Parasagittal Versus Transforaminal Epidural Steroid Injection, a Study of Contrast Flow in the Epidural Space and Clinical Outcomes: An RCT

Parasagittal Versus Transforaminal Epidural Steroid Injection, a Study of Contrast Flow in the Epidural Space and Clinical Outcomes: An RCT | 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 Parasagittal Versus Transforaminal Epidural Steroid Injection, a Study of Contrast Flow in the Epidural Space and Clinical Outcomes: An RCT Narges Khojasteh, Hossein Majedi, Ali Emami Meibodi, Alireza Khajehnasiri, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5555106/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Feb, 2026 Read the published version in Scientific Reports → Version 1 posted 11 You are reading this latest preprint version Abstract Epidural steroid injections are frequently used to treat lumbosacral radicular pain, but the solute spread in the epidural space needs further investigation. This double-blind, randomized study assessed clinical outcomes and contrast spread patterns between the parasagittal interlaminar and transforaminal approaches in 79 adults with low back pain due to herniated or degenerated discs. Participants were randomly assigned to one of two groups: Transforaminal or Parasagittal Interlaminar. All procedures were performed under C-armed fluoroscopic guidance. Contrast spread was evaluated by a separate pain specialist, and clinical outcomes such as analgesia, patient satisfaction, and quality of life were measured at two weeks and one, three, and six months post-treatment. Results showed no statistically significant differences between the two groups in the mean pain intensity at the moment and six months after treatment (p = 0.618, p = 0.484). Comparison of contrast diffusion to the anterior epidural space between the two groups showed no statistically significant differences (P = 0.436). Clinical outcomes were similar between the two groups, but radiation exposure was significantly higher in the transforaminal group. Both approaches had the same rate of contrast flow to the anterior epidural space. However, the parasagittal interlaminar approach resulted in less radiation exposure for patients. Health sciences/Signs and symptoms/Pain Health sciences/Signs and symptoms/Pain/Chronic pain Health sciences/Neurology/Neurological disorders/Neuropathic pain Lumbosacral radicular pain Parasagittal interlaminar epidural steroid injection Transforaminal epidural steroid injection Anterior epidural space Neuropathic pain Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Lumbosacral radicular pain is a type of neuropathic pain that results from stimulation of the sensory root or dorsal root ganglion of the spinal nerve. Lumbar radicular pain is caused by the production of abnormal impulses in the dorsal root ganglion and transmission through peripheral nerve axons. Treatment of radicular symptoms varies from lifestyle changes and protective treatments to surgical interventions. Inadequate pain management is highly prevalent and is associated with significant costs and socioeconomic problems therefore attaining to effective treatments is an important goal. Some of interventional treatments for lumbosacral radicular pain include epidural steroid injection (ESI), and surgery 1 – 4 . Epidural (EP) steroids have neuroprotective properties against nerve damage and reduce nerve inflammation and edema. ESI is the most common intervention to control lumbosacral radicular pain 2 , 3 . The efficacy of ESI varies from twenty to ninety-five percent depending on the injection method 1 , 2 . Some believe that poor treatment outcomes are due to inadequate injection techniques 5 . ESI can be performed by interlaminar (IL), transforaminal (TF), and caudal approaches. Again, the IL approach can be done by parasagittal (PIL) or midline (MIL) interlaminar technique. Following intervertebral disc disease, inflammatory reactions occur in the anterior EP space as well as near nerve roots. The site of our drug effect is most likely between the nerve roots and the disc, in the anterior or anterolateral EP space. Previous studies have shown that by injecting the midline IL EP, the injected substance will be spread in the anterior EP space in only 36% of cases. As a result, physicians are increasingly using the TF method instead of the MIL technique 6 . However, there is insufficient evidence to determine the best method of EP injection. In the IL method, the drug is injected primarily in the posterior EP space, while in the TF method; the medication is placed near the nerve root. None of the procedures exactly places the medication in the anterior EP space. It is assumed that the TF approach is more effective than the IL method due to better diffusion into ventral EP space; however, this assumption has not been clearly shown. Advantages of the TF approach include the use of the least amount of injectate, and that it is closer to the main site of pathology, anterolateral EP space. The TF injection is associated with more technical difficulty to approach the EP space, consequently more radiation exposure, a significant risk compared to caudal and IL approaches, which include damage to the segmental artery, dorsal root ganglion, spinal nerve, and paralysis 7 – 10 . To find a suitable alternative to the TF approach, we examined the PIL technique, in which, unlike the usual midline approach, the drug is injected in the outermost part of the interlaminar space. Few studies have compared these two techniques for contrast flow patterns to the anterior EP space, analgesia, and quality of life (QOL) improvement 11 – 13 . In this randomized clinical trial, we investigated the spread of contrast material in the anterior EP space using fluoroscopic guidance and compared the QOL improvement and analgesia between the TF and PIL approaches for ESI. Materials and Methods The present study is a semi-blind randomized clinical trial and was conducted at a tertiary university hospital in Tehran, Iran. There are two experimental groups, with two parallel arms. ESI was performed whether by transforaminal (TF group) or parasagittal interlaminar approach (PIL group). The university ethics committee approved this study (ID IR.TUMS.IKHC.REC. 1397.359). Additionally, all procedures were performed following the relevant guidelines and regulations. The study was also registered in the National Clinical Trial Registration Center (IRCT20200209046437N1) on 23/04/2020. Informed consent was obtained from each participant. Sample size calculation To calculate sample size, we administered OpenEpi software; considering type 1 error equal to 0.05 and statistical power as 0.8 to achieve a 30% difference between study groups, 40 samples in each group was sufficient. In another approach, this sample size could be efficient for non-inferiority design for α = 0.05 and β = 0.8 and margin for non-inferiority as 0.1 and predicted efficacy difference between groups as 20 percent by online calculator( https://www2.ccrb.cuhk.edu.hk/stat/proportion/tspp_sup.htm ). Inclusion criteria Patients aged 20 to 80 years with unilateral lumbosacral radicular pain due to disc pathologies (including disc herniation, bulging, or degeneration), spinal canal, or foraminal stenosis enrolled in this study. Exclusion criteria Patients with a history of previous vertebral surgery, ESI into the lumbar EP space in recent years, allergy to medications, simultaneously with topical steroid use, patients with diabetic nephropathy, serum creatinine level greater than 2 mg/dl, opioids abuse, pregnancy, failed back surgery syndrome, and refusal to participate were excluded from this study. We randomly assigned the patients to the TF or PIL groups by block randomization. For randomization, we administered block randomization with block size = 4 for intervention groups as A and B. We selected the numbers from 1 to 6 randomly, by Microsoft Excel rand Function 22 times. Then, we wrote the related sequences from first to last, and finally, we had randomization for 88 persons. The randomization was performed by a third person and was concealed from the investigator. The vertebral level and the left or right sides were determined using clinical examination and diagnostic images. All the procedures were performed by the same pain fellowship-trained anesthesiologist with more than 20 years of experience, using the same C-arm fluoroscopy machine, and with the assistance of the same radiology technologist. In the parasagittal interlaminar (PIL) group, a 17 G Touhy needle (B Braun) was placed in the outermost affected side of PIL EP space with loss of resistance technique and under frequent Anteroposterior (AP) and Lateral C-arm fluoroscopy images (Figure-1). (Figure-1) In the transforaminal (TF) group, under frequent Oblique (tunnel views), AP, and Lateral fluoroscopy images, a 22 G blunt curved needle was placed in the affected foramen under the pedicle (Figure-2). (Figure-2) Then, 5 ml of iohexol 240 was slowly injected into the EP space in both groups to make sure that the needle tip is in the right place and the intravascular, subarachnoid, subdural, or intradiscal injections did not happen. Fluoroscopic images were carefully saved for later review of contrast spread in EP space. Then, we prepared 10 ml of a mixture consisting of 40 mg methylprednisolone, 4 ml normal saline, and 5 ml of 2% lidocaine 14 . 