The Effect of Gray Ramus Communicans Nerve Block on Radicular Pain in Patients With Lumbosacral Radicular Pain Who Underwent Transforaminal Epidural Block
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Abstract
Lumbosacral radicular pain (LRP) is usually caused by herniation of intervertebral discs and is characterized by pain arising in the back and radiating to the lower extremities. The current study evaluated the efficacy of gray ramus communicans nerve block (GRCNB) in decreasing LRP in patients with intervertebral disc herniation who underwent transforaminal epidural block. Thirty patients with magnetic resonance imaging indicating a disc herniation on the L4-L5 level participated in this study. All patients were randomly divided into two groups: one whose members underwent GRCNB (n=15) after transforaminal epidural block, and a second group (n=15) whose members underwent only transforaminal epidural block on L4-L5 on the affected side. Follow-up after the procedure ran for a period ranging from 6 to 10 months (mean=8.2±2.1 months) for radicular pain score and the need for analgesics. The mean age of the patients was 54.8±18.4 years (range: 30-65 years). LRP duration in all patients before the procedure was 6-24 months (mean: 12±10.9 months), and there was no significant difference between the two groups. A greater reduction in the numerical rating scale (NRS) one week, 1, and 6 months after the procedure was observed in the group with GRCNB compared to the other group. The reduction in need for analgesics one week, 1, and 6 months after the procedure was statistically significant in the group with GRCNB compared to the group without GRCNB. No major complications were observed in any of the patients in either group. GRCNB is effective in reducing radicular pain and the need for analgesics in patients with lumbosacral radicular pain.
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2. Weinstein JN, Lurie JD, Tosteson TD, Tosteson AN, Blood EA, Abdu WA, et al. Surgical versus nonoperative treatment for lumbar disc herniation: four-year results for the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976) 2008;33:2789-800.
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8. Gracely RH, Lynch SA, Bennett GJ. Painful neuropathy: altered central processing maintained dynamically by peripheral input. Pain 1992;51:175-94.
9. Mizuno S, Takebayashi T, Kirita T, Tanimoto K, Tohse N, Yamashita T. The effects of the sympathetic nerves on lumbar radicular pain: a behavioural and immunohistochemical study. J Bone Joint Surg Br 2007;89:1666-72.
10. Xu Y, Mauer KM, Singh A. Pain Management in Neurosurgery: Back and Lower Extremity Pain, Trigeminal Neuralgia. Anesthesiol Clin 2021;39:179-94.
11. Schousboe JT. Vertebral Fracture Identification as Part of a Comprehensive Risk Assessment in Patients with Osteoporosis. Curr Osteoporos Rep 2018;16:573-83.
12. Das G, Dey S, Sharma RS, Sharma K, Dutta D, Roy C. Rami Communicans Block Prior to Transforaminal Endoscopic Discectomy relieves Procedure Pain Significantly and adds Safety: A Case–control Study. J Recent Adv Pain 2017;3:90-5.
13. El-Badawy MA, El Mikkawy DM. Sympathetic Dysfunction in Patients with Chronic Low Back Pain and Failed Back Surgery Syndrome. Clin J Pain 2016;32:226-31.
14. Rigaud J, Riant T, Labat JJ, Guerineau M, Robert R. Is section of the sympathetic rami communicantes by laparoscopy in patients with refractory low back pain efficient? Eur Spine J 2013;22:775-81.
15. Oo WM, Hunter DJ. Nerve Growth Factor (NGF) Inhibitors and Related Agents for Chronic Musculoskeletal Pain: A Comprehensive Review. BioDrugs 2021;35:611-41.
16. Touj S, Houle S, Ramla D, Jeffrey-Gauthier R, Hotta H, Bronchti G, et al. Sympathetic regulation and anterior cingulate cortex volume are altered in a rat model of chronic back pain. Neuroscience 2017;352:9-18.
17. Roh SW, Kim DH, Cardoso AC, Fessler RG. Endoscopic foraminotomy using MED system in cadaveric specimens. Spine (Phila Pa 1976) 2000;25:260-4.
