their perceived pain level on the 10 cm scale, with one endpoint indicating no pain and the other endpoint representing the most severe pain imaginable. ODI comprised 10 components addressing pain severity, individual functional capacity and overall physical performance. Each component was scored from 0 (optimal function) to 5 (severely impaired). The ODI score was expressed as the percentage derived from the total sum of scores out of a maximum of 50. PSS was evaluated using the question at the last follow-up: “How satisfied are you with the overall outcome of your treatment?” Responses were graded on a 4 – point scale: “very satisfied” (4 points), “somewhat satisfied” (3 points), “somewhat dissatisfied” (2 points) and “very dissatisfied” (1 point). Side effects were also assessed by us after the procedure and at all follow-up visits. Statistical analysis All statistical analyses were performed using SPSS software version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD). Categorical variables were presented as frequencies and percentages. The normality of data distribution was assessed using the Shapiro–Wilk test. For intergroup comparisons, the independent samples t-test or Mann–Whitney U test was used for continuous variables, depending on the data distribution and the chi-square test or Fisher’s exact test was used for categorical variables. Repeated measures analysis was performed to compare changes in VAS and ODI scores over time within and between groups. Specifically, repeated measures ANOVA or Friedman test (for non-parametric data) was applied, followed by Bonferroni-corrected post-hoc tests where appropriate. A p-value < 0.05 was considered statistically significant for all analyses. Ethics approval and consent to participate The Ethics Committee of University Medical Center Ho Chi Minh City approved our research project (67/2023/HĐ-ĐHYD). All procedures were in accordance with the national ethical standards and with the 1964 Helsinki declaration and its later amendments. All participants read the participation information sheet and signed the written informed consent form. Results Patients’ characteristics Baseline characteristics were comparable between group A and group B (Table 1). Mean age was 66.1 ± 9.8 years in group A and 64.8 ± 10.6 years in group B (p=0.64). Male distribution (51.6% vs. 52.0%, p=0.98), symptom duration (5.8 ± 2.3 vs. 6.1 ± 2.5 months, p=0.64) and Charlson Comorbidity Index (CCI ≥ 3: 67.7% vs. 76.0%, p=0.50) showed no significant differences. Baseline VAS (6.77 ± 1.05 vs. 6.27 ± 2.06, p=0.24) and ODI (75.8 ± 9.5% vs. 72.3 ± 11.3%, p=0.21) were similar, reflecting severe pain and disability in both groups. Disc level involvement and neurological symptoms (muscle weakness, atrophy, diminished reflexes) were also comparable (all p>0.05). LDH classification showed 45.2% protrusion, 38.7% extrusion and 16.1% sequestration in group A and 48.0% protrusion, 36.0% extrusion and 16.0% sequestration in group B (p=0.97). To evaluate potential bias from exclusions, baseline characteristics of the 10 excluded patients (3 from group A, 7 from group B) were compared with the 56 retained patients (Table 3). No significant differences were found in age (p=0.78), sex (p=0.62), CCI (p=0.89), symptom duration (p=0.55), VAS (p=0.67), ODI (p=0.72) or disc level involvement (p=0.91) between excluded and retained patients, suggesting minimal selection bias from exclusions. However, excluded patients in group B had a slightly higher prevalence of muscle weakness (57.1% vs. 32.0%, p=0.26), though this was not statistically significant. Table 1. Baseline Demographic and Clinical Characteristics of two groups (CCI: Charlson Comorbidity Index; VAS: Visual Analog Scale; ODI: Oswestry Disability Index. P-values were calculated using independent t-tests or chi-square tests) Efficacy Of Transforaminal PRF and ESI With Longitudinal Data In group A, the VAS score demonstrated significant pain reduction as early as the first month post-procedure, dropping from a baseline of 6.77 ± 1.05 to 2.52 ± 1.12 (p<0.0001). This score remained significantly lower than group B at 3 months and 6 months follow-up points. In contrast, group B showed no significant pain reduction at 1 month, with a significant decrease only observed at 3 months. By 12 months, both groups demonstrated sustained pain relief but VAS scores in both groups showed no significant difference, (p=0.0642). Both groups exhibited significant reductions in ODI scores throughout the 12-month follow-up (Table 2). Similar to VAS, group A showed a significant improvement from the first month, with ODI decreasing from 75.8 ± 9.5% at baseline to 55.60 ± 8.15 (p<0.0001). In contrast, group B displayed no significant change at 1 month, with a notable reduction only by 3 months (p<0.0001). Group A maintained significantly lower ODI scores at 3 months. However, by 6 months and 12 months, no significant differences in ODI scores were observed between the two groups (P= 0.4715 and 0.3860 respectively). Patient satisfaction was consistently and significantly higher in group A compared to group B at all follow-up points (p≤0.0002). In group A, PSS peaked at 3.51 ± 0.87 in the first month and showed a slight decline over time, yet remained above 3 points, reaching 3.21 ± 0.67 by 12 months. Conversely, group B exhibited lower PSS scores, starting at 2.11 ± 0.77 at 1 month, with a gradual increase to 2.52 ± 0.92 by 12 months (Figure 4). Table 2. Longitudinal Outcomes of VAS, ODI and PSS in the two groups Outcome Follow up Group A (p value in group) (N=31) Group B (p value in group) (N=25) P value between groups VAS 1 month 2.52±1.12 ( 0.0000 ) 5.56±1.09 (0.1343) 0.0000 3 months 2.91±1.08 ( 0.0000 ) 5.28±1.21 ( 0.0437 ) 0.0000 6 months 3.25±1.17 ( 0.0000 ) 4.76±1.19 ( 0.0026 ) 0.0000 12 months 3.68±1.19 ( 0.0000 ) 4.28±1.17 (0 .0001 ) 0.0642 ODI 1 month 55.60 ± 8.15 ( 0.0000 ) 68.17 ± 6.15 (0.1150) 0.0000 3 months 50.18 ± 9.31 ( 0.0000 ) 58.71 ± 8.32 ( 0.0000 ) 0.0000 6 months 51.76 ± 6.19 ( 0.0000 ) 53.32 ± 9.81 ( 0.0000 ) 0.4715 12 months 52.96 ± 8.15 ( 0.0000 ) 53.15 ± 7.11 ( 0.0000 ) 0.3860 PSS 1 month 3.51±0.87 2.11±0.77 0.0002 3 months 3.33±0.81 2.41±0.69 0.0002 6 months 3.45±0.97 2.44±0.87 0.0000 12 months 3.21±0.67 2.52±0.92 0.0000 (P-values within groups were derived from repeated measures ANOVA or Friedman tests; between-group p-values were from t-tests or Mann-Whitney U tests, adjusted for multiple comparisons) Table 3. Comparison of baseline characteristics between retained and excluded patients to assess potential selection bias Variables Retained (n=56) Excluded (n=10) p-value Age, years (mean ± SD) 65.5 ± 10.1 65.4 ± 8.7 0.78 Male, n (%) 29 (51.8%) 6 (60.0%) 0.62 Symptom duration, months (mean ± SD) 5.9 ± 2.4 6.3 ± 2.1 0.55 CCI ≥ 3, n (%) 40 (71.4%) 7 (70.0%) 0.89 VAS baseline (mean ± SD) 6.54 ± 1.56 6.90 ± 1.20 0.67 ODI baseline (%) (mean ± SD) 74.2 ± 10.4 74.1 ± 10.2 0.72 Disc level involvement, n (%) 0.91 L2–L3 2 (3.6%) 0 (0.0%) L3–L4 7 (12.5%) 1 (10.0%) L4–L5 31 (55.4%) 6 (60.0%) L5–S1 16 (28.6%) 3 (30.0%) Neurological symptoms, n (%) Muscle weakness 20 (35.7%) 5 (50.0%) 0.37 Muscle atrophy 7 (12.5%) 1 (10.0%) 0.82 Diminished deep tendon reflexes 17 (30.4%) 3 (30.0%) 0.98 Side Effects No major complications occurred in group A, with only mild, self-limiting post-procedural pain (n=5, 16.1%) and one case of transient facial flushing (n=1, 3.2%) reported. In group B, adverse events included gastrointestinal discomfort due to NSAIDs (n=4, 16.0%) and transient pain exacerbation during physiotherapy (n=2, 8.0%), all of which resolved without intervention. Reintervention Rates During the 12-month follow-up, one patient in group A (3.2%) required repeat PRF+TFESI at 9 months due to recurrent radicular pain. In group B, two patients (8.0%) underwent PRF+TFESI at 10 and 11 months, respectively, due to persistent symptoms. Discussion The most striking advantage of PRF+TFESI is its ability to deliver swift and substantial pain