Introduction: There is still controversy regarding the treatment of acute Lumbar Radicular pain. Most authorities recommend bed rest, anti-inflammatory medication and physical therapy (Riew et al JBJS 1982 and Tulder ET AL Spine 22–1997) Comparing the outcome of operative and conservative treatment in selected patients many authors (Weber et al, Hakelius et al) did not find any significant difference after first year and no difference after 4 years. However many patients treated conservatively complains of persistent pain and seek further intervention. Aim: We did a prospective study to determine the effectiveness of selective nerve root injection in relieving pain in patients with Lumbar radicular pain. Material and Methods: We included 27 consecutive patients in our study, who had selective nerve root block. Inclusion criteria were Degenerative Lumbar Radicular pain or spinal stenosis, MRI correlating with Lumbar radiculopathy and no benefit from 6 weeks Anti-inflammatory medication, Rest, Physical treatment and activity modification. Informed consent taken from all patients for this study. Each patient was given Low Back Pain outcome score questionnaire of Greenough and Fraser and Oswestry Disability index of Fairbank, to be filled pre and post injection in day ward and at regular intervals up to 3 months post-injection. Adcortyl 20mg with 1 ml of 1% Lignocaine were injected under image in theatre after confirming the site with radioculogram and pain replication. Results: From the total of 27 patients, 25 (92%) showed improvement in their symptoms in first week. Out of these 25 patients, 18(66%) had long-term improvement and 7(26%) showed short-term relief. Statistically significant improvement at every stage of assessment was observed. Conclusion: The selective nerve root block combined with careful history, physical examination and quality radiolographic studies, is an important tool in the diagnosis and treatment of patients with predominant Lumbar radicular symptoms. It gives acceptable results in form of pain relief in 3 months. It has a role in lumbar Radicular pain largely in patients where surgery is not appropriate for whatever reasons

Abstract: Objective of this study was to assess the adequacy of relief provided by Nerve Root Block for Lumbar Radicular pain. If successful, this treatment can obviate the need for surgery considering the favourable natural history of this pathology. We studied 64 patients who had this injection, from February 2000 to July 2001. These patients had clinical and radiographic confirmation of nerve root compression and were followed up at 2 and 6 weeks post injection and then at an average of 10 months by a questionnaire, which addressed patient satisfaction with injection treatment and pre-injection and present Low Back Outcome Score and Pain intensity on Visual Analogue Scale. Overall, out of 64 patients injected, at 10 months follow-up, 50% (n=32) were satisfied with the treatment, 42% (n=27) injections failed and 8% (n=5) had incomplete follow-up. Pain intensity as measured on Visual Analogue Scale decreased from pre-injection mean value of 9.1 to post injection value of 4.9 the difference being statistically significant (p< 0.01). The Low Back Outcome Score increased from mean of 43 to 61, again the difference being statistically significant (p< 0.01). Nerve Root Block is an effective therapeutic tool for Lumbar Radicular pain and should be recommended as the initial treatment of choice for this condition since it can provide persistent relief to the point that the patient does not require surgery

Objective: To investigate the clinical outcomes, and the requirement of surgery following selective nerve root block performed for cervical radicular pain in patients with MRI proven disc pathology. Methods: Thirty consecutive patients with cervical radiculopathy and correlating MRI pathology were studied. Mean age of patient was 46yrs (range 28–64yrs). Twenty nine of the thirty patients also complained of associated neck pain. All underwent fluoroscopically guided, selective cervical nerve root block with steroid (20mg Depomedrone) and local anaesthetic (0.5ml Bupivo-caine 0.25%). Radiographic contrast was used to confirm needle position. All procedures were conducted by the same clinician. Pre and post procedure pain and physical function scores were noted using the standard SF 36 questionnaire, as well as whether subsequent surgery was required. Mean follow up time was seven months (range 2–13 months). Results: 81% of patients reported an improvement in arm pain, and 66% in neck pain following the procedure. 77% of patients had an improvement in pain score (mean improvement 16 points). 68% of patients had an improvement in physical function score (mean improvement 20 points). At the time of follow up only one patient had undergone surgery for cervical radicular pain. Conclusion: This study suggests that fluoroscopically guided selective nerve root block is a clinically effective interventional procedure in the management of cervical radicular pain, and may prevent the need for open surgery