18. Jang JS, Kwon HK, Lee JJ, Hwang SM, Lim SY. Rami Communicans Nerve Block for the Treatment of Symptomatic Schmorl's Nodes -A Case Report. Korean J Pain 2010;23:262-5.
19. Benditz A, Sprenger S, Rauch L, Weber M, Grifka J, Straub RH. Increased pain and sensory hyperinnervation of the ligamentum flavum in patients with lumbar spinal stenosis. J Orthop Res 2019;37:737-43.
20. Shayota B, Wong TL, Fru D, David G, Iwanaga J, Loukas M, et al. A comprehensive review of the sinuvertebral nerve with clinical applications. Anat Cell Biol 2019;52(2):128-33.
21. Gore S, Yeung A. The "inside out" transforaminal technique to treat lumbar spinal pain in an awake and aware patient under local anesthesia: results and a review of the literature. Int J Spine Surg 2014;8:28.
22. Yeung AT, Yeung CA. Minimally invasive techniques for the management of lumbar disc herniation. Orthop Clin North Am 2007;38:363-72.
23. Kojima Y, Maeda T, Arai R, Shichikawa K. Nerve supply to the posterior longitudinal ligament and the intervertebral disc of the rat vertebral column as studied by acetylcholinesterase histochemistry. I. Distribution in the lumbar region. J Anat 1990;169:237-46.
24. Zheng Z, Ma R, Zhang R, Liu Z, Liu Z, Chen J, et al. Anatomical study and clinical significance of rami communicantes of the lumbar spine. Reg Anesth Pain Med 2022;47:253-8.
25. Wang WH, Zhang L, Dong GX, Zhao J, Li X. Targeting Gray Rami Communicantes in Selective Chemical Lumbar Sympathectomy. J Vis Exp 2019;143.
26. Takebayashi T, Cavanaugh JM, Kallakuri S, Chen C, Yamashita T. Sympathetic afferent units from lumbar intervertebral discs. J Bone Joint Surg Br 2006;88:554-7.
27. Nakamura SI, Takahashi K, Takahashi Y, Yamagata M, Moriya H. The afferent pathways of discogenic low-back pain. Evaluation of L2 spinal nerve infiltration. J Bone Joint Surg Br 1996;78:606-12.
28. Huygen F, Liem L, Cusack W, Kramer J. Stimulation of the L2-L3 Dorsal Root Ganglia Induces Effective Pain Relief in the Low Back. Pain Pract 2018;18:205-13.
29. Bossut DF, Shea VK, Perl ER. Sympathectomy induces adrenergic excitability of cutaneous C-fiber nociceptors. J Neurophysiol 1996;75:514-7.
30. Davis KD, Treede RD, Raja SN, Meyer RA, Campbell JN. Topical application of clonidine relieves hyperalgesia in patients with sympathetically maintained pain. Pain 1991;47:309-17.
31. Iwase T, Takebayashi T, Tanimoto K, Terashima Y, Miyakawa T, Kobayashi T, et al. Sympathectomy attenuates excitability of dorsal root ganglion neurons and pain behaviour in a lumbar radiculopathy model. Bone Joint Res 2012;1:198-204.
32. Kanaan T, Abusaleh R, Abuasbeh J, Al Jammal M, Al-Haded S, Al-Rafaiah S, et al. The Efficacy of Therapeutic Selective Nerve Block in Treating Lumbar Radiculopathy and Avoiding Surgery. J Pain Res 2020;13:2971-8.
33. De M, Mohan VK, Bhoi D, Talawar P, Kumar A, Garg B, et al. Transforaminal Epidural Injection of Local Anesthetic and Dorsal Root Ganglion Pulsed Radiofrequency Treatment in Lumbar Radicular Pain: A Randomized, Triple-Blind, Active-Control Trial. Pain Pract 2020;20:154-67.
34. Gerdesmeyer L, Noe C, Prehn-Kristensen A, Harrasser N, Muderis MA, Weuster M, Klueter T. Long-term Efficacy of Percutaneous Epidural Neurolysis of Adhesions in Chronic Lumbar Radicular Pain: 10 Year Follow-up of a Randomized Controlled Trial. Pain Physician 2021;24:359-67.