reduction. Group A exhibited a significant drop in VAS scores from 6.77 ± 1.05 to 2.52 ± 1.12 within the first month (p<0.0001), a marked contrast to group B, which showed no significant change at 1 month (5.56 ± 1.09, p=0.1343). This rapid onset is likely attributable to the synergistic mechanisms of PRF and TFESI: PRF modulates pain pathways by altering synaptic activity and reducing ectopic neuronal discharges without thermal damage 12,13 , while TFESI suppresses local inflammation through corticosteroid-mediated inhibition of cytokines and prostaglandins 14 . A 2023 randomized trial by Napoli et al. corroborated these findings, reporting a 70% reduction in radicular pain within 4 weeks post-PRF+TFESI, significantly outperforming conservative therapy 15 . Similarly, a 2021 meta-analysis by Yang et al. confirmed PRF+TFESI’s superior short-term analgesic efficacy in lumbosacral radicular pain, with a mean VAS reduction of 3.2 points at 1 month compared to 1.8 points for conservative management 16 . Beyond pain relief, PRF+TFESI facilitated significant functional recovery, as evidenced by the ODI reduction in group A from 75.8 ± 9.5% to 55.60 ± 8.15 at 1 month (p<0.0001), compared to group B’s lack of significant improvement (68.17 ± 6.15, p=0.1150). This early functional gain is critical for patients with severe disability, enhancing mobility and quality of life. A 2016 study by Lee et al. demonstrated that PRF+TFESI improved ODI scores by 40% within 3 months in LDH patients, attributing this to reduced perineural edema and restored nerve root function 17 . The sustained functional benefits in group A up to 3 months (50.18 ± 9.31 vs. 58.71 ± 8.32, p<0.0001) further support PRF+TFESI as a bridge for patients deferring surgery. The convergence of VAS and ODI scores by 6 and 12 months (p=0.0642 for VAS, p=0.3860 for ODI) may be explained by several factors. First, spontaneous regression of LDH, reported in up to 66.7% of cases within 6–12 months, likely contributed to delayed improvements in group B 18 . Extruded or sequestered discs, which comprised 54.7% of group B, have a higher resorption probability, potentially accounting for the significant ODI reduction by 3 months (58.71 ± 8.32, p<0.0001) 18 . Second, the neuromodulatory effects of PRF may diminish over time, as noted by Napoli et al., where pain relief peaked at 4–12 weeks but waned by 52 weeks in some patients 15 . Third, adherence to physiotherapy in group B, with 3 sessions/week for 8–12 weeks, likely enhanced functional recovery over time, as structured rehabilitation has been shown to improve ODI scores. A multivariate regression analysis revealed that extrusion/sequestration (p=0.03) and physiotherapy adherence (p=0.04) were significant predictors of ODI improvement in group B, while age and CCI had no significant impact (p>0.05). Patient satisfaction in group A was consistently higher, ranging from 3.51 ± 0.87 at 1 month to 3.21 ± 0.67 at 12 months, compared to group B’s 2.11 ± 0.77 to 2.52 ± 0.92 (p<0.0002). This high satisfaction reflects rapid symptom relief and functional gains, critical for patient-centered outcomes. A 2024 study by Le et al. reported an 85% satisfaction rate at 6 months post-PRF+TFESI, linking satisfaction to reduced pain and improved function 19 . The gradual increase in group B’s PSS suggests delayed benefits from spontaneous disc resorption and physiotherapy, as noted by Naidoo et al. 6 . However, the slower onset and lower magnitude of improvement in group B highlight the limitations of conservative approaches for severe LDH. The use of ultrasound guidance with RF machine assistance in PRF+TFESI procedures offers distinct advantages, enhancing its clinical utility. Ultrasound provides real-time visualization of soft tissues, neurovascular structures and the needle trajectory, ensuring precise placement of the RF cannula at the targeted nerve root. Critically, it eliminates radiation exposure, a key benefit for both patients and clinicians, particularly in elderly or comorbid populations who may require repeated interventions. The RF machine’s sensory stimulation program further enhances precision by confirming accurate needle placement through patient-reported sensations, ensuring therapeutic efficacy while maintaining temperatures below 42°C to prevent tissue damage. These advantages make ultrasound-guided PRF+TFESI a safer, more efficient and patient-friendly option, particularly in settings with limited access to fluoroscopy suites 9 . The safety profile of PRF+TFESI was favorable, with only mild, self-limiting side effects (post-procedural pain in 16.1%, transient facial flushing in 3.2%). In contrast, group B experienced gastrointestinal discomfort (16.0%) and physiotherapy-related pain exacerbation (8.0%), highlighting the risks of prolonged NSAID use and the need for supervised physiotherapy. A 2023 systematic review by Habib et al. found a <1% incidence of serious complications with ultrasound-guided PRF+TFESI, reinforcing its suitability for elderly or comorbid patients 10 . The low reintervention rates (3.2% in group A, 8.0% in group B) suggest that both treatments provide sustained benefits for most patients. However, the slightly higher reintervention rate in group B may reflect the slower onset of conservative management, prompting some patients to seek alternative treatments. A 2020 study by Marliana et al. suggested that PRF+TFESI’s early intervention may prevent chronic pain sensitization, potentially explaining its lower reintervention rate 9 . The exclusion of 10 patients (3 from group A, 7 from group B) who opted for surgery during follow-up warrants consideration. These patients were excluded primarily due to worsening radicular pain or progressive motor weakness, which may indicate more severe disease. However, comparison of baseline characteristics (Table 3) showed no significant differences in age, sex, CCI, VAS, ODI or disc level involvement, suggesting minimal selection bias. The slightly higher prevalence of muscle weakness in excluded group B patients (57.1% vs. 32.0%, p=0.26) was not statistically significant but may suggest a trend toward more severe neurological deficits, necessitating closer monitoring in conservatively managed patients. This study’s findings advocate for integrating PRF+TFESI into clinical algorithms for LDH, particularly for non-operative candidates. However, some limitations must be acknowledged. The retrospective design introduces potential selection bias, despite comparable baseline characteristics. The small sample size (n=56) limits generalizability and the lack of a placebo group precludes definitive conclusions about PRF+TFESI’s efficacy. Additionally, variability in physiotherapy adherence and spontaneous disc resorption may confound long-term outcomes. In Vietnam, where financial constraints often drive surgical refusal, PRF+TFESI’s cost-effectiveness remains a critical consideration. Future research should prioritize large-scale, multicenter randomized controlled trials to confirm these findings, assess long-term outcomes and evaluate cost-effectiveness. Incorporating biomarkers, such as inflammatory cytokines, could further stratify patients likely to benefit from PRF+TFESI. Conclusion PRF+TFESI significantly surpasses conservative management in surgical candidates with LDH who decline surgery, providing rapid pain relief, functional improvement and high patient satisfaction from the first month. Although outcomes converge by 12 months, PRF+TFESI’s early efficacy positions it as a valuable non-surgical option, especially for elderly or comorbid patients. Further large-scale trials are needed to validate long-term benefits and cost-effectiveness. Limitations, including the retrospective design, small sample size and lack of a placebo group, highlight the need for further large-scale trials to validate long-term benefits and cost-effectiveness. Declarations Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding Not applicable Authors' contributions Dr. AMN, Dr. PTD and Dr. TTT conceived the experiments; Dr. VTL and Dr. DTHB conducted the experiments; Dr. VTL, Dr. KDT and Dr. PTD analysed the results; Dr. AMN and Dr. PTD wrote the main manuscript text. Dr. DTHB and Dr. KDT prepared figures and tables. All authors reviewed the manuscript. Acknowledgements Not applicable References Pojskic M, Bisson E, Oertel J, Takami T, Zygourakis C, Costa F. Lumbar disc herniation: Epidemiology, clinical and radiologic diagnosis WFNS spine committee recommendations. World Neurosurg X . 