Review

Selective Nerve Root Block in Treatment of Lumbar

Radiculopathy: A Narrative Review
Jacqueline Chu Ruo Yang 1,† , Shi Ting Chiu 2,† , Jacob Yoong-Leong Oh 3 and Arun-Kumar Kaliya-Perumal 1, *

1 Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
2 Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597, Singapore
3 Division of Spine, Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore
* Correspondence: [email protected]
† These authors contributed equally to this work.

Abstract: Selective Nerve Root Block (SNRB) is a precise local injection technique that can be utilised
to target a particular inflamed nerve root causing lumbar radiculopathy for both diagnostic and
therapeutic purposes. Usually, for SNRB to be therapeutic, a combination of a local anaesthetic agent
and a steroid is injected under imaging guidance, whereas for diagnostic purposes, just the local
anaesthetic agent is injected. While the ideal treatment strategy is to relieve the nerve root from
its compressing pathology, local injection of steroids targeted at the affected nerve root can also be
attempted to reduce inflammation and thus achieve pain relief. Although the general principle for
administering an SNRB remains largely the same across the field, there are differences in techniques
depending on the region and level of the spine that is targeted. Moreover, drug combinations utilised
by clinicians vary based on preference. The proven benefits of SNRBs largely outweigh their risks,
and the procedure is deemed safe and well tolerated in a majority of patients. In this narrative, we
explore the existing literature and seek to provide a comprehensive understanding of SNRB as a
treatment for lumbar radiculopathy, its indications, techniques, outcomes, and complications.

Citation: Yang, J.C.R.; Chiu, S.T.; Oh,

Keywords: lumbar region; nerve block; radiculopathy; spine; spondylosis
J.Y.-L.; Kaliya-Perumal, A.-K.
Selective Nerve Root Block in
Treatment of Lumbar Radiculopathy:
A Narrative Review. Surgeries 2022, 3,
1. Introduction
259–270. https://doi.org/10.3390/
surgeries3030028
1.1. Low Back Pain and Lumbar Radiculopathy
Low back pain is one of the most common complaints faced in medical practice [1],
Academic Editor: Cornelis F.M. Sier
with an alarming increase in incidence and prevalence over the past 20 years [2]. Various
Received: 22 August 2022 studies have assessed the risk factors leading to back pain, including genome-wide associa-
Accepted: 8 September 2022 tion studies, with the primary aim of understanding the biology behind this problem and
Published: 14 September 2022 thus progress towards identifying novel therapeutic strategies [3–8]. Looking at the pain
Publisher’s Note: MDPI stays neutral
generators, degeneration involving the bony elements of the spine or the intervertebral
with regard to jurisdictional claims in
discs plays a major role [9,10]. Such degeneration could also lead to compression of nerve
published maps and institutional affil- roots. Here, the cause of compression could be a herniating disc, thickened ligamentum
iations. flavum, hypertrophied facet or neural foraminal stenosis secondary to disc height loss. In
these conditions, patients often present with lumbar radiculopathy where there is shooting
pain down their legs along the course of an affected nerve. Associated symptoms include
tingling and numbness, and in severe cases, motor weakness [11].
Copyright: © 2022 by the authors.
Licensee MDPI, Basel, Switzerland. 1.2. Diagnosing Lumbar Radiculopathy
This article is an open access article Lumbar radiculopathy can be diagnosed clinically by doing various sciatic stretch
distributed under the terms and tests. The most commonly used is the straight leg raising test (SLRT) where the patient
conditions of the Creative Commons is positioned supine and the clinician passively lifts the patient’s affected leg, while the
Attribution (CC BY) license (https://
knee is fully extended. Doing so generates tensile stresses at the sciatic nerve and the
creativecommons.org/licenses/by/
lumbosacral nerve roots, and a positive test is when radicular pain is reproduced between
4.0/).