Purpose: The clinical sequelae associated with acute sciatica have been traditionally attributed to mechanical compression of the spinal nerve root by a herniated disc (HD). More recent studies have demonstrated that the HD induces the release of inflammatory mediators and that a tumor necrosis factor alpha-inhibiting agent can resolve the symptoms.|Selective nerve root block (SNRB) involves the transforaminal application of steroid under fluoroscopic guidance adjacent to the selected nerve root. Well-defined criteria for patients that will most likely benefit from SNRB remain unclear. The goal of this study was to determine whether or not the morphology (i.e. posterolateral, sequestrated, foraminal, far lateral) of HD influences the therapeutic value of SNRB treatment. Methods: An observational cohort study of 37 patients with acute sciatica of less than 12 weeks duration, McCulloch scores of 4 or 5 and evidence of HD on MRI scan at the appropriate level was completed. Disc morphology was determined by blinded interpretation of the MRI scans by a Musculoskeletal Radiologist. Outcome measures included the Modified Roland-Morris Disability Questionnaire (RDQ), administered on the day of, and 6 weeks following, the SNRB procedure and the Visual Analogue Scale (VAS) filled out by the patient immediately before, 30 minutes after and 6 weeks after SNRB. Results: Of the 37 patients enrolled in this study, the HD morphology was classified as: posterolateral 20, sequestrated 9, foraminal 6, far lateral 2. 35 of 37 patients (95%) reported a 30 minute VAS score of less than 3/10. 14 of 20 patients (70%) with posterolateral HD reported > 3 point improvement in RDQ and > 5 point improvement in VAS at 6 weeks post procedure. 1 of 9 patients (11%) with sequestrated HD showed the same level of improvement in RDQ and VAS scores. None of the patients with foraminal or far lateral HD reported > 1 point improvement in RDQ or > 2 point improvement in VAS scores. Conclusions: Patients with posterolateral HD were found to have significantly more favorable outcomes from SNRB than those with sequestrated, foraminal or far lateral HD morphology

Northumbria Healthcare NHS Trust, Ashington, UK. To assess if a pain diary is useful in assessment and management of patients who undergo diagnostic nerve root block (NRB) for lumbar radicular pain. Prospective study. 23 patients who underwent diagnostic NRB for lumbar radicular pain were given a pain diary. They recorded their response to one of four options from Day 0 to Day 14 (good relief, partial satisfactory, partial unsatisfactory, and no relief of leg pain) and could also add additional comments. A Consultant Spinal Surgeon reviewed the diary with the patient at 6-week follow up appointment to formulate a management plan. Patient response, completion of the pain diary and final clinical outcome (surgical or non surgical treatment). The response rate was 91% (21/23). The pain diary was very useful in 43% (9/21), useful in 33% (7/21) and not useful in 24% (5/21) of patients in formulating further management. There was a tendency for patients with complex problems and poor response to add descriptive notes and comments (9/ 23). Patient compliance with pain diary was good and it has been valuable in making further management decisions. We found the pain diary to be a useful and inexpensive adjunct in the assessment of patients who underwent diagnostic NRB

Purpose of study and background

The use of NRB (Nerve Root Block) in radicular pain caused by stenosis is considered controversial in some centres, whereas its indication in radiculitis caused by disc herniation is widely accepted. Most studies evaluating NRB have combined disc herniation and stenosis pathologies in their inclusion criteria. This study explores the efficacy of NRB in different categories of stenosis: lateral recess, foraminal and combined.