10 ml was injected into the IL EP space in the PIL group. For TF group, we prepared 3 ml of a mixture consisting of 40 mg methylprednisolone (1 ml), 1.5 ml of 2% lidocaine and 0.5 ml of normal saline. \ Measurements We recorded the total number of fluoroscopic shots in both groups. Another pain specialist investigated and recorded the diffusion of the contrast agent into the anterior and posterior EP space as well as its diffusion into adjacent EP segments (Figure-3). ‘Anterior’ spread was defined if the contrast reached the posterior longitudinal ligament or touched the posterior wall of the vertebral body at the level of needle placement (Figure-4). (Figure-3) (Figure-4) The physician performing the procedures was different from the physicians evaluating the outcomes, and the evaluating physicians were unaware of the groups to which the patients were belonging. A blind observer recorded the pain intensity and quality of life (QOL) at 2 weeks, 1, 2, and 6 months after injection. We evaluated and recorded the pain intensity with an 11-point Numeric Rating Scale (NRS). We asked for overall pain intensity in the preceding week before and at the moment of the patient's visit to the pain clinic 15 . We investigated the QOL according to the Modified Oswestry Low Back Pain Questionnaire (MOLBPQ). This questionnaire has been locally validated and confirmed for the local population of this study 16 . It is a widely used tool for evaluating the impact of low back pain on an individual's ability to perform daily activities. The questionnaire consists of 10 items that assess the degree of interference caused by low back pain in various aspects of life, including personal care, lifting, walking, sitting, standing, sleeping, sex life, social life, and traveling. Each item is scored on a scale from 0 to 5, with higher scores indicating greater disability. The scores for each item are then summed to yield a total score, which ranges from 0 to 50. Satisfaction with treatment A zero to 10 numerical scale was used to measure the satisfaction of treatment in patients. The number 10 indicates the highest level of satisfaction and the number zero means dissatisfaction with treatment. This scale relies on patient self-report to measure treatment satisfaction by asking the patient to choose a number between zero and 10. Impact of Overall Perception (GPE) The Perceived Global Impact Scale (GPE) is a method commonly used in both research and practice to measure patients' assessment of their condition. One of the basic assumptions of GPE is that it measures the global assessment of change in the patient's main complaint. Global Impact Perception Scale (GPE) as described by Costa et al. An example of a prescription is to measure the global perception of change in patients with low back pain. GPE was assessed with a 7-point Likert scale. Very dissatisfied (score 1), dissatisfied (score 2), somewhat dissatisfied (score 3), undecided (score 4), somewhat satisfied (score 5), satisfied (score 6), and very satisfied (score 7). Other studied variables included contrast diffusion, sex, age, pain relief, weight, height, BMI, duration of pain, pathology, MRI findings about the discopathy, EMG/NCV findings, ESI-TF, and ESI-PIL technique 17 , 18 . Statistical Analysis The information was coded from the questionnaires and entered into SPSS.23 software (IBM Corp., Armonk, NY, USA). Intention to treat (ITT) approach was administered for analysis the data in this trial. Mean ± SD was used to report for quantitative variables. Number and percent was used for qualitative variables. A significance level of less than 0.05 was considered. Quantitative data were analyzed for normal distribution by Shapiro Wilk test and all had normal distribution so independent samples t test was used to compare these data between two study groups. Chi square and Fisher exact tests were used to compare categorical data between groups. Results nd 40 patients were enrolled in PIL and TF groups respectively. The demographic and pre-procedure data have been shown in Table 1 . There was no significant difference between the two groups in the studied demographic parameters and in the pre-procedure data. Consequently, the two groups were comparable in baseline characters (Table 1 ). Table-1 Based on the results of the independent T-test, there was no statistically significant difference in the mean pain intensity between the two treatment groups before, during, and, after six months period of the treatment (Table 2 ). Table-2 The mean pain relief (in percentage), satisfaction, and quality of life of patients during six months period after the treatment had no statistically significant difference between the two study groups (Table 3 ). Table-3 Table-4 Table 4 shows that the PIL group had a higher percentage of injections on the right side and in the L5-S1 level (52.62%). The TF group had a higher percentage of injections on the left side and in the L5 level (77.5%). The P value of 0.651 indicates that there is no significant difference in the distribution of the sides between the two groups. Diffusion of the contrast in the anterior EP space in all cases extended to more than two vertebral levels (Table 5). The comparison of contrast diffusion into the anterior EP space between the two groups showed no statistically significant difference (P = 0.436). The mean number of fluoroscopic shots taken in the PIL and TF groups was significantly different and less in the PIL group. However, the caudal distribution of the contrast is more in the PIL group than in the TF group (Table 5). No complications happened in this study. Discussion This study showed that the results of ESI between the two groups of study were not significantly different. This lack of difference was assessed for contrast diffusion into the anterior EP space, pain relief, and patient satisfaction at different time intervals, up to six months. However, the amount of radiation exposure in the TF group was significantly more than in the PIL group. Our results are consistent with other studies that have compared the effectiveness of PIL and TF ESI in relieving radicular low back pain. A systematic review and meta-analysis of studies comparing PIL and TF approaches of lumbar epidural steroid injection found that PIL showed benefits in terms of lower mean fluoroscopy time, less radiation exposure, zero adverse events in all the included studies, no cases of intravascular spread compared with the TF approach, and a higher anterior epidural spread of PIL compared with TF. Although both techniques showed statistically and clinically significant pain relief, the PIL technique had a slightly better control of pain and functionality improvement 19 . After 6 months of follow-up, the pain intensity of the patients significantly decreased in both treatment groups. This finding is consistent with the results of Beyaz (2017) study. He compared the effect of two approaches of steroid injection in the lumbar region with a 12-month follow-up period in patients with chronic low back pain. He showed that the mean pain intensity significantly decreased in both groups and most patients (85.1%) felt satisfied 20 . Another study showed that no statistically significant difference was observed between the two groups of IL or TF ESI in terms of pain relief. Finally, the study showed that both approaches to ESI significantly relieved pain in patients 21 . Therefore, the results of our study are consistent with the above research. In this study, the mean satisfaction of patients with treatment six months after the start of treatment was significantly higher compared to before treatment 22 . Although, in the study, no side effects were observed following ESI in either group; the documentation of scientific texts indicates that more complications occur in the TF compared to IL ESI 23 . In the present study, diffusion in the anterior EP space in all cases extended to more than two levels, and the two groups of PIL and TF did not differ in terms of diffusion into the anterior EP space (p = 0.138). Lutz and Wisneski evaluated 50 patients with lumbar radiculopathy following intervertebral disc herniation who responded well to TF ESI and showed that more contrast diffusion into the anterior EP space resulted in good clinical outcomes 24 . Thomas et al. Also showed that the IL approach was preferable by comparing ESI with both TF and IL approaches 25 . Given that drug delivery to the anterior EP space was described by the PIL approach; In 2008, Kenneth et al. described and compared the PIL method with the TF approach under fluoroscopic guidance, which showed that diffusion into the anterior EP space was statistically better than the TF method. The authors showed that this method was not only technically very effective but also required less time to perform than the TF method under fluoroscopic guidance, which resulted in less radiation exposure for the patient and the interventionist. The results of the mentioned studies are consistent with our findings. The results of this study suggest that the PIL approach has a more extensive caudal spread of the contrast compared to the TF approach. This difference in contrast distribution may have implications for the effectiveness of the two techniques in providing pain relief and improving patient outcomes. In a study comparing the effectiveness of PIL and TF ESI in relieving radicular low back pain, it was found that the PIL approach showed an 89–100% ventral spread of contrast dye, compared to just a 31.7% of the conventional IL approach 19 . Another study comparing the effectiveness of caudal epidural steroid injections and TF epidural steroid injections found that patients who underwent TF ESI had significantly better outcomes at six months 26 . However, Kolsi et al., By comparing these two injection approaches, could not find an advantage between the two 27 . An important advantage of this study is that it has a long-term follow-up of 6 months; and in addition to the evaluation of the spread of contrast to the anterior EP space, it evaluated and compared pain intensity, quality of life, patient satisfaction, and Pain relief in two groups. Consequently, the main advantage of PIL-ESI would be significantly less radiation exposure to the patient and interventionist. The procedure is less time-consuming; it needs less training and expertise to safely perform it. The complications attributed to PIL-ESI are much less than the TF-ESI method. The advantage that can be given to the TF-ESI is that if the pressure or inflammation near the nerve root is limited to certain foramen(s), then the drug can be administered in very close proximity to the lesion. If the number of the affected roots is very limited, then the TF-ESI will need less medication and therefore, fewer possible side effects of the injectate. Limitations of our study: The recommended corticosteroid for injection into the epidural space is non-particulate steroids, such as dexamethasone, due to their lower risk of thromboembolic complications. "Total number of fluoroscopic shots" is not a legitimate measure of radiation exposure. Dose should be calculated in a radiation exposure unit (e.g., mREM, Gy, Sv) and/or reported fluoroscopy time. Another limitation of