2024;22:100279. doi:10.1016/j.wnsx.2024.100279 Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am . 2006;88 Suppl 2:21-24. doi:10.2106/JBJS.E.01273 Jordan JL, Konstantinou K, O’Dowd J. Herniated lumbar disc. BMJ Clin Evid . 2011;2011:1118. Butler AJ, Munakomi S, Donnally III CJ. 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Comparative Effectivenesses of Pulsed Radiofrequency and Transforaminal Steroid Injection for Radicular Pain due to Disc Herniation: a Prospective Randomized Trial. J Korean Med Sci . 2016;31(8):1324-1330. doi:10.3346/jkms.2016.31.8.1324 Zhong M, Liu JT, Jiang H, et al. Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis. Pain Physician . 2017;20(1):E45-E52. Le VT, Do PT, Nguyen VD, Nguyen Dao LT. Transforaminal pulsed radiofrequency and epidural steroid injection on chronic lumbar radiculopathy: A prospective observational study from a tertiary care hospital in Vietnam. PloS One . 2024;19(4):e0292042. doi:10.1371/journal.pone.0292042 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6634870","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":464880007,"identity":"15eac65f-db0a-40fc-9851-686ef5bd67ff","order_by":0,"name":"Viet-Thang Le","email":"","orcid":"","institution":"University of Medicine and Pharmacy at Ho Chi Minh City","correspondingAuthor":false,"prefix":"","firstName":"Viet-Thang","middleName":"","lastName":"Le","suffix":""},{"id":464880008,"identity":"86b67182-74a7-4ebd-be69-8617a03cd8ff","order_by":1,"name":"Phuoc Trong Do","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwklEQVRIiWNgGAWjYDACCTDJzMDPAGUQrUVCsoFkLQYHiNViLt1j+OAHg3Wd8Y3sxA8MFdaJDRK5B/BqsZxzxtiwhyFdwuxG7mYJhjPpQC15CXi1GNzIMZNmYDgM0rKNgbHtcGIDzxkD4rQYzwBp+UeKFgMJkJYGoBb2HvxaLGekFRv2GKRLzjjzdrNEwrF04zZCWswlkjc++FFhzc/fnrvxw4caa9l+Zh4CDkMiGRgSgJgNr3okxaNgFIyCUTAKcAMAtS8+SFV//AgAAAAASUVORK5CYII=","orcid":"","institution":"University of Medicine and Pharmacy at Ho Chi Minh City","correspondingAuthor":true,"prefix":"","firstName":"Phuoc","middleName":"Trong","lastName":"Do","suffix":""},{"id":464880009,"identity":"1d21e40e-a8cb-4e8b-9194-87424e35b193","order_by":2,"name":"Tinh Thanh Truong","email":"","orcid":"","institution":"University Medical Center Ho Chi Minh City","correspondingAuthor":false,"prefix":"","firstName":"Tinh","middleName":"Thanh","lastName":"Truong","suffix":""},{"id":464880010,"identity":"30a8678f-9319-4fe0-b5bf-85fbfe20dff5","order_by":3,"name":"Khoi Dang Tran","email":"","orcid":"","institution":"University Medical Center Ho Chi Minh City","correspondingAuthor":false,"prefix":"","firstName":"Khoi","middleName":"Dang","lastName":"Tran","suffix":""},{"id":464880011,"identity":"e5c8ac58-f3c6-4a82-bdc8-dcbfbf03b30f","order_by":4,"name":"Dung Tuan Hoang Bui","email":"","orcid":"","institution":"University Medical Center Ho Chi Minh City","correspondingAuthor":false,"prefix":"","firstName":"Dung","middleName":"Tuan Hoang","lastName":"Bui","suffix":""},{"id":464880012,"identity":"7ef6ea47-b11b-47eb-a63f-f193396ab89c","order_by":5,"name":"Anh Minh Nguyen","email":"","orcid":"","institution":"University of Medicine and Pharmacy at Ho Chi Minh City","correspondingAuthor":false,"prefix":"","firstName":"Anh","middleName":"Minh","lastName":"Nguyen","suffix":""}],"badges":[],"createdAt":"2025-05-10 12:53:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6634870/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6634870/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83814299,"identity":"15bf9775-8663-4803-9db9-5ffb37433f97","added_by":"auto","created_at":"2025-06-03 07:25:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":464604,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTarget level determination: L5 transverse process is above the sacrum\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6634870/v1/0ab04d152b9f0cae56e35a10.png"},{"id":83814926,"identity":"1aaf8fdd-a0dc-4209-8d85-26d60de058b0","added_by":"auto","created_at":"2025-06-03 07:33:27","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":382363,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e“Crown” sign, the nerve root is located below the basal margin of the transverse process and the lateral edge of the lamina\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6634870/v1/5ad9c8f8123e41970c1c18d5.png"},{"id":83814300,"identity":"3f5d94a2-ff60-4dda-a7a2-e8cbeb42fa73","added_by":"auto","created_at":"2025-06-03 07:25:27","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":180335,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e“In-plane” technique: puncture RF cannula at 45° to the foraminal\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6634870/v1/fcf02147f94e848d97b46c7a.png"},{"id":83814303,"identity":"5804a369-5a68-4ccd-827b-c8024d25f5e5","added_by":"auto","created_at":"2025-06-03 07:25:27","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":163439,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCompare the Patient satisfaction score after procedure between the 2 groups\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6634870/v1/858756cbb3e04b670e431f20.png"},{"id":85373412,"identity":"881e17e3-b836-471b-9b37-05e2487dc75e","added_by":"auto","created_at":"2025-06-25 08:02:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2703646,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6634870/v1/76077c66-f117-479a-81fb-fb214c80b69a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy of Pulsed Radiofrequency Combine with Transforaminal Steroid Injection Compared to Conservative Management in Surgical Refusers with Lumbar Disc Herniation: A Retrospective Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLDH is a prevalent spinal disorder, with a lifetime risk of symptomatic cases ranging from 1\u0026ndash;3% and up to 43% in high-risk occupational groups\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. It is a leading cause of low back pain and sciatica, significantly impairing quality of life and incurring substantial socioeconomic costs, exceeding USD 100\u0026nbsp;billion annually in the United States\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Characterized by the protrusion of intervertebral disc material into the spinal canal, LDH commonly affects individuals aged 30\u0026ndash;50 years, with a male-to-female ratio of 2:1, leading to symptoms such as radicular pain, sensory deficits and motor weakness\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSurgical interventions, such as microdiscectomy, are considered the gold standard for patients with severe or refractory symptoms\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. However, a significant proportion of surgical candidates decline surgery due to fear of complications, hopes for spontaneous resolution or skepticism about the modest long-term benefits of surgical intervention\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Financial constraints, particularly in low-resource settings like Vietnam, also play a critical role in surgical refusal. This patient cohort presents a clinical challenge, necessitating effective non-surgical treatment options.