Aims

Cervical radiculopathy is a significant cause of pain and morbidity. For patients with severe and poorly controlled symptoms who may not be candidates for surgical management, treatment with transforaminal epidural steroid injections (CTFESI) has gained widespread acceptance. However, a paucity of high-quality evidence supporting their use balanced against perceived high risks of the procedure potentially undermines the confidence of clinicians who use the technique. We undertook a systematic review of the available literature regarding CTFESI to assess the clinical efficacy and complication rates of the procedure.

Background: Although needle tip position has been correlated with outcome with respect to pain relief, and to complication rate, to our knowledge, no previous study assesses the location of the needle tip with respect to its ability to isolate injectate around the exiting nerve root without blocking the traversing nerve root to the next caudal level. Aim: To study the location of injectate when diagnostic selective nerve root blockade is performed. Method: 87 consecutive selective nerve root blocks performed by a single surgeon were assessed. A consistent surgical technique was utilised. Antero-Posterior fluoroscopy films were analysed to determine the location of injectate in relation to the foraminal and pedicle anatomy. A pro-forma operation note ensured all necessary data was collected prospectively. Results: Of needle tips positioned lateral to the middle third of the superior pedicle on the AP view, 45 of 51 flowed into the nerve sheath alone, and 6 flowed into both the nerve sheath, and spinal canal. Of these 6, 2 were due to a larger volume of contrast injected, and 2 were due to abnormal anatomy from marked lumbar degenerative scoliosis. Of tips located below the middle third of the pedicle, 2 of 29 flowed into the nerve sheath alone, 2 flowed into the canal alone, and 27 flowed into both. Of those placed medial to zone below the middle third of the pedicle, all seven flowed into the canal only. Analysis using Fisher’s Exact test yielded an extremely statistically significant result, with p < 0.001 comparing needle tip positions in the lateral position with the mid-zone and medial tip positions, and their relationship with injectate reaching the traversing nerve root. Discussion: For a nerve root block to be truly selective, no injectate must flow past the exiting root to the traversing root. Low volumes of injectate must be placed predictably and accurately. This paper demonstrates the importance of needle tip location in preventing flow beyond the foramen. It is also recommended that contrast be used when significant deformity is present. In cases where there is a therapeutic rather than diagnostic intention, such accuracy is unnecessary. This study does not address the efficacy of the selective nerve root block as a non-operative intervention, nor does it assess the ability of the block to predict operative benefit. It does, however, provide a benchmark for accuracy achievable in patients without significant spinal deformity. Conclusion: Care must be taken to ensure that the needle tip is positioned lateral to the zone below the middle third of the pedicle if a selective nerve root block is to be used for diagnostic purposes, particularly if there is significant deformity or no contrast is used. In the absence of deformity, however, selective nerve root block may be performed reliably, with a location accuracy of 96%

Following the implementation of the Ionising Radiations (Medical Exposure) Regulations Act 2000 and recommendation from International Commission on Radiological Protection (ICRP), the establishment of diagnostic reference levels (DRLs) for all radiological examinations became mandatory. There are no recommended or published standards or national dosage guidelines in the UK of diagnostic reference levels available for fluoroscopy-guided diagnostic and therapeutic spinal procedures. The aim of this study is to establish reference dose area product (DAP) levels for the diagnostic spinal procedures requiring fluoroscopy as a basis for setting DRLs. All patient data consisted of diagnostic spinal procedures done in 2009 at Newcastle General Hospital under care of 4 spinal surgeons. Radiation data were collected on specific type of the procedure, DAP and screening time. Nerve root blocks, facet joint blocks and facet joint rhizolysis were included for data collection and analysis for this study. The third-quartile values were used to establish the DRLs. There were 387 nerve root blocks with a mean exposure per injection 171.3 cGycm. 2. (range, 3.0 to 2029.1; third quartile 209.4). Facet joint injections were 669 at a mean radiation dose 41.3 cGycm. 2. (range, 1.9 to 541.0; third quartile 48.9). In a total 430 facet joint rhizolysis, the mean exposure was 44.4 cGycm. 2. (range, 7.7 to 154.5; third quartile 58.4). The mean screening times were 36.7s (range, 0.4-281s; third quartile 41s) for nerve root blocks, mean 11.2s (range, 1.8-37s, third quartile 13.3s) for single facet joint block and mean 14.6s (range, 0.1-162s, third quartile 15.1s) for single facet rhizolysis. We found the third-quartile values for setting DRLs for single level nerve root block, single facet joint block and single facet joint rhizolysis to be 209.4, 48.9 and 58.4 cGycm. 2 . respectively. We recommend that all spinal units in the UK should establish their own local DRLs to help in establishing national dosage guidelines for fluoroscopy-guided diagnostic and also therapeutic spinal procedures