Surgeries 2022, 3, 259–270. https://doi.org/10.3390/surgeries3030028 https://www.mdpi.com/journal/surgeries

Surgeries 2022, 3 260

30 to 70 degrees of hip flexion [12]. In addition, once the SLRT turns out to be positive, the
leg can be lowered just below the pain threshold and the foot can be passively dorsiflexed.
If this manoeuvre causes a similar pain as that of the SLRT, then Bragard’s sign is said
to be positive [13]. Another sensitive diagnostic test is the slump test where the patient,
being seated with hands behind the back is asked to slump forward, followed by flexion
of the neck to achieve chin on chest, followed by extension of affected side knee and
then dorsiflexion of the ipsilateral ankle [12,14]. This progressive series of manoeuvres
generate increasing tension at the sciatic nerve roots and the test is considered positive when
radicular pain is reproduced at any step of the procedure. The slump test when combined
with the Dejerine triad, which includes performing a Valsalva manoeuvre, coughing, and
sneezing was shown to have high diagnostic validity [13]. Ultimately, Magnetic Resonance
(MR) imaging is the gold standard for identifying the exact pathology that is affecting
the nerve root [15]. Electrodiagnostic testing using sensory nerve action potentials and
compound muscle action potentials can also be performed to differentiate other neurologic
conditions that may present similar to lumbar radiculopathy. Typically, such assessment is
indicated in patients who present with sensory or motor loss without any correlation to
MR imaging findings [16,17].

1.3. Management Strategies

Multiple reports provide evidence for complete resolution of lumbar radiculopathy
symptoms caused by various pathologies with conservative management, analgesics, rest
and physiotherapy [18–22]. Hence, first-line management is predominantly conservative
unless otherwise indicated. Usually, a trial of oral non-steroidal anti-inflammatory drugs
(NSAIDs) and in severe cases corticosteroids along with non-pharmacological interventions,
such as rest and traction physiotherapy are attempted [1,23], whereas surgery at the first
instance is reserved for patients with red flag signs, such as neurological deficits or loss
of bladder and bowel function [24]. However, there is always a dilemma regarding when
conservative treatment should be abandoned in favour of other interventions [19,24].
Reports suggest that if symptoms worsen or persist for more than six weeks despite
conservative management or if there is neurological deterioration, invasive procedures
may be considered [25–27]. While surgery to relieve the compression on the nerve root
is the most ideal option, local injection of steroids targeted at the affected nerve root or
epidural space of the affected level can also be attempted to reduce inflammation and thus
achieve pain relief [28]. In all cases, patients need to be clearly explained the pros and cons
of SNRB in comparison to other surgical options available and a concordant decision needs
to be made.
Targeting the epidural space for such injections can be via interlaminar, transforaminal
or caudal approaches. The interlaminar approach is the midline approach where the needle
is advanced between the laminae of two adjacent vertebrae towards the epidural space [29].
The transforaminal approach is where the needle is inserted far lateral to the midline on the
affected side and advanced towards the intervertebral foramen of the affected disc level.
This approach is similar to targeting the affected nerve root for a selective nerve root block
(SNRB) and is performed under imaging guidance [30]. The caudal approach is through the
sacral hiatus where the needle is advanced into the sacral canal through the sacrococcygeal
ligament and into the epidural space [31,32]. Moreover, in circumstances where a patient
is reluctant to go for surgery despite being indicated, a steroid injection can provide
temporary pain relief before deciding on the next line of management [33,34]. Even though
SNRBs have become increasingly popular, there is still discourse over many aspects of
their administration, such as the medications used and the method of administration. Here,
we seek to provide a comprehensive understanding of SNRB and its existing literature,
including its indications, methods, outcomes and complications.
Surgeries 2022, 3 261

2. Selective Nerve Root Block

Selective Nerve Root Block (SNRB) is a precise local injection procedure where a partic-
ular inflamed nerve root causing lumbar radiculopathy can be targeted both for diagnostic
and therapeutic purposes [35–38]. Usually, for SNRB to be therapeutic, a combination of
a local anaesthetic and a steroid is injected around the affected nerve root under imaging
guidance, whereas for diagnostic purposes, it is just the local anaesthetic that is injected.
Immediate relief of pain indicates that the targeted nerve root is the cause of pain; besides,
no relief of pain is also an important indicator that the pain is originating from a different
level or nerve root [39]. It is for this reason that SNRB is considered by various authors a
useful diagnostic tool [35,36,40]. In addition, owing to its therapeutic efficiency whenever
a steroid and local anaesthetic combo is injected, many pain physicians, interventional
radiologists and spine surgeons have adopted this procedure in their routine practice for
therapeutic purposes.