our study is the absence of a measure for systemic steroid suppression, such as cortisol levels or other assessments of hypothalamic-pituitary-adrenal (HPA) axis function. The complete absence of collimation also has significant implications for the radiation dose. Best practice is to collimate the beam where possible, both to improve image quality and to minimize dose to patient and operator. Conclusion The clinical outcomes of the two ESI techniques, i.e. PIL or TF, and the spread of the contrast (medication) in the anterior EP space are not significantly different after 6 months of follow-up. However, the radiation exposure, complications, and skills needed to safely perform a TF-ESI are more than the PIL-ESI. We would recommend that further studies would be performed with more patients and over a longer period, to be able to elucidate the advantage of these two ESI techniques. Declarations Declaration of interest: The authors declare that they have no competing interests or personal relationships that could have influence in this paper. Funding: The authors have not received any financial support for the research, authorship, and publication of this article. Author Contribution N.K.: project administration, writing the original draft and methodology. H.M.: conceptualization, project administration, writing the original draft and performing surgical interventions. A.E. and A.K.: performing surgical interventions. R.A. and N.N.: evaluating the outcomes. M.R., K.K. and H.A.: data analyzing, writing and editing. All authors read and approved the final manuscript. Acknowledgement Authors would like to appreciate the support and constructive comments of the research development office, Imam Khomeini Hospital complex, Tehran, Iran. Data Availability The original contributions presented in the study are included in the article; further inquiries can be directed to the corresponding author. References Rosenberg, S. K., Grabinsky, A., Kooser, C. & Boswell, M. V. 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Demographic and Pre-procedure Data PIL Group (n=39) TF Group (n=40) P value Age (years) Mean ±SD 55.69 ± 14.78 55.73 ± 12.97 0.992 sex Male 12 (15.2%) 15 (19%) 0.528 Female 27 (34.2%) 25 (31.6%) Weight (kg) Mean ±SD 77.59 ± 11.88 78.98 ± 12.00 0.608 Height (cm) Mean ±SD 165.36 ± 10.57 166.65 ± 11.74 0.609 Body mass Index (kg/m2) Mean ±SD 28.50 ± 4.53 28.61 ± 4.69 0.915 Duration of Pain (month) Mean ±SD 38.89 ± 46.80 34.14 ± 42.87 0.643 Pathology Lumbosacral Radicular pain 25 (31.6%) 27 (34.2%) 0.631 ٭ Foraminal Stenosis & Degenerative Disk Disease 2 (2.5%) 0 Spinal Stenosis 5 (6.3%) 3 (3.8%) Degenerative Disk Disease 1 (1.3%) 2 (2.5%) Foraminal Stenosis 4 (5.1%) 7 (8.9%) Foraminal Stenosis & Lumbosacral Radicular pain 2 (2.5%) 1 (1.3%) MRI findings P (Protrusion) 11 (13.9%) 12 (15.2%) 0.795 B, P 13 (16.5%) 14 (17.7%) B (Bulging) 4 (5.1%) 6 (7.6%) E (Extrusion) 11 (13.9%) 8 (10.1) EMG-NCV findings Normal 5 (6.3%) 2 (2.5%) 0.841 ٭ Right L3 1 (1.3%) 1 (1.3%) Left L4 0 1 (1.3%) Left L5 2 (2.5%) 2 (2.5%) Right L5 1 (1.3%) 1 (1.3%) Bilateral L5 3 (3.8%) 7 (8.9%) Bilateral S1 4 (5.1%) 4 (5.1%) Bilateral L3-L4 2 (2.5%) 0 Right L4-L5 1 (1.3%) 3 (3.8%) Left L5-S1 3 (3.8%) 6 (7.6%) Right L5-S1 2 (2.5%) 2 (2.5%) Bilateral L5-S1 11 (13.9%) 7 (8.9%) Bilateral L3-L4-L5-S1 2 (2.5%) 1 (1.3%) Bilateral L4-L5-S1 1 (1.3%) 2 (2.5%) Right L5-Left S1 1 (1.3%) 1 (1.3%) * Fisher exact test p value Table 2 . Intensity of pain measured by NRS. Pain intensity (PI) PIL Group (n=39) ( Mean ± SD) TF Group (n=40) (Mean ± SD) P value Pre-injection at the moment 5.46 ± 1.94 5.80 ± 2.18 0.470 Pre-injection Overall PI 5.46 ± 2.08 5.73 ± 2.23 0.590 2 weeks at the moment 3.49 ± 1.80 3.95 ± 2.09 0.297 2 weeks Overall PI 3.13 ± 1.88 3.50 ± 2.19 0.422 1 month at the moment 3.62 ± 2.03 3.63 ± 1.87 0.983 1 month Overall PI 3.33 ±± 1.89 3.23 ± 1.96 0.804 2 months at the moment 3.69 ± 1.93 3.60 ± 1.94 0.833 2 months Overall PI 3.64 ± 2.03 3.50 ± 2.27 0.772 6 months at the moment 3.67 ± 2.49 3.95 ± 2.53 0.618 6 months Overall PI 3.23 ± 2.12 3.60 ± 2.50 0.484 Table 3 . Comparison of clinical effectiveness between parasagittal interlaminar and transforaminal Epidural injections Clinical Effectiveness Parameters PIL Group (n=39) Mean ±SD TF Group (n=40) Mean ±SD P value 2-week Pain relief (%) 58.97 ± 24.92 57.13 ± 25.54 0.746 6-month Pain relief (%) 49.49 ± 26.79 46.25 ± 31.61 0.625 2-week Satisfaction 7.00 ± 2.36 6.78 ± 2.46 0.680 6-month Satisfaction 5.92 ± 3.09 5.38 ± 3.74 0.480 2-week Quality of Life 47.00 ± 0.22 44.00 ± 0.21 0.533 6-month Quality of Life 44.00 ± 0.24 38.00 ± 0.20 0.265 2-week GPE 4.10 ± 0.96 4.08 ± 0.91 0.897 6-month GPE 3.59 ± 1.18 3.40 ± 1.35 0.510 Table 4 –The distribution of the levels and the sides of the epidural space where the injections were administered in the two groups . L2-L3 L3 L3-L4 L4 L4-L5 L5 L5-S1 S1 Right Left PIL Group, n=39, (%) 1 (2.6) 0 (0) 3 (7.9) 0 (0) 13 (34.2) 0 (0) 22 (52.6) 0 (0) 19 (47.4) 20 (52.6) TF Group, n=40, (%) 0 (0) 1 (2.5) 0 (0) 6 (15) 0 (0) 31 (77.5) 0 (0) 2 (5) 21 (52.5) 19 (47.5) Total, n=79, (%) 1 (1.3) 1 (1.3) 3 (3.8) 6 (7.7) 13 (16.7) 31 (39.7) 20 (25.6) 3 (3.8) 40 (50) 39 (49) Fisher exact test P value = 0.651, comparison between left and right sides Table 5- The number, and direction of vertebral levels in the epidural space that the contrast spreads after IL or TF injection Spread of contrast PIL Group (n=39) mean ±(SD) TF Group (n=40) mean ±(SD) P value Anterior epidural space 4.90±2.03 4.51±2.22 0.436 Cephalad spread 3.16 (1.636) 2.78 (1.405) 0.270 Anterior cephalad spread 2.5 (1.867) 2.43 (1.551) 0.853 Posterior cephalad spread 2.72 (1.529) 2.18 (1.299) 0.107 Caudal spread 2.70 (0.812) 2.10 (0.778) 0.001 Anterior caudal spread 2.36 (0.742) 1.85 (0.630) 0.002 Posterior caudal spread 2.67 (0.990) 1.90 (0.788) 0.001 Number of fluoroscopy shots 12.05 ± 6.66 23.25 ± 10.73 <0.001 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 03 Feb, 2026 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 28 Apr, 2025 Reviews received at journal 24 Apr, 2025 Reviewers agreed at journal 26 Mar, 2025 Reviewers agreed at journal 21 Feb, 2025 Reviews received at journal 09 Feb, 2025 Reviewers agreed at journal 09 Feb, 2025 Reviewers invited by journal 05 Feb, 2025 Editor assigned by journal 05 Feb, 2025 Editor invited by journal 02 Jan, 2025 Submission checks completed at journal 31 Dec, 2024 First submitted to journal 30 Nov, 2024 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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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-5555106","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":396177373,"identity":"d1b83fa0-98ad-41bd-bfac-b73151c1e5f0","order_by":0,"name":"Narges Khojasteh","email":"","orcid":"","institution":"Anesthesia, Critical Care, and Pain Management Research Center, Tehran University of Medical Sciences, Tehran, Iran","correspondingAuthor":false,"prefix":"","firstName":"Narges","middleName":"","lastName":"Khojasteh","suffix":""},{"id":396177374,"identity":"b2c1b41f-fd79-4ee6-9a79-ac235d7ce424","order_by":1,"name":"Hossein Majedi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxUlEQVRIiWNgGAWjYBACAzBmk5CDi7ARq8WYhyQtIGWJPUQ7zFzs8IOCD2UW6fslspM/MNTYMfBJH8CvxXJ2moHhjHMSuT0SudskGI4lM7DxJRBw2O0EA2PeNogWoAsPMLDx4NcB1JL+wfhvm0Q6j0Tu5g8M/4jSkmNgzNgmkQDUskGCsY04LQWGPeckDHvOvN0mkdiXzEOMw7YZ/Cirk2dvBzrswzc7OXkigpvNAM5MYGAgZAcYMD8gRtUoGAWjYBSMYAAAstI5hLyZJugAAAAASUVORK5CYII=","orcid":"","institution":"Pain Research Center, Neuroscience Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran","correspondingAuthor":true,"prefix":"","firstName":"Hossein","middleName":"","lastName":"Majedi","suffix":""},{"id":396177375,"identity":"934ff2a1-7ec2-4e5a-a534-a1889056b30b","order_by":2,"name":"Ali Emami Meibodi","email":"","orcid":"","institution":"Pain Research Center, Neuroscience Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"Emami","lastName":"Meibodi","suffix":""},{"id":396177376,"identity":"04a4bd64-0ba2-4249-a404-13b976d399d8","order_by":3,"name":"Alireza Khajehnasiri","email":"","orcid":"","institution":"Pain Research Center, Neuroscience Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran","correspondingAuthor":false,"prefix":"","firstName":"Alireza","middleName":"","lastName":"Khajehnasiri","suffix":""},{"id":396177377,"identity":"682f3bab-7fac-4235-ada4-b3a1d81d3331","order_by":4,"name":"Reza Atef Yekta","email":"","orcid":"","institution":"Pain Research Center, Neuroscience Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran","correspondingAuthor":false,"prefix":"","firstName":"Reza","middleName":"Atef","lastName":"Yekta","suffix":""},{"id":396177378,"identity":"04596009-75a0-49d5-b5ed-a31e3c291597","order_by":5,"name":"Nader Ali Nazemian Yazdi","email":"","orcid":"","institution":"Pain Research Center, Neuroscience Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran","correspondingAuthor":false,"prefix":"","firstName":"Nader","middleName":"Ali Nazemian","lastName":"Yazdi","suffix":""},{"id":396177379,"identity":"58f72e06-762a-4220-afc8-c319363a9d61","order_by":6,"name":"Mojgan Rahimi","email":"","orcid":"","institution":"Pain Research Center, Neuroscience Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran","correspondingAuthor":false,"prefix":"","firstName":"Mojgan","middleName":"","lastName":"Rahimi","suffix":""},{"id":396177383,"identity":"b5e03af4-51b3-4eaa-87c3-3f16a50615c3","order_by":7,"name":"Koorosh Kamali","email":"","orcid":"","institution":"Department of Public Health, School of Public Health, Zanjan University of Medical Sciences, Zanjan, Iran","correspondingAuthor":false,"prefix":"","firstName":"Koorosh","middleName":"","lastName":"Kamali","suffix":""},{"id":396177387,"identity":"1c9cf1d6-aef3-4288-8cb3-cfa48367b01c","order_by":8,"name":"Hamed Abdollahi","email":"","orcid":"","institution":"Critical Care Medicine Department of Anesthesiology, School of Medicine, Amir Alam Hospital, Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hamed","middleName":"","lastName":"Abdollahi","suffix":""}],"badges":[],"createdAt":"2024-11-30 15:23:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5555106/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5555106/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-026-36056-6","type":"published","date":"2026-02-03T15:59:47+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":72811490,"identity":"b9eb62aa-9e83-4bbc-a97f-987cc4aaf2fe","added_by":"auto","created_at":"2025-01-02 11:26:17","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":94709,"visible":true,"origin":"","legend":"\u003cp\u003eThe needle is placed in L5S1 interlaminar parasagittal epidural space. In lateral projection, the spread of contrast can be seen in anterior and posterior epidural spaces and multiple adjacent segments (rail road pattern).