Background. There is growing evidence for an important role of central sensitization (CS) in the development and maintenance of chronic pain. This accounts for patients with chronic low back pain radiating to the leg (CLBPr) as well. Care as Usual (CaU) in these patients consists of diagnostic segmental nerve root blocks (dSNRB) followed by therapeutic interventions, i.e. a therapeutic segmental nerve root block (tSNRB) or pulsed radiofrequency (pRF). However, it is unknown if these procedures affect the amount of CS in these patients. Aim. The aim of the present study is to determine the alterations in the presentation of CS in CLBPr patients during care as usual. Hypothesis. A decrease in pain measured by NRS correlates with a decrease in CS (signs) in CLBPr patients undergoing SNRBs. Method/design. Case control study in 50 patients with CLBPr, for whom the physician is considering dSNRB and tSNRB or pRF, and 50 sex- and age-matched healthy controls. Following care as usual protocol, patients will receive dSNRB and tSNRB or pRF. Healthy control subjects will not undergo any procedure. The study has three to five visits, depending on the number of dSNRBs performed (max. 3). Evaluation. The bedside examination and questionnaires that are part of CaU will be extended with QST and CSI, NRS, PCS and PVAQ. The measurements will take place just before the dSNRBs, the tSNRBs or pRF and a follow-up four weeks after the intervention. Data collection will take 1 year. No conflict of interest. No funding obtained

Aim: To study the location of injectate when diagnostic selective nerve root blockade is performed. Method: 87 consecutive selective nerve root blocks performed by a single surgeon were assessed. A consistent surgical technique was utilised for all patients. Antero-Posterior fluoroscopy films were analysed to determine the location of injectate in relation to the foraminal and pedicle anatomy. Results: Of needle tips positioned lateral to the middle third of the superior pedicle on the AP view, 45 of 51 flowed into the nerve sheath alone, and 6 flowed into both the nerve sheath, and spinal canal. Of these 6, 2 were due to a larger volume of contrast injected, and 2 were due to abnormal anatomy from marked lumbar degenerative scoliosis. Of needle tips located below the middle third of the pedicle, 2 of 29 flowed into the nerve sheath alone, 2 flowed into the canal alone, and 27 flowed into both. Of those placed medial to zone below the middle third of the pedicle, all seven flowed into the canal only. Conclusion: Care must be taken to ensure that the needle tip is positioned lateral to the zone below the middle third of the pedicle if a selective nerve root block is to be used for diagnostic purposes, particularly if there is significant deformity or no contrast is used. In the absence of deformity, however, selective nerve root block may be performed reliably, with a location accuracy of 96% providing the tip of the needle lies in the lateral position described

We describe results of a new ‘two needle technique’ of selective nerve root blocks done through posterior triangle of neck in the management of cervical radiculopathy with 2 year results. Methods: Patients presenting with cervical radiculopathy were evaluated clinically and radiologically and were initially managed with supervised physiotherapy, analgesics and rest. Selective cervical nerve root block was offered to the patients, who did not respond to conservative management. The procedure was performed as a day case, under local anesthesia, with image intensifier guidance, using ‘two needle technique’. A thinner needle is rail-roaded through the lumen of large diameter guide needle to reach the target nerve root foramen and a mixture of Bupivacaine and Triamcinolone acetonide is injected. The outcome was measured using visual analogue score (VAS) and neck disability index (NDI) done on the day of the procedure and compared to the scores at 3 months and 1 year after the procedure. Results: Outcome in 30 patients who underwent this procedure over three years’ period is presented. Average Visual Analogue Score was 7.36 (range 6 – 10) before the intervention, which improved to 2.27 (range 0 – 7) at 3 months and 1.9 (range 0 – 4) at 1 year. The average Neck Disability Index score prior to intervention was 66.87 (range 44 to 82), which improved to 31.67 (range 18 – 66) at 3 months and 30.44 (range 20 – 48) at 1 year. There were no major complications noted. We conclude that selective cervical nerve root block using ‘two-needle technique’ is safe and reproducible. The therapeutic effect achieved is long lasting, making this procedure a good alternative to surgical management in patients with cervical radiculopathy who do not respond to conservative management