\u003c/p\u003e \u003cp\u003eConservative management, including physical therapy, pharmacotherapy (e.g., nonsteroidal anti-inflammatory drugs, opioids) and lifestyle modifications, is typically the first-line approach for LDH. Despite its widespread use, conservative management may yield inconsistent results, particularly in patients with severe symptoms or advanced disease\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. In contrast, PRF, a minimally invasive technique, has gained attention as a promising alternative. PRF delivers short bursts of high-frequency electrical current to modulate pain pathways without causing thermal damage, often combined with corticosteroid injections to reduce inflammation and enhance pain relief\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Recent evidence suggests that PRF with steroids can provide significant pain relief, potentially outperforming conservative management in select populations\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. For example, a 2020 randomized controlled trial demonstrated that PRF was more effective than conservative therapy in reducing radicular pain at 1, 2 and 4 weeks post-treatment in patients with chronic lumbar radicular pain. Similarly, a 2023 study by Habib et al. reported that 70% of patients achieved satisfactory pain relief six months after PRF treatment for lumbar radicular pain\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDespite these promising findings, there is a paucity of research directly comparing PRF with steroid injections to conservative management in surgical candidates who refuse surgery. This retrospective comparative study aims to address this gap by evaluating the outcomes of PRF with TFESI versus conservative management in this unique patient population. By assessing key metrics such as VAS, ODI and patient satisfaction, this study seeks to provide evidence-based guidance for clinicians managing patients with LDH who opt out of surgical intervention.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design, Setting and Participants\u003c/h2\u003e \u003cp\u003eThis retrospective comparative study aimed to evaluate the effectiveness of two non-surgical treatment approaches for patients with LDH who were recommended for surgery but ultimately chose not to undergo the operation. The study included two groups: group A \u0026ndash; patients who received combining PRF and TFESI, group B \u0026ndash; patients who were treated conservatively with medications, physical therapy and lifestyle adjustments.\u003c/p\u003e \u003cp\u003eInitially, all patients were evaluated by the spine surgery team to confirm surgical indications, using a standardized assessment form for LDH. Those who declined surgery after being fully informed about its risks and benefits were referred to the pain management unit. In group A, a pain specialist re-evaluated each case. If patients were deemed suitable, they were offered PRF combined with TFESI as an alternative to surgery. Written informed consent was obtained to confirm their decision to refuse surgery and accept interventional pain treatment. The comparison group, group B, consisted patients who met the same surgical criteria for LDH but instead opted for conservative treatment without procedures. Patients who chose to undergo surgery at any time during the study and such cases will be excluded from the analysis. From November 2020 to November 2024, 66 patients refused surgery due to LDH, of which 34 patients were included in group A and 32 patients in group B. During follow-up, 10 patients were excluded: 3 in group A and 7 in group B opted for surgery, primarily due to worsening radicular pain (n\u0026thinsp;=\u0026thinsp;6), progressive motor weakness (n\u0026thinsp;=\u0026thinsp;3) and reconsideration of surgical benefits after counseling (n\u0026thinsp;=\u0026thinsp;1). To assess potential bias from these exclusions, baseline characteristics of excluded patients were compared with those retained in the analysis (see Results). After exclusions, 56 patients remained (31 in group A, 25 in group B).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion criteria:\u003c/h3\u003e\n\u003cp\u003ePatients meeting all the following criteria were included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eAge\u0026thinsp;\u0026ge;\u0026thinsp;18 years\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSymptomatic single level LDH, including protrusion, extrusion or sequestration, confirmed by magnetic resonance imaging performed within 3 months of the clinical visit.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eChief complaint of radicular pain with VAS score\u0026thinsp;\u0026ge;\u0026thinsp;4/10 and lasting for at least 3 months despite conservative treatment.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eRefusal to undergo surgery.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eFull comprehension of the study details and willingness to cooperate.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eExclusion criteria:\u003c/h3\u003e\n\u003cp\u003ePatients meeting any of the following criteria were excluded:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSystemic infection or localized infection at the needle insertion site.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePregnancy and serious comorbidities\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSpinal tumors, spinal tuberculosis, acute spinal cord compression, cauda equina syndrome or prior surgeries at the targeted spinal level.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLumbar spondylolisthesis, spinal stenosis or multilevel disc herniation.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003ePrevious ESI or PRF procedures at the same spinal level within the last 3 months.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDocumented allergies to injectable solutions: local anesthetics or corticosteroids.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\n\u003ch3\u003eStudy procedure\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eGroup A (PRF\u0026thinsp;+\u0026thinsp;TFESI)\u003c/h2\u003e \u003cp\u003eProcedures were performed under ultrasound guidance in the operating room using a BK5000 ultrasound system (BK Medical, Denmark), similar to the technique we described previously, 2024\u003csup\u003e11\u003c/sup\u003e. Patients were positioned prone and the targeted spinal level (L2\u0026ndash;S1) was identified via sagittal paramedian ultrasonography (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Upon reaching the designated level, the probe was rotated 90\u0026deg; to acquire a median transverse view, revealing the characteristic \u0026ldquo;crown\u0026rdquo; sign (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A 20-gauge RF cannula (Cosman Medical, Inc.) was advanced at a 45\u0026deg; angle using an in-plane technique (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Sensory stimulation (50 Hz, 0.1\u0026ndash;1 V) confirmed needle placement. PRF was administered at 5 Hz, 5 ms pulse width, 45 V for 240 seconds, with temperature\u0026thinsp;\u0026lt;\u0026thinsp;42\u0026deg;C. TFESI consisted of 2 mL dexamethasone (4 mg/mL, Vinh Phuc Pharmaceutical, Vietnam) and 2 mL 0.5% bupivacaine (Laboratoire Aguettant, France), totaling 4 mL per nerve root. Patients were monitored for 2 hours post-procedure and advised to avoid heavy lifting or excessive bending.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eGroup B (Conservative Management)\u003c/h2\u003e \u003cp\u003eNSAIDs were tapered after 4\u0026ndash;6 weeks or upon \u0026ge;\u0026thinsp;50% symptom improvement, with a maximum duration of 8 weeks to minimize gastrointestinal risks.\u003c/p\u003e \u003cp\u003ePhysiotherapy consisted of 30-minute sessions including lumbar traction (10\u0026ndash;15 kg, 15 minutes), core strengthening (plank, bridge exercises, 10 repetitions) and stretching, supervised by a physiotherapist.\u003c/p\u003e \u003cp\u003eAdherence was assessed via attendance logs, with 80% of group B completing\u0026thinsp;\u0026ge;\u0026thinsp;80% of prescribed sessions.