\u003c/p\u003e","description":"","filename":"figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5555106/v1/87a28a2c07d9b0d1e105925d.jpg"},{"id":72812890,"identity":"2116223b-fc40-47d0-8549-6d708660314e","added_by":"auto","created_at":"2025-01-02 11:42:17","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":65899,"visible":true,"origin":"","legend":"\u003cp\u003eThe needle is placed in epidural space through the left L1 transforaminal approach (A). The contrast spread in anterior, and posterior epidural spaces, and adjacent epidural segments can be seen in lateral projection (B).\u003c/p\u003e","description":"","filename":"figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5555106/v1/fd0fdb83c625e72621a73e19.jpg"},{"id":72813012,"identity":"97f89ed1-2a74-4c7f-bee0-3807a3a459b5","added_by":"auto","created_at":"2025-01-02 11:50:17","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":59526,"visible":true,"origin":"","legend":"\u003cp\u003eThe needle is placed in the left parasagittal L5S1 epidural space (A). The contrast has spread to anterior, and posterior epidural spaces, and adjacent segments (B). Cephalad and posterior spread in epidural space is more prominent.\u003c/p\u003e","description":"","filename":"figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5555106/v1/796ddab98a9c8ba1c7f1ae3c.jpg"},{"id":72811501,"identity":"7f7b2a73-e5cb-450e-9311-b36f10c9a05c","added_by":"auto","created_at":"2025-01-02 11:26:18","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":96428,"visible":true,"origin":"","legend":"\u003cp\u003eThe needle is placed in epidural space through the left S1 transforaminal approach. The contrast spread in the posterior epidural space and adjacent epidural segments can be seen in AP and lateral projections. The contrast spread in the anterior epidural space is minimal.\u003c/p\u003e","description":"","filename":"figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5555106/v1/8059b688fbab562db5e2dcb0.jpg"},{"id":102235501,"identity":"df86c2d3-eb4a-4d56-a338-4b523c59eea2","added_by":"auto","created_at":"2026-02-09 16:16:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1364791,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5555106/v1/16ff192f-b2b2-4180-8553-2af6c52dab11.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Parasagittal Versus Transforaminal Epidural Steroid Injection, a Study of Contrast Flow in the Epidural Space and Clinical Outcomes: An RCT","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLumbosacral radicular pain is a type of neuropathic pain that results from stimulation of the sensory root or dorsal root ganglion of the spinal nerve. Lumbar radicular pain is caused by the production of abnormal impulses in the dorsal root ganglion and transmission through peripheral nerve axons. Treatment of radicular symptoms varies from lifestyle changes and protective treatments to surgical interventions. Inadequate pain management is highly prevalent and is associated with significant costs and socioeconomic problems therefore attaining to effective treatments is an important goal. Some of interventional treatments for lumbosacral radicular pain include epidural steroid injection (ESI), and surgery \u003csup\u003e\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eEpidural (EP) steroids have neuroprotective properties against nerve damage and reduce nerve inflammation and edema. ESI is the most common intervention to control lumbosacral radicular pain \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. The efficacy of ESI varies from twenty to ninety-five percent depending on the injection method \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Some believe that poor treatment outcomes are due to inadequate injection techniques \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. ESI can be performed by interlaminar (IL), transforaminal (TF), and caudal approaches. Again, the IL approach can be done by parasagittal (PIL) or midline (MIL) interlaminar technique. Following intervertebral disc disease, inflammatory reactions occur in the anterior EP space as well as near nerve roots. The site of our drug effect is most likely between the nerve roots and the disc, in the anterior or anterolateral EP space. Previous studies have shown that by injecting the midline IL EP, the injected substance will be spread in the anterior EP space in only 36% of cases. As a result, physicians are increasingly using the TF method instead of the MIL technique \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. However, there is insufficient evidence to determine the best method of EP injection. In the IL method, the drug is injected primarily in the posterior EP space, while in the TF method; the medication is placed near the nerve root. None of the procedures exactly places the medication in the anterior EP space. It is assumed that the TF approach is more effective than the IL method due to better diffusion into ventral EP space; however, this assumption has not been clearly shown. Advantages of the TF approach include the use of the least amount of injectate, and that it is closer to the main site of pathology, anterolateral EP space. The TF injection is associated with more technical difficulty to approach the EP space, consequently more radiation exposure, a significant risk compared to caudal and IL approaches, which include damage to the segmental artery, dorsal root ganglion, spinal nerve, and paralysis \u003csup\u003e\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTo find a suitable alternative to the TF approach, we examined the PIL technique, in which, unlike the usual midline approach, the drug is injected in the outermost part of the interlaminar space. Few studies have compared these two techniques for contrast flow patterns to the anterior EP space, analgesia, and quality of life (QOL) improvement \u003csup\u003e\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. In this randomized clinical trial, we investigated the spread of contrast material in the anterior EP space using fluoroscopic guidance and compared the QOL improvement and analgesia between the TF and PIL approaches for ESI.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThe present study is a semi-blind randomized clinical trial and was conducted at a tertiary university hospital in Tehran, Iran. There are two experimental groups, with two parallel arms. ESI was performed whether by transforaminal (TF group) or parasagittal interlaminar approach (PIL group). The university ethics committee approved this study (ID IR.TUMS.IKHC.REC. 1397.359). Additionally, all procedures were performed following the relevant guidelines and regulations. The study was also registered in the National Clinical Trial Registration Center (IRCT20200209046437N1) on 23/04/2020. Informed consent was obtained from each participant.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSample size calculation\u003c/h2\u003e \u003cp\u003eTo calculate sample size, we administered OpenEpi software; considering type 1 error equal to 0.05 and statistical power as 0.8 to achieve a 30% difference between study groups, 40 samples in each group was sufficient. In another approach, this sample size could be efficient for non-inferiority design for α\u0026thinsp;=\u0026thinsp;0.05 and β\u0026thinsp;=\u0026thinsp;0.8 and margin for non-inferiority as 0.1 and predicted efficacy difference between groups as 20 percent by online calculator(\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www2.ccrb.cuhk.edu.hk/stat/proportion/tspp_sup.htm\u003c/span\u003e\u003cspan address=\"https://www2.ccrb.cuhk.edu.hk/stat/proportion/tspp_sup.htm\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInclusion criteria\u003c/strong\u003e \u003cp\u003ePatients aged 20 to 80 years with unilateral lumbosacral radicular pain due to disc pathologies (including disc herniation, bulging, or degeneration), spinal canal, or foraminal stenosis enrolled in this study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eExclusion criteria\u003c/strong\u003e \u003cp\u003ePatients with a history of previous vertebral surgery, ESI into the lumbar EP space in recent years, allergy to medications, simultaneously with topical steroid use, patients with diabetic nephropathy, serum creatinine level greater than 2 mg/dl, opioids abuse, pregnancy, failed back surgery syndrome, and refusal to participate were excluded from this study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eWe randomly assigned the patients to the TF or PIL groups by block randomization. For randomization, we administered block randomization with block size\u0026thinsp;=\u0026thinsp;4 for intervention groups as A and B. We selected the numbers from 1 to 6 randomly, by Microsoft Excel rand Function 22 times. Then, we wrote the related sequences from first to last, and finally, we had randomization for 88 persons. The randomization was performed by a third person and was concealed from the investigator.\u003c/p\u003e \u003cp\u003eThe vertebral level and the left or right sides were determined using clinical examination and diagnostic images. All the procedures were performed by the same pain fellowship-trained anesthesiologist with more than 20 years of experience, using the same C-arm fluoroscopy machine, and with the assistance of the same radiology technologist.\u003c/p\u003e \u003cp\u003eIn the parasagittal interlaminar (PIL) group, a 17 G Touhy needle (B Braun) was placed in the outermost affected side of PIL EP space with loss of resistance technique and under frequent Anteroposterior (AP) and Lateral C-arm fluoroscopy images (Figure-1).\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e(Figure-1)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eIn the transforaminal (TF) group, under frequent Oblique (tunnel views), AP, and Lateral fluoroscopy images, a 22 G blunt curved needle was placed in the affected foramen under the pedicle (Figure-2).