Purpose:. To evaluate if adding clonidine to a standard nerve root block containing local anaesthetic and steroid improved the outcome of patients with severe lumbar nerve root pain secondary to MRI proven lumbar disc prolapse. Methods:. We undertook a single blind, prospective, randomised controlled trial evaluating 100 consecutive patients with nerve root pain secondary to lumbar disc prolapse undergoing trans-foraminal epidural steroid injection either with or without the addition of clonidine. 50 patients were allocated to each arm of the study. The primary outcome measure was the avoidance of a second procedure- repeat injection or micro-discectomy surgery. Secondary outcome measures were also studied: pain scores for leg and back pain using a visual analogue scale (VAS), the Roland Morris Disability Questionnaire (RMDQ) and the Measure Your Own Medical Outcome Profile (MYMOP). Follow up was carried out at 6 weeks, 6 months and 1 year. Results:. No serious complications occurred. Of the 50 patients who received the addition of clonidine, 56% were classified as successful injections, with no further intervention required, as opposed to 40% who received the standard injection. This difference did not reach statistical significance (p=0.109, chi-squared test). All secondary measures showed no statistically significant differences between the groups except curiously, the standard group who had been classified as successful had better leg pain relief than the clonidine group (p=0.026) at 1 year. Conclusions:. This pilot study has shown a 16% treatment effect with adding clonidine to lumbar nerve root blocks and that it is a safe injectate for this purpose

To analyse if patients with pain improvement following a nerve root block had better outcomes following lumbar microdiscectomy. Fifty-six patients who had a lumbar microdiscectomy were retrospectively followed up to 1 year. All patients had a selective nerve root block (SNRB) as a primary treatment or diagnostic procedure. VAS pain scores were measured daily for 1 week following injection. Patients were grouped into responders and non-responders at 1 week. The 2 groups of patients were followed at 1 year following a lumbar microdiscetomy (LMD). A total of 118 patients had SNRB over a period of 3 years. Of the 56 patients studied retrospectively, 52% and 36% of patients had a VAS score improvement of more than 2 points at 4 days and 1 week respectively. At 1 year post op, 85% of patients had better outcomes in the responder group compared to 74% in the non responder group. Although there was a difference this was not statistically significant. Improvement with SNRB is not a positive predictor of good response with surgery. The ability to evaluate the effect of diagnostic or therapeutic blocks on surgical outcomes is limited by a lack of randomized studies and wide-ranging discrepancies with regard to injection techniques, surgical technique, and outcome measures. More research is needed to determine if diagnostic screening blocks can improve surgical outcomes

To analyse if patients with pain improvement following a nerve root block had better outcomes following lumbar microdiscectomy. Fifty-six patients who had a lumbar microdiscectomy were retrospectively followed up to 1 year. All patients had a selective nerve root block (SNRB) as a primary treatment or diagnostic procedure. VAS pain scores were measured daily for 1 week following injection. Patients were grouped into responders and non-responders at 1 week. The 2 groups of patients were followed at 1 year following a lumbar microdiscetomy (LMD). A total of 118 patients had SNRB over a period of 3 years. Of the 56 patients studied retrospectively, 52% and 36% of patients had a VAS score improvement of more than 2 points at 4 days and 1 week respectively. At 1 year post op, 85% of patients had better outcomes in the responder group compared to 74% in the non responder group. Although there was a difference this was not statistically significant. Improvement with SNRB is not a positive predictor of good response with surgery. The ability to evaluate the effect of diagnostic or therapeutic blocks on surgical outcomes is limited by a lack of randomized studies and wide-ranging discrepancies with regard to injection techniques, surgical technique, and outcome measures. More research is needed to determine if diagnostic screening blocks can improve surgical outcomes