2. Weinstein JN, Lurie JD, Tosteson TD, Tosteson AN, Blood EA, Abdu WA, et al. Surgical versus nonoperative treatment for lumbar disc herniation: four-year results for the Spine Patient Outcomes Research Trial (SPORT). Spine (Phila Pa 1976) 2008;33:2789-800.
3. Peul WC, van Houwelingen HC, van den Hout WB, Brand R, Eekhof JA, Tans JT, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 2007;356:2245-56.
4. Oliveira CB, Maher CG, Ferreira ML, Hancock MJ, Oliveira VC, McLachlan AJ, et al. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database Syst Rev 2020;4:CD013577.
5. Khorami AK, Oliveira CB, Maher CG, Bindels PJE, Machado GC, Pinto RZ, et al. Recommendations for Diagnosis and Treatment of Lumbosacral Radicular Pain: A Systematic Review of Clinical Practice Guidelines. J Clin Med 2021;10:2482.
6. Urits I, Burshtein A, Sharma M, Testa L, Gold PA, Orhurhu V, Viswanath O, et al. Low Back Pain, a Comprehensive Review: Pathophysiology, Diagnosis, and Treatment. Curr Pain Headache Rep 2019;23:23.
7. Bogduk N. On the definitions and physiology of back pain, referred pain, and radicular pain. Pain 2009;147:17-9.
8. Gracely RH, Lynch SA, Bennett GJ. Painful neuropathy: altered central processing maintained dynamically by peripheral input. Pain 1992;51:175-94.
9. Mizuno S, Takebayashi T, Kirita T, Tanimoto K, Tohse N, Yamashita T. The effects of the sympathetic nerves on lumbar radicular pain: a behavioural and immunohistochemical study. J Bone Joint Surg Br 2007;89:1666-72.
10. Xu Y, Mauer KM, Singh A. Pain Management in Neurosurgery: Back and Lower Extremity Pain, Trigeminal Neuralgia. Anesthesiol Clin 2021;39:179-94.
11. Schousboe JT. Vertebral Fracture Identification as Part of a Comprehensive Risk Assessment in Patients with Osteoporosis. Curr Osteoporos Rep 2018;16:573-83.
12. Das G, Dey S, Sharma RS, Sharma K, Dutta D, Roy C. Rami Communicans Block Prior to Transforaminal Endoscopic Discectomy relieves Procedure Pain Significantly and adds Safety: A Case–control Study. J Recent Adv Pain 2017;3:90-5.
13. El-Badawy MA, El Mikkawy DM. Sympathetic Dysfunction in Patients with Chronic Low Back Pain and Failed Back Surgery Syndrome. Clin J Pain 2016;32:226-31.
14. Rigaud J, Riant T, Labat JJ, Guerineau M, Robert R. Is section of the sympathetic rami communicantes by laparoscopy in patients with refractory low back pain efficient? Eur Spine J 2013;22:775-81.
15. Oo WM, Hunter DJ. Nerve Growth Factor (NGF) Inhibitors and Related Agents for Chronic Musculoskeletal Pain: A Comprehensive Review. BioDrugs 2021;35:611-41.
16. Touj S, Houle S, Ramla D, Jeffrey-Gauthier R, Hotta H, Bronchti G, et al. Sympathetic regulation and anterior cingulate cortex volume are altered in a rat model of chronic back pain. Neuroscience 2017;352:9-18.
17. Roh SW, Kim DH, Cardoso AC, Fessler RG. Endoscopic foraminotomy using MED system in cadaveric specimens. Spine (Phila Pa 1976) 2000;25:260-4.
18. Jang JS, Kwon HK, Lee JJ, Hwang SM, Lim SY. Rami Communicans Nerve Block for the Treatment of Symptomatic Schmorl's Nodes -A Case Report. Korean J Pain 2010;23:262-5.
19. Benditz A, Sprenger S, Rauch L, Weber M, Grifka J, Straub RH. Increased pain and sensory hyperinnervation of the ligamentum flavum in patients with lumbar spinal stenosis. J Orthop Res 2019;37:737-43.
20. Shayota B, Wong TL, Fru D, David G, Iwanaga J, Loukas M, et al. A comprehensive review of the sinuvertebral nerve with clinical applications. Anat Cell Biol 2019;52(2):128-33.