\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e(Figure-2)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThen, 5 ml of iohexol 240 was slowly injected into the EP space in both groups to make sure that the needle tip is in the right place and the intravascular, subarachnoid, subdural, or intradiscal injections did not happen. Fluoroscopic images were carefully saved for later review of contrast spread in EP space. Then, we prepared 10 ml of a mixture consisting of 40 mg methylprednisolone, 4 ml normal saline, and 5 ml of 2% lidocaine \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. 10 ml was injected into the IL EP space in the PIL group. For TF group, we prepared 3 ml of a mixture consisting of 40 mg methylprednisolone (1 ml), 1.5 ml of 2% lidocaine and 0.5 ml of normal saline. \\\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eMeasurements\u003c/strong\u003e \u003cp\u003eWe recorded the total number of fluoroscopic shots in both groups. Another pain specialist investigated and recorded the diffusion of the contrast agent into the anterior and posterior EP space as well as its diffusion into adjacent EP segments (Figure-3).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e\u0026lsquo;Anterior\u0026rsquo; spread was defined if the contrast reached the posterior longitudinal ligament or touched the posterior wall of the vertebral body at the level of needle placement (Figure-4).\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e(Figure-3)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e(Figure-4)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThe physician performing the procedures was different from the physicians evaluating the outcomes, and the evaluating physicians were unaware of the groups to which the patients were belonging. A blind observer recorded the pain intensity and quality of life (QOL) at 2 weeks, 1, 2, and 6 months after injection.\u003c/p\u003e \u003cp\u003eWe evaluated and recorded the pain intensity with an 11-point Numeric Rating Scale (NRS). We asked for overall pain intensity in the preceding week before and at the moment of the patient's visit to the pain clinic \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWe investigated the QOL according to the Modified Oswestry Low Back Pain Questionnaire (MOLBPQ). This questionnaire has been locally validated and confirmed for the local population of this study \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. It is a widely used tool for evaluating the impact of low back pain on an individual's ability to perform daily activities. The questionnaire consists of 10 items that assess the degree of interference caused by low back pain in various aspects of life, including personal care, lifting, walking, sitting, standing, sleeping, sex life, social life, and traveling. Each item is scored on a scale from 0 to 5, with higher scores indicating greater disability. The scores for each item are then summed to yield a total score, which ranges from 0 to 50.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSatisfaction with treatment\u003c/strong\u003e \u003cp\u003eA zero to 10 numerical scale was used to measure the satisfaction of treatment in patients. The number 10 indicates the highest level of satisfaction and the number zero means dissatisfaction with treatment. This scale relies on patient self-report to measure treatment satisfaction by asking the patient to choose a number between zero and 10.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eImpact of Overall Perception (GPE)\u003c/strong\u003e \u003cp\u003eThe Perceived Global Impact Scale (GPE) is a method commonly used in both research and practice to measure patients' assessment of their condition. One of the basic assumptions of GPE is that it measures the global assessment of change in the patient's main complaint. Global Impact Perception Scale (GPE) as described by Costa et al. An example of a prescription is to measure the global perception of change in patients with low back pain. GPE was assessed with a 7-point Likert scale. Very dissatisfied (score 1), dissatisfied (score 2), somewhat dissatisfied (score 3), undecided (score 4), somewhat satisfied (score 5), satisfied (score 6), and very satisfied (score 7).\u003c/p\u003e \u003c/p\u003e \u003cp\u003eOther studied variables included contrast diffusion, sex, age, pain relief, weight, height, BMI, duration of pain, pathology, MRI findings about the discopathy, EMG/NCV findings, ESI-TF, and ESI-PIL technique \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStatistical Analysis\u003c/strong\u003e \u003cp\u003eThe information was coded from the questionnaires and entered into SPSS.23 software (IBM Corp., Armonk, NY, USA). Intention to treat (ITT) approach was administered for analysis the data in this trial. Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD was used to report for quantitative variables. Number and percent was used for qualitative variables. A significance level of less than 0.05 was considered. Quantitative data were analyzed for normal distribution by Shapiro Wilk test and all had normal distribution so independent samples t test was used to compare these data between two study groups. Chi square and Fisher exact tests were used to compare categorical data between groups.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003end 40 patients were enrolled in PIL and TF groups respectively. The demographic and pre-procedure data have been shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. There was no significant difference between the two groups in the studied demographic parameters and in the pre-procedure data. Consequently, the two groups were comparable in baseline characters (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Table-1\u003c/p\u003e\n\u003cp\u003eBased on the results of the independent T-test, there was no statistically significant difference in the mean pain intensity between the two treatment groups before, during, and, after six months period of the treatment (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eTable-2\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe mean pain relief (in percentage), satisfaction, and quality of life of patients during six months period after the treatment had no statistically significant difference between the two study groups (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\n \u003cp\u003eTable-3\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003eTable-4\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e shows that the PIL group had a higher percentage of injections on the right side and in the L5-S1 level (52.62%). The TF group had a higher percentage of injections on the left side and in the L5 level (77.5%). The P value of 0.651 indicates that there is no significant difference in the distribution of the sides between the two groups.\u003c/p\u003e\n\u003cp\u003eDiffusion of the contrast in the anterior EP space in all cases extended to more than two vertebral levels (Table\u0026nbsp;5). The comparison of contrast diffusion into the anterior EP space between the two groups showed no statistically significant difference (P\u0026thinsp;=\u0026thinsp;0.436). The mean number of fluoroscopic shots taken in the PIL and TF groups was significantly different and less in the PIL group. However, the caudal distribution of the contrast is more in the PIL group than in the TF group (Table\u0026nbsp;5). No complications happened in this study.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study showed that the results of ESI between the two groups of study were not significantly different. This lack of difference was assessed for contrast diffusion into the anterior EP space, pain relief, and patient satisfaction at different time intervals, up to six months. However, the amount of radiation exposure in the TF group was significantly more than in the PIL group.\u003c/p\u003e \u003cp\u003eOur results are consistent with other studies that have compared the effectiveness of PIL and TF ESI in relieving radicular low back pain. A systematic review and meta-analysis of studies comparing PIL and TF approaches of lumbar epidural steroid injection found that PIL showed benefits in terms of lower mean fluoroscopy time, less radiation exposure, zero adverse events in all the included studies, no cases of intravascular spread compared with the TF approach, and a higher anterior epidural spread of PIL compared with TF. Although both techniques showed statistically and clinically significant pain relief, the PIL technique had a slightly better control of pain and functionality improvement \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAfter 6 months of follow-up, the pain intensity of the patients significantly decreased in both treatment groups. This finding is consistent with the results of Beyaz (2017) study. He compared the effect of two approaches of steroid injection in the lumbar region with a 12-month follow-up period in patients with chronic low back pain. He showed that the mean pain intensity significantly decreased in both groups and most patients (85.1%) felt satisfied \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAnother study showed that no statistically significant difference was observed between the two groups of IL or TF ESI in terms of pain relief. Finally, the study showed that both approaches to ESI significantly relieved pain in patients \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Therefore, the results of our study are consistent with the above research.\u003c/p\u003e \u003cp\u003eIn this study, the mean satisfaction of patients with treatment six months after the start of treatment was significantly higher compared to before treatment \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Although, in the study, no side effects were observed following ESI in either group; the documentation of scientific texts indicates that more complications occur in the TF compared to IL ESI \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn the present study, diffusion in the anterior EP space in all cases extended to more than two levels, and the two groups of PIL and TF did not differ in terms of diffusion into the anterior EP space (p\u0026thinsp;=\u0026thinsp;0.138).