To review our practice of requesting nerve root blocks, to see how effective our therapeutic blocks are and how many of our diagnostic blocks confirm clinical suspicion and help decision making. Retrospective cohort analysis. 120 fluoroscopically guided nerve root blocks were performed between 20/08/2008 and 29/12/2008. There were 100 patients who had pain diary data available, 42 males (mean age 52.02 range 20-76) 58 females (mean age 60.03, range 22-88). We recorded: clinical diagnosis, reason for block, result of block on a 10 point visual analogue pain diary on days 0, 2, 14 and at review. A successful block was defined as an improvement of at least 2 points. For the diagnostic blocks we also recorded whether the block result influenced surgical decision making. Block methods will be illustrated in diagram. Results will be displayed graphically and in text. 18 blocks were cervical (1 purely diagnostic, 6 therapeutic, and 10 mixed, 1 data unavailable). 71 blocks were lumbar (1 purely diagnostic, 28 purely therapeutic, and 37 mixed, 5 data unavailable). 28% of all blocks were successful immediately (2 unavailable data) and 22% at two weeks (1 unavailable data). By 3 months the success rate for therapeutic blocks was 26%. Of the blocks done for diagnostic reasons, 86% influenced a clinical decision at the next outpatient appointment. Our results justify the continuance of this service. Increased care should be taken that patients' outcome data is collected

The use of nerve root blocks is common in the management of radicular pain due to lumbar disc prolapse. However, most papers reporting their use do not necessarily specify the position or level at which the needle is positioned with respect to the level of pathology. We therefore set out to investigate this. We performed a survey of medical practitioners across the UK with an interest or involvement in the management of radicular pain secondary to lumbar disc prolapse The survey depicted the clinical scenario of a patient with radicular pain from an L4/5 disc prolapse and a number of questions were asked in relation to the use of nerve root blocks. Questionnaires were sent to 319 practitioners. We received 153 responses of which, 120 (37.6%) were sufficiently complete to be analysed. Of those who responded, 83% used a combination of local anaesthetic and steroids together with or without contrast. There were variations across the respondents in terms of the level injected with 22.5% injecting at the level of the L4/5 foramen, while 45% injected at the level of the L5/1 foramen. Differences were also noted when respondents were subgrouped according to their speciality. Of those who worked in pain management, 34.1% injected at the L4/5 foramen while 31.8% injected at the L5/1 foramen. For spine surgeons the respective figures were 20.5% and 43.2% and for radiologists 9.4% and 65.6%. In the treatment of radicular leg pain, there are apparent variations in the use and positioning of root blocks for a given level of disc pathology. This suggests that caution is necessary when considering the validity of published studies on the use of root blocks relative to an individual clinician's practice

Objective. Our aim is to assess the use of the cervical nerve root block (CNRB) in the treatment of radicular pain associated with degenerative cervical spine disease and its potential to limit the need for surgical intervention. Methods. A retrospective review of consecutive CNRB procedures carried out between January 2008 and June 2010. All procedures were performed using a combination of local anaesthetic and steroid under fluoroscopic guidance. The inclusion criteria were brachialgia with MRI proven nerve compression and inadequate response to physiotherapy. Patients that underwent both a CNRB and facet joint injections were excluded. The outcome measures assessed were the response gained (complete/temporary/no relief) and the choice of further management. Results. A total of 121 patients underwent CNRBs within our study period. 11 patients were lost to follow up. A cohort of 110 patients was studied (49 male and 61 female) with a mean age of 51.5 years (standard deviation 12.3 years). Following the initial CNRB, 49 patients (44.5%) had complete relief requiring no further interventions. Temporary symptom relief was achieved for 30 patients (27.3%) and no relief was gained in 31 patients (31.2%). A repeat CNRB was carried out in 19 patients who gained temporary or no benefit following the initial block. Of the 97 patients who have a complete follow up, complete resolution of symptoms was achieved in 53 patients (54.6%), 25 patients (25.8%) progressed to requiring surgery and no further treatment was offered to 19 patients (19.6%). No complications related to the procedure were identified. Conclusion. Cervical nerve root blocks can be performed to treat patients suffering with cervical radiculopathy symptoms. It is a minimally invasive intervention that can reduce the need for operative intervention