21. Gore S, Yeung A. The "inside out" transforaminal technique to treat lumbar spinal pain in an awake and aware patient under local anesthesia: results and a review of the literature. Int J Spine Surg 2014;8:28.
22. Yeung AT, Yeung CA. Minimally invasive techniques for the management of lumbar disc herniation. Orthop Clin North Am 2007;38:363-72.
23. Kojima Y, Maeda T, Arai R, Shichikawa K. Nerve supply to the posterior longitudinal ligament and the intervertebral disc of the rat vertebral column as studied by acetylcholinesterase histochemistry. I. Distribution in the lumbar region. J Anat 1990;169:237-46.
24. Zheng Z, Ma R, Zhang R, Liu Z, Liu Z, Chen J, et al. Anatomical study and clinical significance of rami communicantes of the lumbar spine. Reg Anesth Pain Med 2022;47:253-8.
25. Wang WH, Zhang L, Dong GX, Zhao J, Li X. Targeting Gray Rami Communicantes in Selective Chemical Lumbar Sympathectomy. J Vis Exp 2019;143.
26. Takebayashi T, Cavanaugh JM, Kallakuri S, Chen C, Yamashita T. Sympathetic afferent units from lumbar intervertebral discs. J Bone Joint Surg Br 2006;88:554-7.
27. Nakamura SI, Takahashi K, Takahashi Y, Yamagata M, Moriya H. The afferent pathways of discogenic low-back pain. Evaluation of L2 spinal nerve infiltration. J Bone Joint Surg Br 1996;78:606-12.
28. Huygen F, Liem L, Cusack W, Kramer J. Stimulation of the L2-L3 Dorsal Root Ganglia Induces Effective Pain Relief in the Low Back. Pain Pract 2018;18:205-13.
29. Bossut DF, Shea VK, Perl ER. Sympathectomy induces adrenergic excitability of cutaneous C-fiber nociceptors. J Neurophysiol 1996;75:514-7.
30. Davis KD, Treede RD, Raja SN, Meyer RA, Campbell JN. Topical application of clonidine relieves hyperalgesia in patients with sympathetically maintained pain. Pain 1991;47:309-17.
31. Iwase T, Takebayashi T, Tanimoto K, Terashima Y, Miyakawa T, Kobayashi T, et al. Sympathectomy attenuates excitability of dorsal root ganglion neurons and pain behaviour in a lumbar radiculopathy model. Bone Joint Res 2012;1:198-204.
32. Kanaan T, Abusaleh R, Abuasbeh J, Al Jammal M, Al-Haded S, Al-Rafaiah S, et al. The Efficacy of Therapeutic Selective Nerve Block in Treating Lumbar Radiculopathy and Avoiding Surgery. J Pain Res 2020;13:2971-8.
33. De M, Mohan VK, Bhoi D, Talawar P, Kumar A, Garg B, et al. Transforaminal Epidural Injection of Local Anesthetic and Dorsal Root Ganglion Pulsed Radiofrequency Treatment in Lumbar Radicular Pain: A Randomized, Triple-Blind, Active-Control Trial. Pain Pract 2020;20:154-67.
34. Gerdesmeyer L, Noe C, Prehn-Kristensen A, Harrasser N, Muderis MA, Weuster M, Klueter T. Long-term Efficacy of Percutaneous Epidural Neurolysis of Adhesions in Chronic Lumbar Radicular Pain: 10 Year Follow-up of a Randomized Controlled Trial. Pain Physician 2021;24:359-67.
| Files | ||
| Issue | Vol 61 No 10 (2023) | |
| Section | Original Article(s) | |
| DOI | https://doi.org/10.18502/acta.v61i10.15663 | |
| Keywords | ||
| Lumbosacral radicular pain Transforaminal epidural block Gray ramus communicans nerve block | ||
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This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Sanatkar M, Espahbodi E, Sanatkar M. The Effect of Gray Ramus Communicans Nerve Block on Radicular Pain in Patients With Lumbosacral Radicular Pain Who Underwent Transforaminal Epidural Block. Acta Med Iran. 2024;61(10):626-631.