\u003c/p\u003e \u003cp\u003eLutz and Wisneski evaluated 50 patients with lumbar radiculopathy following intervertebral disc herniation who responded well to TF ESI and showed that more contrast diffusion into the anterior EP space resulted in good clinical outcomes \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Thomas et al. Also showed that the IL approach was preferable by comparing ESI with both TF and IL approaches \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Given that drug delivery to the anterior EP space was described by the PIL approach; In 2008, Kenneth et al. described and compared the PIL method with the TF approach under fluoroscopic guidance, which showed that diffusion into the anterior EP space was statistically better than the TF method. The authors showed that this method was not only technically very effective but also required less time to perform than the TF method under fluoroscopic guidance, which resulted in less radiation exposure for the patient and the interventionist. The results of the mentioned studies are consistent with our findings.\u003c/p\u003e \u003cp\u003eThe results of this study suggest that the PIL approach has a more extensive caudal spread of the contrast compared to the TF approach. This difference in contrast distribution may have implications for the effectiveness of the two techniques in providing pain relief and improving patient outcomes. In a study comparing the effectiveness of PIL and TF ESI in relieving radicular low back pain, it was found that the PIL approach showed an 89\u0026ndash;100% ventral spread of contrast dye, compared to just a 31.7% of the conventional IL approach \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Another study comparing the effectiveness of caudal epidural steroid injections and TF epidural steroid injections found that patients who underwent TF ESI had significantly better outcomes at six months \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. However, Kolsi et al., By comparing these two injection approaches, could not find an advantage between the two \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. An important advantage of this study is that it has a long-term follow-up of 6 months; and in addition to the evaluation of the spread of contrast to the anterior EP space, it evaluated and compared pain intensity, quality of life, patient satisfaction, and Pain relief in two groups.\u003c/p\u003e \u003cp\u003eConsequently, the main advantage of PIL-ESI would be significantly less radiation exposure to the patient and interventionist. The procedure is less time-consuming; it needs less training and expertise to safely perform it. The complications attributed to PIL-ESI are much less than the TF-ESI method. The advantage that can be given to the TF-ESI is that if the pressure or inflammation near the nerve root is limited to certain foramen(s), then the drug can be administered in very close proximity to the lesion. If the number of the affected roots is very limited, then the TF-ESI will need less medication and therefore, fewer possible side effects of the injectate.\u003c/p\u003e \u003cp\u003eLimitations of our study:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe recommended corticosteroid for injection into the epidural space is non-particulate steroids, such as dexamethasone, due to their lower risk of thromboembolic complications.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e\"Total number of fluoroscopic shots\" is not a legitimate measure of radiation exposure. Dose should be calculated in a radiation exposure unit (e.g., mREM, Gy, Sv) and/or reported fluoroscopy time.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAnother limitation of our study is the absence of a measure for systemic steroid suppression, such as cortisol levels or other assessments of hypothalamic-pituitary-adrenal (HPA) axis function.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eThe complete absence of collimation also has significant implications for the radiation dose. Best practice is to collimate the beam where possible, both to improve image quality and to minimize dose to patient and operator.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe clinical outcomes of the two ESI techniques, i.e. PIL or TF, and the spread of the contrast (medication) in the anterior EP space are not significantly different after 6 months of follow-up. However, the radiation exposure, complications, and skills needed to safely perform a TF-ESI are more than the PIL-ESI.\u003c/p\u003e \u003cp\u003eWe would recommend that further studies would be performed with more patients and over a longer period, to be able to elucidate the advantage of these two ESI techniques.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eDeclaration of interest:\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests or personal relationships that could have influence in this paper.\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThe authors have not received any financial support for the research, authorship, and publication of this article.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eN.K.: project administration, writing the original draft and methodology. H.M.: conceptualization, project administration, writing the original draft and performing surgical interventions. A.E. and A.K.: performing surgical interventions. R.A. and N.N.: evaluating the outcomes. M.R., K.K. and H.A.: data analyzing, writing and editing. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eAuthors would like to appreciate the support and constructive comments of the research development office, Imam Khomeini Hospital complex, Tehran, Iran.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe original contributions presented in the study are included in the article; further inquiries can be directed to the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRosenberg, S. K., Grabinsky, A., Kooser, C. \u0026amp; Boswell, M. V. 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Efficacy of nerve root versus interspinous injections of glucocorticoids in the treatment of disk-related sciatica. A pilot, prospective, randomized, double-blind study. \u003cem\u003eJoint Bone Spine\u003c/em\u003e. \u003cb\u003e67\u003c/b\u003e, 113\u0026ndash;118 (2000).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e. Demographic and Pre-procedure Data\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePIL Group (n=39)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTF Group (n=40)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\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 valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eMean\u003cspan dir=\"RTL\"\u003e\u0026plusmn;SD\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e55.69\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e14.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e55.73\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e12.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.992\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003esex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e12 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e15 (19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.528\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e27 (34.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e25 (31.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eWeight (kg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eMean\u003cspan dir=\"RTL\"\u003e\u0026plusmn;SD\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e77.59\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e11.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e78.98\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e12.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.608\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eHeight (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eMean\u003cspan dir=\"RTL\"\u003e\u0026plusmn;SD\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e165.36\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e10.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e166.65\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e11.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.609\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eBody mass Index (kg/m2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eMean\u003cspan dir=\"RTL\"\u003e\u0026plusmn;SD\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e28.50\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e4.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e28.61\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e4.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.915\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eDuration of Pain (month)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eMean\u003cspan dir=\"RTL\"\u003e\u0026plusmn;SD\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e38.89\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e46.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e34.14\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e42.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.643\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003ePathology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eLumbosacral Radicular pain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e25 (31.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e27 (34.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"6\" valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.631\u003cspan dir=\"RTL\"\u003e٭\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eForaminal Stenosis \u0026amp; Degenerative Disk Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e2 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eSpinal Stenosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e5 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e3 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eDegenerative Disk Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e2 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eForaminal Stenosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e4 (5.