Aim. To identify a means to reduce the duration and radiation dose coupled with fluoroscopic guided nerve root blocks (NRB). Method. Consecutive prospective two cohort comparative study. A similar method performed during CT guided NRBs was employed to guide needle placement for transforaminal nerve root injections with the aid of static MR images and fluoroscopy. Axial MR images at the level of the target nerve root were used. An angle of inclination of 60 degrees was created from the nerve root to the skin of the back, the apex of this to represent the site of needle introduction. Triangulation on the MRI enabled the lateral entry point to be determined. The transforaminal injections were then performed with the simple expedient of a skin marker line at the appropriate lateral distance from the midline for needle entry. The radiation dose and fluoroscopic time as measured by the image intensifier were recorded. This method was performed for 20 patients and compared to the same parameters for 23 previous patients in whom the transforaminal injections were performed without such a technique. Results. 20 patients in the navigated arm (group 1) and 23 in the non-navigated (group 2). Average fluoroscopic time (seconds) was 17.7 seconds (range 8-40) for group 1 and 16.4 seconds (range 6-45) for group 2 (P value 0.625). Radiation dose measured was 79.76 cgycm. 2. (range 8-212) for group 1 and 63.05 cgycm. 2. (range 8-260) for group 2 (P value 0.247). Conclusion. This method of navigating nerve root blocks via fluoroscopy did not appear to reduce the duration of the procedure or radiation dose involved on objective data. Subjectively it was found to be a useful training aid for triangulation for those new to the technique but the available objective evidence was not obtained

Purpose: Purpose of the study was to evaluate the incidence of spinal surgery for patients with back pain. Methods and results: During past five years 5145 patients were seen in the back pain screening clinic. 823 patients (16%) were referred to the spine clinic (p< 0.001). 127 patients (2.47%) were operated on (p< 0.001).106 patients (2.1%) had lumbar discectomy/decompression, 9 (0.59%) cervical discectomy, 3 (0.06%) pars reconstruction, 9 (0.17%) fusion and PLIF for spondylolisthesis, 5 (0.1%) decompression for spinal stenosis and 1 (0.01%) subtraction osteotomy for kyphosis. 5 patients (0.1%) were referred with “red flag” symptoms: 4 with spinal stenosis and 1 with tumour. 17 patients (0.3%) had discogram. 4 of them went for surgery: 1 had L4/5 PLIF, 2 L5/S1PLIF and 1 L5/S1 discectomy. 289 patients (5.6%) had nerve root blockade. Following NRB 47 patients (0.9%) had discectomy/decompression (p< 0.001). 62 patients had discectomy/decompression without previous NRB. L5/S1 discectomy was the most common (48 pts; 0.9%). 86 patients (1.7%) had facet joint injections. 8 patients (0.15%) had surgery following FJI (p< 0.001). 1 patient had L4 nerve root decompression, 3 L4/5 discectomy, 1 L5/S1 nerve rot decompression, 1 alartransverse fusion and 1 L5/S1 PLIF. 465 patients (9%) did not have nerve root blocks or facet joint injections. 3 patients (0.06%) had epidural injections of local anaesthetic and steroid. Conclusion: Spinal surgery is not commonly performed in patients with back pain. Majority of patients can be treated conservatively. Prior to surgery nerve root blocks and facet joint injections are useful in selected patients