Periradicular Therapy - Medical Experts

The indication – that is, the medical reason for the treatment – is primarily radiating nerve pain that can be traced to a nerve root. Back pain without any evidence of nerve irritation, on the other hand, does not justify PRT.

In the case of sciatica, a herniated disc may irritate or compress the nerve root. The pain can then radiate from the lumbar spine (LWS for short) down into the leg. For these symptoms, the effectiveness of lumbar injections has been better studied than for spinal canal stenosis.

• Herniated disc: An injection may be considered for radiating leg pain.
• Spinal canal stenosis: It is not yet sufficiently clear whether the treatment is effective.
• Non-specific back pain: In the absence of evidence of an irritated nerve root, this is not an indication for PRT.
• Pain originating from the facet joints: PRT is not intended to treat this source of pain.
• Recurrent pain following disc surgery: Suitability depends on whether the symptoms can again be attributed to a nerve root.

In cases of radiating pain caused by a herniated disc, a lumbar transforaminal cortisone injection can alleviate the symptoms. ‘Transforaminal’ means that access to the nerve root is via a lateral opening in the spine. The medication can reduce inflammation in the surrounding area, but does not repair the damaged disc.

Only limited relief is to be expected. In a meta-analysis, the additional benefit of epidural cortisone injections for nerve pain was, on average, small and did not persist in the long term. Nor did the long-term risk of surgery decrease. Immediately after the injection, it is not yet possible to reliably assess the longer-term effect.

In cases of spinal canal stenosis, the benefits are less certain. A meta-analysis found no clear advantage for epidural cortisone injections. This does not prove either a benefit or a lack of efficacy specifically for CT-guided PRT.

In a prospective German study, pain relief was observed for up to three months after the last procedure following CT-guided PRT and facet joint injections. As both procedures were evaluated together, the study does not demonstrate the effect of PRT alone.

Before treatment, the symptoms must be consistent with the suspected cause of the pain, as indicated by available imaging. In the case of spinal canal stenosis, the spine is also assessed using imaging before any injection near the spine is administered.

Blood-thinning medication must not be stopped on one’s own initiative, nor should it be continued without a medical assessment. The doctor will weigh up the risk of bleeding against the risk of thrombosis and then decide on the next course of action.

Before treatment begins, a decision is also made as to which medication is to be injected. In cases of symptoms caused by a herniated disc, local anaesthetics and/or anti-inflammatory drugs are usually injected close to the irritated nerve root.

PRT is carried out under continuous or repeated imaging guidance. This may involve a computed tomography (CT) scan or fluoroscopy. The required patient position depends on the access route; therefore, lying on one’s stomach is not necessary for every nerve root.

1. The doctor determines which nerve root to treat based on the patient’s symptoms and imaging findings.
2. Under imaging guidance, the needle is guided through a lateral opening in the spine to the nerve root.
3. The selected medication is injected close to the irritated nerve root.
4. The doctor then checks the nerve function.

In a comparative study, the CT-guided procedure on a lumbosacral nerve root took an average of around 14 minutes. The measured duration ranged from 7 to 32 minutes, but did not include the entire hospital stay.

Inpatient admission is not always necessary following a CT-guided PRT. In one group of patients studied, no one needed to be admitted to hospital after the procedure. Whether the treatment can be carried out on an outpatient basis depends on the individual’s circumstances and how they respond following the injection.

Serious complications are rare, but can have significant consequences. These include post-procedure bleeding, infections, nerve damage, damage to the spinal cord and strokes.

In an observational study of various epidural injections, around 3 per cent of those treated reacted to cortisone. Around 2 per cent reported increasing pain and around 1 per cent reported a circulatory reaction. These figures do not represent specific rates for CT-guided PRT.

CT guidance involves exposure to X-rays. A study on procedures involving the cervical spine showed that optimised CT protocols can reduce radiation exposure.

Nerve function is assessed following the injection. Within the first 14 days, patients should also report any complications that may arise later. These include new or worsening pain, as well as circulatory reactions.

Disturbances in bladder or bowel function may indicate cauda equina syndrome. In such cases, rapid surgical decompression of the nerves is required; PRT must not be used as a substitute for this treatment.

The suitability of an alternative depends on the cause of the symptoms. For pain following a herniated disc, exercise therapy as part of physiotherapy may be considered. PRT can form part of a more comprehensive pain management programme.

There is no standard fixed price for a full PRT treatment as a self-pay service. The costs depend on the complexity of the procedure and the individual services billed. Patients must be informed in writing in advance of the estimated costs and should request a quote.

The epidural administration of cortisone is not authorised. It is therefore not automatically possible to claim this as a standard service under statutory health insurance. If a practice contracted to the statutory health insurance scheme bills for PRT privately for patients with statutory cover, a written treatment contract is usually required.

Privately insured patients may receive an invoice in accordance with the scale of fees; however, this does not automatically entitle them to reimbursement. They should submit the cost estimate to their insurer before the procedure and clarify whether the costs will be covered. A doctor’s referral alone does not constitute a promise of reimbursement.

In the case of private billing, PRT can be offered as an individual healthcare service. This requires a written cost estimate and an agreement on the services to be paid for privately.

Image-guided injections for pain management form part of specialist training in radiology. Periradicular infiltration is also an explicit component of the recommended training programme for neurosurgery. Practical experience with the specific access route and the imaging guidance used is crucial.

The additional qualification in ‘Specialised Pain Management’ requires recognition as a specialist, practical further training and a training course. It is a verifiable qualification, but not a proven prerequisite for every PRT.

The following questions are suitable for the initial consultation:

• Which nerve root is to be treated, and do my symptoms correspond to the imaging findings?
• Which medication is to be injected?
• How will my blood-thinning medication be managed prior to the procedure?
• What imaging guidance will be used, and how will radiation exposure be minimised?

You can find specialists in periradicular therapy at the end of this text.