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e7 (8.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eForaminal Stenosis \u0026amp; Lumbosacral Radicular pain\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e2 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eMRI findings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eP (Protrusion)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e11 (13.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e12 (15.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.795\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eB, P\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e13 (16.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e14 (17.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eB (Bulging)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e4 (5.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e6 (7.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eE (Extrusion)\u003c/p\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e11 (13.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e8 (10.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"15\" valign=\"top\" style=\"width: 23px;\"\u003e\n \u003cp\u003eEMG-NCV findings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e5 (6.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e2 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"15\" valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.841\u003cspan dir=\"RTL\"\u003e٭\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eRight L3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eLeft L4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eLeft L5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e2 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e2 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eRight L5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eBilateral L5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e3 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e7 (8.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eBilateral S1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e4 (5.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e4 (5.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eBilateral L3-L4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e2 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eRight L4-L5\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e3 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eLeft L5-S1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e3 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e6 (7.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eRight L5-S1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e2 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e2 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eBilateral L5-S1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e11 (13.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e7 (8.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eBilateral L3-L4-L5-S1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e2 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eBilateral L4-L5-S1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e2 (2.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003eRight L5-Left S1\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e1 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e1 (1.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e* Fisher exact test p value\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003cstrong\u003e. Intensity of pain measured by NRS.\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePain intensity (PI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePIL Group (n=39)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(\u003c/strong\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003eSD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTF Group (n=40)\u0026nbsp;(Mean\u003c/strong\u003e\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003eSD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\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 valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003ePre-injection\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eat the moment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e5.46\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e1.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e5.80\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e2.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.470\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003ePre-injection\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eOverall PI\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e5.46\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e2.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e5.73\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e2.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.590\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e2 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eat the moment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e3.49\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e1.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e3.95\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e2.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.297\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e2 weeks\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eOverall PI\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e3.13\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e1.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e3.50\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e2.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.422\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e1 month\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eat the moment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e3.62\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e2.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e3.63\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e1.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.983\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e1 month\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eOverall PI\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e3.33\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u0026plusmn;\u003c/span\u003e1.89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e3.23\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e1.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.804\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e2 months\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eat the moment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e3.69\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e1.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e3.60\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e1.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.833\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e2 months\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eOverall PI\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e3.64\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e2.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e3.50\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e2.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.772\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e6 months\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eat the moment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e3.67\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e2.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e3.95\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e2.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.618\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e6 months \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003eOverall PI\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e3.23\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e2.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e3.60\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e2.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.484\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e3\u003c/strong\u003e\u003cstrong\u003e. Comparison of clinical effectiveness between parasagittal interlaminar and transforaminal Epidural injections\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eClinical Effectiveness Parameters\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePIL Group (n=39)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTF Group (n=40)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\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: 44px;\"\u003e\n \u003cp\u003e2-week Pain relief (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e58.97\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e24.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e57.13\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e25.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.746\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e6-month Pain relief (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e49.49\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e26.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e46.25\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e31.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.625\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e2-week Satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e7.00\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e2.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e6.78\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e2.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.680\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e6-month Satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e5.92\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e3.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e5.38\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e3.