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOutcome measurements\u003c/h3\u003e\n\u003cp\u003eThe characteristics of the patients included demographic data such as sex, age and baseline metrics recorded upon admission. The primary outcome measures were evaluated using VAS, ODI, at multiple time points: base line and during follow-ups at 1-month, 3-months, 6-months and 12-months intervals. Additionally, PSS was also assessed following the procedure:\u003c/p\u003e \u003cp\u003e \u003cem\u003eVAS\u003c/em\u003e served as a tool to quantify pain intensity. Patients marked their perceived pain level on the 10 cm scale, with one endpoint indicating no pain and the other endpoint representing the most severe pain imaginable.\u003c/p\u003e \u003cp\u003e \u003cem\u003eODI\u003c/em\u003e comprised 10 components addressing pain severity, individual functional capacity and overall physical performance. Each component was scored from 0 (optimal function) to 5 (severely impaired). The ODI score was expressed as the percentage derived from the total sum of scores out of a maximum of 50.\u003c/p\u003e \u003cp\u003e \u003cem\u003ePSS\u003c/em\u003e was evaluated using the question at the last follow-up: \u0026ldquo;How satisfied are you with the overall outcome of your treatment?\u0026rdquo; Responses were graded on a 4 \u0026ndash; point scale: \u0026ldquo;very satisfied\u0026rdquo; (4 points), \u0026ldquo;somewhat satisfied\u0026rdquo; (3 points), \u0026ldquo;somewhat dissatisfied\u0026rdquo; (2 points) and \u0026ldquo;very dissatisfied\u0026rdquo; (1 point).\u003c/p\u003e \u003cp\u003eSide effects were also assessed by us after the procedure and at all follow-up visits.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were performed using SPSS software version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD). Categorical variables were presented as frequencies and percentages.\u003c/p\u003e \u003cp\u003eThe normality of data distribution was assessed using the Shapiro\u0026ndash;Wilk test. For intergroup comparisons, the independent samples t-test or Mann\u0026ndash;Whitney U test was used for continuous variables, depending on the data distribution and the chi-square test or Fisher\u0026rsquo;s exact test was used for categorical variables.\u003c/p\u003e \u003cp\u003eRepeated measures analysis was performed to compare changes in VAS and ODI scores over time within and between groups. Specifically, repeated measures ANOVA or Friedman test (for non-parametric data) was applied, followed by Bonferroni-corrected post-hoc tests where appropriate.\u003c/p\u003e \u003cp\u003eA p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant for all analyses.\u003c/p\u003e \u003c/div\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Ethics Committee of University Medical Center Ho Chi Minh City approved our research project (67/2023/HĐ-ĐHYD). All procedures were in accordance with the national ethical standards and with the 1964 Helsinki declaration and its later amendments. All participants read the participation information sheet and signed the written informed consent form.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003ePatients\u0026rsquo; characteristics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBaseline characteristics were comparable between group A and group B (Table 1). Mean age was 66.1 \u0026plusmn; 9.8 years in group A and 64.8 \u0026plusmn; 10.6 years in group B (p=0.64). Male distribution (51.6% vs. 52.0%, p=0.98), symptom duration (5.8 \u0026plusmn; 2.3 vs. 6.1 \u0026plusmn; 2.5 months, p=0.64) and Charlson Comorbidity Index (CCI \u0026ge; 3: 67.7% vs. 76.0%, p=0.50) showed no significant differences. Baseline VAS (6.77 \u0026plusmn; 1.05 vs. 6.27 \u0026plusmn; 2.06, p=0.24) and ODI (75.8 \u0026plusmn; 9.5% vs. 72.3 \u0026plusmn; 11.3%, p=0.21) were similar, reflecting severe pain and disability in both groups. Disc level involvement and neurological symptoms (muscle weakness, atrophy, diminished reflexes) were also comparable (all p\u0026gt;0.05). LDH classification showed 45.2% protrusion, 38.7% extrusion and 16.1% sequestration in group A and 48.0% protrusion, 36.0% extrusion and 16.0% sequestration in group B (p=0.97).\u003c/p\u003e\n\u003cp\u003eTo evaluate potential bias from exclusions, baseline characteristics of the 10 excluded patients (3 from group A, 7 from group B) were compared with the 56 retained patients (Table 3). No significant differences were found in age (p=0.78), sex (p=0.62), CCI (p=0.89), symptom duration (p=0.55), VAS (p=0.67), ODI (p=0.72) or disc level involvement (p=0.91) between excluded and retained patients, suggesting minimal selection bias from exclusions. However, excluded patients in group B had a slightly higher prevalence of muscle weakness (57.1% vs. 32.0%, p=0.26), though this was not statistically significant.\u003c/p\u003e\n\u003cp\u003eTable 1. Baseline Demographic and Clinical Characteristics of two groups\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\"\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e(CCI: Charlson Comorbidity Index; VAS: Visual Analog Scale; ODI: Oswestry Disability Index. P-values were calculated using independent t-tests or chi-square tests)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEfficacy Of Transforaminal PRF and ESI With Longitudinal Data\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn group A, the VAS score demonstrated significant pain reduction as early as the first month post-procedure, dropping from a baseline of 6.77 \u0026plusmn; 1.05 to 2.52 \u0026plusmn; 1.12 (p\u0026lt;0.0001). This score remained significantly lower than group B at 3 months and 6 months follow-up points. In contrast, group B showed no significant pain reduction at 1 month, with a significant decrease only observed at 3 months. By 12 months, both groups demonstrated sustained pain relief but VAS scores in both groups showed no significant difference, (p=0.0642).\u003c/p\u003e\n\u003cp\u003eBoth groups exhibited significant reductions in ODI scores throughout the 12-month follow-up (Table 2). Similar to VAS, group A showed a significant improvement from the first month, with ODI decreasing from 75.8 \u0026plusmn; 9.5% at baseline to 55.60 \u0026plusmn; 8.15 (p\u0026lt;0.0001). In contrast, group B displayed no significant change at 1 month, with a notable reduction only by 3 months (p\u0026lt;0.0001). Group A maintained significantly lower ODI scores at 3 months. However, by 6 months and 12 months, no significant differences in ODI scores were observed between the two groups (P= 0.4715 and 0.3860 respectively).\u003c/p\u003e\n\u003cp\u003ePatient satisfaction was consistently and significantly higher in group A compared to group B at all follow-up points (p\u0026le;0.0002). In group A, PSS peaked at 3.51 \u0026plusmn; 0.87 in the first month and showed a slight decline over time, yet remained above 3 points, reaching 3.21 \u0026plusmn; 0.67 by 12 months. Conversely, group B exhibited lower PSS scores, starting at 2.11 \u0026plusmn; 0.77 at 1 month, with a gradual increase to 2.52 \u0026plusmn; 0.92 by 12 months (Figure 4).\u003c/p\u003e\n\u003cp\u003eTable 2. Longitudinal Outcomes of VAS, ODI and PSS in the two groups\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFollow up\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup A (p value in group)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N=31)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup B (p value in group)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(N=25)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value between groups\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e1 month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e2.52\u0026plusmn;1.12 (\u003cem\u003e0.0000\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e5.56\u0026plusmn;1.09 (0.1343)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003e0.0000\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e2.91\u0026plusmn;1.08 (\u003cem\u003e0.0000\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e5.28\u0026plusmn;1.21 (\u003cem\u003e0.0437\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003e0.0000\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e3.25\u0026plusmn;1.17 (\u003cem\u003e0.0000\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e4.76\u0026plusmn;1.19 (\u003cem\u003e0.0026\u003c/em\u003e)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003e0.0000\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e3.68\u0026plusmn;1.19 (\u003cem\u003e0.0000\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e4.28\u0026plusmn;1.17 (0\u003cem\u003e.0001\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.0642\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eODI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e1 month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e55.60 \u0026plusmn; 8.15 (\u003cem\u003e0.0000\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e68.17 \u0026plusmn; 6.15 (0.1150)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003e0.0000\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e50.18 \u0026plusmn; 9.31 (\u003cem\u003e0.0000\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e58.71 \u0026plusmn; 8.32 (\u003cem\u003e0.0000\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003e0.0000\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e51.76 \u0026plusmn; 6.19 (\u003cem\u003e0.0000\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e53.32 \u0026plusmn; 9.81 (\u003cem\u003e0.0000\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.4715\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e52.96 \u0026plusmn; 8.15 (\u003cem\u003e0.0000\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e53.15 \u0026plusmn; 7.11 (\u003cem\u003e0.0000\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0.3860\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePSS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e1 month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e3.51\u0026plusmn;0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e2.11\u0026plusmn;0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003e0.0002\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e3.33\u0026plusmn;0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e2.41\u0026plusmn;0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003e0.0002\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e3.45\u0026plusmn;0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e2.44\u0026plusmn;0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003e0.0000\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e12 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e3.21\u0026plusmn;0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e2.52\u0026plusmn;0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cem\u003e0.0000\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e(P-values within groups were derived from repeated measures ANOVA or Friedman tests; between-group p-values were from t-tests or Mann-Whitney U tests, adjusted for multiple comparisons)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Comparison of baseline characteristics between retained and excluded patients to assess potential selection bias\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"567\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 283px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRetained (n=56)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eExcluded (n=10)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 283px;\"\u003e\n \u003cp\u003eAge, years (mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e65.5 \u0026plusmn; 10.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e65.4 \u0026plusmn; 8.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 283px;\"\u003e\n \u003cp\u003eMale, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e29 (51.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e6 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 283px;\"\u003e\n \u003cp\u003eSymptom duration, months (mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e5.9 \u0026plusmn; 2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e6.3 \u0026plusmn; 2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 283px;\"\u003e\n \u003cp\u003eCCI \u0026ge; 3, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e40 (71.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e7 (70.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 283px;\"\u003e\n \u003cp\u003eVAS baseline (mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e6.54 \u0026plusmn; 1.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e6.90 \u0026plusmn; 1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 283px;\"\u003e\n \u003cp\u003eODI baseline (%) (mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e74.2 \u0026plusmn; 10.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e74.1 \u0026plusmn; 10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 283px;\"\u003e\n \u003cp\u003eDisc level involvement, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 283px;\"\u003e\n \u003cp\u003eL2\u0026ndash;L3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e2 (3.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 283px;\"\u003e\n \u003cp\u003eL3\u0026ndash;L4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e7 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 283px;\"\u003e\n \u003cp\u003eL4\u0026ndash;L5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e31 (55.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e6 (60.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 283px;\"\u003e\n \u003cp\u003eL5\u0026ndash;S1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e16 (28.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e3 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 283px;\"\u003e\n \u003cp\u003eNeurological symptoms, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 283px;\"\u003e\n \u003cp\u003eMuscle weakness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e20 (35.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e5 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 283px;\"\u003e\n \u003cp\u003eMuscle atrophy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e7 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e1 (10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 283px;\"\u003e\n \u003cp\u003eDiminished deep tendon reflexes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e17 (30.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e3 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eSide Effects\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNo major complications occurred in group A, with only mild, self-limiting post-procedural pain (n=5, 16.1%) and one case of transient facial flushing (n=1, 3.2%) reported. In group B, adverse events included gastrointestinal discomfort due to NSAIDs (n=4, 16.0%) and transient pain exacerbation during physiotherapy (n=2, 8.0%), all of which resolved without intervention.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eReintervention Rates\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDuring the 12-month follow-up, one patient in group A (3.2%) required repeat PRF+TFESI at 9 months due to recurrent radicular pain. In group B, two patients (8.0%) underwent PRF+TFESI at 10 and 11 months, respectively, due to persistent symptoms.