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.480\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e2-week Quality of Life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e47.00\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e44.00\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.533\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e6-month Quality of Life\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e44.00\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e38.00\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.265\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e2-week GPE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e4.10\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e4.08\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.897\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 44px;\"\u003e\n \u003cp\u003e6-month GPE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e3.59\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e1.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e3.40\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e1.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.510\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4 \u0026ndash;The distribution of the levels and the sides of the epidural space where the injections were administered in the two groups\u003c/strong\u003e.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eL2-L3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eL3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eL3-L4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eL4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eL4-L5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eL5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eL5-S1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003ePIL Group, n=39, (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e1 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e3 (7.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e13 (34.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e22 (52.6) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0 (0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e19 (47.4)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e20 (52.6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003eTF Group, n=40, (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0 (0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e1 (2.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e6 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e0 (0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e31 (77.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e0 (0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e2 (5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e21 (52.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e19 (47.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 58px;\"\u003e\n \u003cp\u003eTotal, n=79, (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e1 (1.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e3 (3.8)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e6 (7.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e13 (16.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e31 (39.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e20 (25.6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e3 (3.8)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e40 (50)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003e39 (49) \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFisher exact test P value = 0.651, comparison between left and right sides\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5- The number, and direction of vertebral levels in the epidural space that the contrast spreads after IL or TF injection\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpread of contrast\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePIL Group (n=39)\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;mean \u0026plusmn;(SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTF Group (n=40)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003emean \u0026plusmn;(SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eAnterior epidural space\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e4.90\u0026plusmn;2.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e4.51\u0026plusmn;2.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e0.436\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eCephalad spread\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e3.16 (1.636)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e2.78 (1.405)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.270\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eAnterior cephalad spread\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e2.5 (1.867)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e2.43 (1.551)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.853\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003ePosterior cephalad spread\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e2.72 (1.529)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e2.18 (1.299)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.107\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eCaudal spread\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e2.70 (0.812)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e2.10 (0.778)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eAnterior caudal spread\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e2.36 (0.742)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e1.85 (0.630)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.002\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003ePosterior caudal spread\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e2.67 (0.990)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21px;\"\u003e\n \u003cp\u003e1.90 (0.788) \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.001\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 42px;\"\u003e\n \u003cp\u003eNumber of fluoroscopy shots\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e12.05\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e6.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 21px;\"\u003e\n \u003cp\u003e23.25\u003cspan dir=\"RTL\"\u003e\u0026plusmn;\u003c/span\u003e10.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Lumbosacral radicular pain, Parasagittal interlaminar epidural steroid injection, Transforaminal epidural steroid injection, Anterior epidural space, Neuropathic pain","lastPublishedDoi":"10.21203/rs.3.rs-5555106/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5555106/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eEpidural steroid injections are frequently used to treat lumbosacral radicular pain, but the solute spread in the epidural space needs further investigation. This double-blind, randomized study assessed clinical outcomes and contrast spread patterns between the parasagittal interlaminar and transforaminal approaches in 79 adults with low back pain due to herniated or degenerated discs. Participants were randomly assigned to one of two groups: Transforaminal or Parasagittal Interlaminar. All procedures were performed under C-armed fluoroscopic guidance. Contrast spread was evaluated by a separate pain specialist, and clinical outcomes such as analgesia, patient satisfaction, and quality of life were measured at two weeks and one, three, and six months post-treatment. Results showed no statistically significant differences between the two groups in the mean pain intensity at the moment and six months after treatment (p\u0026thinsp;=\u0026thinsp;0.618, p\u0026thinsp;=\u0026thinsp;0.484). Comparison of contrast diffusion to the anterior epidural space between the two groups showed no statistically significant differences (P\u0026thinsp;=\u0026thinsp;0.436). Clinical outcomes were similar between the two groups, but radiation exposure was significantly higher in the transforaminal group. Both approaches had the same rate of contrast flow to the anterior epidural space. However, the parasagittal interlaminar approach resulted in less radiation exposure for patients.\u003c/p\u003e","manuscriptTitle":"Parasagittal Versus Transforaminal Epidural Steroid Injection, a Study of Contrast Flow in the Epidural Space and Clinical Outcomes: An RCT","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-02 11:26:13","doi":"10.21203/rs.3.rs-5555106/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-28T08:34:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-25T01:34:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"319815867712479469682740082340989826882","date":"2025-03-26T13:32:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"178679218913452392840325899210170474566","date":"2025-02-22T04:56:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-09T14:33:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"81445100782130516768234430894208672519","date":"2025-02-09T13:01:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-02-05T21:47:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-02-05T21:35:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-01-02T13:25:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-12-31T11:51:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-11-30T15:13:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a2cec40e-6512-46ad-bdad-df30bf13d6b5","owner":[],"postedDate":"January 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":42208373,"name":"Health sciences/Signs and symptoms/Pain"},{"id":42208374,"name":"Health sciences/Signs and symptoms/Pain/Chronic pain"},{"id":42208375,"name":"Health sciences/Neurology/Neurological disorders/Neuropathic pain"}],"tags":[],"updatedAt":"2026-02-09T16:14:45+00:00","versionOfRecord":{"articleIdentity":"rs-5555106","link":"https://doi.org/10.1038/s41598-026-36056-6","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2026-02-03 15:59:47","publishedOnDateReadable":"February 3rd, 2026"},"versionCreatedAt":"2025-01-02 11:26:13","video":"","vorDoi":"10.1038/s41598-026-36056-6","vorDoiUrl":"https://doi.org/10.1038/s41598-026-36056-6","workflowStages":[]},"version":"v1","identity":"rs-5555106","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5555106","identity":"rs-5555106","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}