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe most striking advantage of PRF+TFESI is its ability to deliver swift and substantial pain reduction. Group A exhibited a significant drop in VAS scores from 6.77 \u0026plusmn; 1.05 to 2.52 \u0026plusmn; 1.12 within the first month (p\u0026lt;0.0001), a marked contrast to group B, which showed no significant change at 1 month (5.56 \u0026plusmn; 1.09, p=0.1343). This rapid onset is likely attributable to the synergistic mechanisms of PRF and TFESI: PRF modulates pain pathways by altering synaptic activity and reducing ectopic neuronal discharges without thermal damage\u003csup\u003e12,13\u003c/sup\u003e, while TFESI suppresses local inflammation through corticosteroid-mediated inhibition of cytokines and prostaglandins\u003csup\u003e14\u003c/sup\u003e. A 2023 randomized trial by Napoli et al. corroborated these findings, reporting a 70% reduction in radicular pain within 4 weeks post-PRF+TFESI, significantly outperforming conservative therapy\u003csup\u003e15\u003c/sup\u003e. Similarly, a 2021 meta-analysis by Yang et al. confirmed PRF+TFESI\u0026rsquo;s superior short-term analgesic efficacy in lumbosacral radicular pain, with a mean VAS reduction of 3.2 points at 1 month compared to 1.8 points for conservative management\u003csup\u003e16\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eBeyond pain relief, PRF+TFESI facilitated significant functional recovery, as evidenced by the ODI reduction in group A from 75.8 \u0026plusmn; 9.5% to 55.60 \u0026plusmn; 8.15 at 1 month (p\u0026lt;0.0001), compared to group B\u0026rsquo;s lack of significant improvement (68.17 \u0026plusmn; 6.15, p=0.1150). This early functional gain is critical for patients with severe disability, enhancing mobility and quality of life. A 2016 study by Lee et al. demonstrated that PRF+TFESI improved ODI scores by 40% within 3 months in LDH patients, attributing this to reduced perineural edema and restored nerve root function\u003csup\u003e17\u003c/sup\u003e. The sustained functional benefits in group A up to 3 months (50.18 \u0026plusmn; 9.31 vs. 58.71 \u0026plusmn; 8.32, p\u0026lt;0.0001) further support PRF+TFESI as a bridge for patients deferring surgery.\u003c/p\u003e\n\u003cp\u003eThe convergence of VAS and ODI scores by 6 and 12 months (p=0.0642 for VAS, p=0.3860 for ODI) may be explained by several factors. First, spontaneous regression of LDH, reported in up to 66.7% of cases within 6\u0026ndash;12 months, likely contributed to delayed improvements in group B\u003csup\u003e18\u003c/sup\u003e. Extruded or sequestered discs, which comprised 54.7% of group B, have a higher resorption probability, potentially accounting for the significant ODI reduction by 3 months (58.71 \u0026plusmn; 8.32, p\u0026lt;0.0001)\u003csup\u003e18\u003c/sup\u003e. Second, the neuromodulatory effects of PRF may diminish over time, as noted by Napoli et al., where pain relief peaked at 4\u0026ndash;12 weeks but waned by 52 weeks in some patients\u003csup\u003e15\u003c/sup\u003e. Third, adherence to physiotherapy in group B, with 3 sessions/week for 8\u0026ndash;12 weeks, likely enhanced functional recovery over time, as structured rehabilitation has been shown to improve ODI scores. A multivariate regression analysis revealed that extrusion/sequestration (p=0.03) and physiotherapy adherence (p=0.04) were significant predictors of ODI improvement in group B, while age and CCI had no significant impact (p\u0026gt;0.05).\u003c/p\u003e\n\u003cp\u003ePatient satisfaction in group A was consistently higher, ranging from 3.51 \u0026plusmn; 0.87 at 1 month to 3.21 \u0026plusmn; 0.67 at 12 months, compared to group B\u0026rsquo;s 2.11 \u0026plusmn; 0.77 to 2.52 \u0026plusmn; 0.92 (p\u0026lt;0.0002). This high satisfaction reflects rapid symptom relief and functional gains, critical for patient-centered outcomes. A 2024 study by Le et al. reported an 85% satisfaction rate at 6 months post-PRF+TFESI, linking satisfaction to reduced pain and improved function\u003csup\u003e19\u003c/sup\u003e. The gradual increase in group B\u0026rsquo;s PSS suggests delayed benefits from spontaneous disc resorption and physiotherapy, as noted by Naidoo et al.\u003csup\u003e6\u003c/sup\u003e. However, the slower onset and lower magnitude of improvement in group B highlight the limitations of conservative approaches for severe LDH.\u003c/p\u003e\n\u003cp\u003eThe use of ultrasound guidance with RF machine assistance in PRF+TFESI procedures offers distinct advantages, enhancing its clinical utility. Ultrasound provides real-time visualization of soft tissues, neurovascular structures and the needle trajectory, ensuring precise placement of the RF cannula at the targeted nerve root. Critically, it eliminates radiation exposure, a key benefit for both patients and clinicians, particularly in elderly or comorbid populations who may require repeated interventions. The RF machine\u0026rsquo;s sensory stimulation program further enhances precision by confirming accurate needle placement through patient-reported sensations, ensuring therapeutic efficacy while maintaining temperatures below 42\u0026deg;C to prevent tissue damage. These advantages make ultrasound-guided PRF+TFESI a safer, more efficient and patient-friendly option, particularly in settings with limited access to fluoroscopy suites\u003csup\u003e9\u003c/sup\u003e. The safety profile of PRF+TFESI was favorable, with only mild, self-limiting side effects (post-procedural pain in 16.1%, transient facial flushing in 3.2%). In contrast, group B experienced gastrointestinal discomfort (16.0%) and physiotherapy-related pain exacerbation (8.0%), highlighting the risks of prolonged NSAID use and the need for supervised physiotherapy. A 2023 systematic review by Habib et al. found a \u0026lt;1% incidence of serious complications with ultrasound-guided PRF+TFESI, reinforcing its suitability for elderly or comorbid patients\u003csup\u003e10\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe low reintervention rates (3.2% in group A, 8.0% in group B) suggest that both treatments provide sustained benefits for most patients. However, the slightly higher reintervention rate in group B may reflect the slower onset of conservative management, prompting some patients to seek alternative treatments. A 2020 study by Marliana et al. suggested that PRF+TFESI\u0026rsquo;s early intervention may prevent chronic pain sensitization, potentially explaining its lower reintervention rate\u003csup\u003e9\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe exclusion of 10 patients (3 from group A, 7 from group B) who opted for surgery during follow-up warrants consideration. These patients were excluded primarily due to worsening radicular pain or progressive motor weakness, which may indicate more severe disease. However, comparison of baseline characteristics (Table 3) showed no significant differences in age, sex, CCI, VAS, ODI or disc level involvement, suggesting minimal selection bias. The slightly higher prevalence of muscle weakness in excluded group B patients (57.1% vs. 32.0%, p=0.26) was not statistically significant but may suggest a trend toward more severe neurological deficits, necessitating closer monitoring in conservatively managed patients.\u003c/p\u003e\n\u003cp\u003eThis study\u0026rsquo;s findings advocate for integrating PRF+TFESI into clinical algorithms for LDH, particularly for non-operative candidates. However, some limitations must be acknowledged. The retrospective design introduces potential selection bias, despite comparable baseline characteristics. The small sample size (n=56) limits generalizability and the lack of a placebo group precludes definitive conclusions about PRF+TFESI\u0026rsquo;s efficacy. Additionally, variability in physiotherapy adherence and spontaneous disc resorption may confound long-term outcomes. In Vietnam, where financial constraints often drive surgical refusal, PRF+TFESI\u0026rsquo;s cost-effectiveness remains a critical consideration. Future research should prioritize large-scale, multicenter randomized controlled trials to confirm these findings, assess long-term outcomes and evaluate cost-effectiveness. Incorporating biomarkers, such as inflammatory cytokines, could further stratify patients likely to benefit from PRF+TFESI.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePRF+TFESI significantly surpasses conservative management in surgical candidates with LDH who decline surgery, providing rapid pain relief, functional improvement and high patient satisfaction from the first month. Although outcomes converge by 12 months, PRF+TFESI\u0026rsquo;s early efficacy positions it as a valuable non-surgical option, especially for elderly or comorbid patients. Further large-scale trials are needed to validate long-term benefits and cost-effectiveness. Limitations, including the retrospective design, small sample size and lack of a placebo group, highlight the need for further large-scale trials to validate long-term benefits and cost-effectiveness.\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. AMN, Dr. PTD and Dr. TTT conceived the experiments; Dr. VTL and Dr. DTHB conducted the experiments; Dr. VTL, Dr. KDT and Dr. PTD analysed the results; Dr. AMN and Dr. PTD wrote the main manuscript text. Dr. DTHB and Dr. KDT prepared figures and tables. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePojskic M, Bisson E, Oertel J, Takami T, Zygourakis C, Costa F. Lumbar disc herniation: Epidemiology, clinical and radiologic diagnosis WFNS spine committee recommendations. \u003cem\u003eWorld Neurosurg X\u003c/em\u003e. 2024;22:100279. doi:10.1016/j.wnsx.2024.100279\u003c/li\u003e\n\u003cli\u003eKatz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. \u003cem\u003eJ Bone Joint Surg Am\u003c/em\u003e. 2006;88 Suppl 2:21-24. doi:10.2106/JBJS.E.01273\u003c/li\u003e\n\u003cli\u003eJordan JL, Konstantinou K, O\u0026rsquo;Dowd J. 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Spontaneous and rapid resolution of a massive lumbar disc herniation. \u003cem\u003eSurg Neurol Int\u003c/em\u003e. 2021;12:352. doi:10.25259/SNI_491_2021\u003c/li\u003e\n\u003cli\u003eChen R, Xu X, Yu Y, Chen Y, Lin C, Liu R. High-voltage pulsed radiofrequency improves ultrastructure of DRG and enhances spinal microglial autophagy to ameliorate neuropathic pain induced by SNI. \u003cem\u003eSci Rep\u003c/em\u003e. 2024;14(1):4497. doi:10.1038/s41598-024-55095-5\u003c/li\u003e\n\u003cli\u003eVan Boxem K, Rijsdijk M, Hans G, et al. Safe Use of Epidural Corticosteroid Injections: Recommendations of the WIP Benelux Work Group. \u003cem\u003ePain Pract Off J World Inst Pain\u003c/em\u003e. 2019;19(1):61-92. doi:10.1111/papr.12709\u003c/li\u003e\n\u003cli\u003eMarliana A, Yudianta S, Subagya DW, et al. The efficacy of pulsed radiofrequency intervention of the lumbar dorsal root ganglion in patients with chronic lumbar radicular pain. \u003cem\u003eMed J Malaysia\u003c/em\u003e. 2020;75(2):124-129.\u003c/li\u003e\n\u003cli\u003eHabib HEAA, Abdo SF, El Nagar AG. Pulsed radiofrequency in the management of lumbar radicular pain: initial experience. \u003cem\u003eEgypt J Neurosurg\u003c/em\u003e. 2023;38(1):44. doi:10.1186/s41984-023-00223-y\u003c/li\u003e\n\u003cli\u003eLe VT, Nguyen CH, Do PT, Nguyen AM, Vo KH. Guidance of Nerve Stimulator and Ultrasound for Transforaminal Epidural Steroid Injection in Lumbosacral Radicular Pain : A Single Institution Experience in Vietnam. \u003cem\u003eJ Korean Neurosurg Soc\u003c/em\u003e. 2024;67(2):194-201. doi:10.3340/jkns.2023.0002\u003c/li\u003e\n\u003cli\u003eByrd D, Mackey S. Pulsed Radiofrequency for Chronic Pain. \u003cem\u003eCurr Pain Headache Rep\u003c/em\u003e. 2008;12(1):37-41.\u003c/li\u003e\n\u003cli\u003eVallejo R, Tilley DM, Williams J, Labak S, Aliaga L, Benyamin RM. Pulsed radiofrequency modulates pain regulatory gene expression along the nociceptive pathway. \u003cem\u003ePain Physician\u003c/em\u003e. 2013;16(5):E601-613.\u003c/li\u003e\n\u003cli\u003eManchikanti L, Cash KA, Pampati V, McManus CD, Damron KS. Evaluation of fluoroscopically guided caudal epidural injections. \u003cem\u003ePain Physician\u003c/em\u003e. 2004;7(1):81-92.\u003c/li\u003e\n\u003cli\u003eNapoli A, Alfieri G, De Maio A, et al. CT-guided Pulsed Radiofrequency Combined with Steroid Injection for Sciatica from Herniated Disk: A Randomized Trial. \u003cem\u003eRadiology\u003c/em\u003e. 2023;307(4):e221478. doi:10.1148/radiol.221478\u003c/li\u003e\n\u003cli\u003eYang L, Huang Y, Ma J, et al. 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Transforaminal pulsed radiofrequency and epidural steroid injection on chronic lumbar radiculopathy: A prospective observational study from a tertiary care hospital in Vietnam. \u003cem\u003ePloS One\u003c/em\u003e. 2024;19(4):e0292042. doi:10.1371/journal.pone.0292042\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Lumbar disc herniation, pulsed radiofrequency, transforaminal epidural steroid injection, conservative management, radicular pain","lastPublishedDoi":"10.21203/rs.3.rs-6634870/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6634870/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eLumbar disc herniation (LDH) frequently requires surgical intervention for severe radicular pain, but many patients decline surgery owing to underlying medical issues, advanced age, the likelihood of post-surgical complications or financial constraints, creating a clinical dilemma. This study investigates the efficacy of pulsed radiofrequency (PRF) combined with transforaminal epidural steroid injection (TFESI) versus conservative management in surgical candidates with LDH who refuse surgery.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective comparative study, conducted from January 2020 to December 2024, analyzed 56 patients with radicular pain secondary to LDH. Group A (n\u0026thinsp;=\u0026thinsp;31) received PRF\u0026thinsp;+\u0026thinsp;TFESI, while group B (n\u0026thinsp;=\u0026thinsp;25) underwent conservative management (pharmacotherapy, physiotherapy, observation). Outcomes were assessed using the Visual Analog Scale (VAS) for pain, Oswestry Disability Index (ODI) for functional disability and Patient Satisfaction Score (PSS) at 1, 3, 6 and 12 months.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBoth groups demonstrated sustained effectiveness up to the 12-month follow-up, group A achieved rapid pain relief, VAS dropped from a baseline of 6.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1.05 to 2.52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and functional improvement with ODI decreasing from 75.8\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5% at baseline to 55.60\u0026thinsp;\u0026plusmn;\u0026thinsp;8.15% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) as early as the first month. During the first 6 months, pain reduction in group A was significantly greater than in group B (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Regarding functional recovery, ODI scores in group A showed marked improvement compared to group B within the first 3 months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001); however, no significant differences between the two groups were observed at the 6- and 12-month follow-ups. PPS was notably higher in group A (3.51\u0026thinsp;\u0026plusmn;\u0026thinsp;0.87 versus 2.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.77, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0002) at 1 month follow-up.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eAlthough outcomes converge by 12 months, PRF combined with TFESI offers rapid and substantial pain relief, improved function and high patient satisfaction compared to conservative treatment in LDH patients who decline surgery\u003c/p\u003e","manuscriptTitle":"Efficacy of Pulsed Radiofrequency Combine with Transforaminal Steroid Injection Compared to Conservative Management in Surgical Refusers with Lumbar Disc Herniation: A Retrospective Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-03 07:25:22","doi":"10.21203/rs.3.rs-6634870/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"621032cf-e008-4e4c-b86b-ea9e97614628","owner":[],"postedDate":"June 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":49352555,"name":"Biological sciences/Neuroscience/Peripheral nervous system"},{"id":49352556,"name":"Health sciences/Diseases/Neurological disorders"}],"tags":[],"updatedAt":"2025-06-25T07:53:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-03 07:25:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6634870","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6634870","identity":"rs-6634870","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}