2.1. Indications for Therapeutic SNRB

Since therapeutic SNRB works well for reducing pain caused by inflammation of
a particular nerve root, it is advised after a trial of failed conservative management for
unilateral lumbar radiculopathy where only a single nerve root is affected [30]. However,
it can also be used for bilateral or ipsilateral multilevel pathology as in most cases of
spondylosis [41], but it should be noted that injecting steroids at multiple levels or in higher
volumes may lead to complications.

2.2. Intervertebral Disc Herniations

The most common pathology causing nerve root inflammation leading to lumbar
radiculopathy is intervertebral disc herniation where the nucleus pulposus gets displaced
from its normal location (Figure 1a,b). This can happen acutely due to an injury or more
chronically when the intervertebral disc gets degenerated and desiccated as part of the
natural ageing process [42]. There are multiple nomenclature systems to describe disc
herniations, with many existing classification methods. Broadly, disc herniations can be
categorised based on the anatomical location of the herniation, which can be defined as
central, paracentral, foraminal or far lateral [43]. It can also be described as protrusion, ex-
trusion, or sequestration, depending on the morphology of the displaced disc material [44].
A more elaborate system based on the morphology of the herniation is the Michigan State
University (MSU) classification system [45]. Here, grading is based on the size and location
of disc herniation as visualised on a T2 axial cut MR image at the level of maximal disc her-
niation [45]. Meanwhile, Pfirrmann’s grading also utilises a similar T2 axial cut MR image
at the level of maximal disc herniation but grades the amount of nerve root compromise
caused by the herniated disc into four categories demonstrating a high correlation with
surgical findings [46]. While it is theoretically possible to try out therapeutic SNRBs for any
type of disc herniations described in these classification systems causing radiculopathy, it
is often not used for severe cases for the reason that those with severe disc herniations get
no relief except for temporary postprocedural pain relief [33]. However, not many studies
assess and describe outcomes following SNRBs based on these elaborate classification
systems; hence, a structured evidence-based guideline is lacking.

2.3. Spondylosis
Spondylosis is a general term that is given for a wide range of age-related degenerative
wear and tear that affects all the components of the spine including the bony elements of
the vertebra, intervertebral discs, ligamentum flavum and facet joints [47]. Some of these
conditions could result in foraminal narrowing leading to nerve root compromise and
result in radiculopathy. Firstly, the most common form of spondylosis is intervertebral disc
degeneration, which can cause significant disc height loss and stiffness [48,49]. When this
happens, the neural foraminal height also decreases, which can potentially cause exiting
Surgeries 2022, 3 262

Surgeries 2022, 3, FOR PEER REVIEW

nerve
root compromise, leading to radiculopathy. It should also be noted that structural 4
changes from such degenerative discs increase the risk for intervertebral disc herniation.

Figure1.1. MRI
Figure MRI images
imagesshowing
showingintervertebral disc
intervertebral herniations.
disc (a) Sagittal
herniations. viewview
(a) Sagittal showing L5-S1L5-S1
showing disc
herniation (arrow), (b) corresponding axial view, (c) Sagittal view showing front and back compres-
disc herniation (arrow), (b) corresponding axial view, (c) Sagittal view showing front and back
sion due to herniating L4-L5 disc (arrow) and a thick buckled ligamentum flavum (star), (d) corre-
compression due to herniating L4-L5 disc (arrow) and a thick buckled ligamentum flavum (star),
sponding axial view showing circumferential compression.
(d) corresponding axial view showing circumferential compression.
2.3. Spondylosis
Secondly, the ligamentum flavum, bridging the upper and lower lamina of every
spinalSpondylosis is a general
level, maintains tension term
when thatinismotion
given foranda wide
also inrange
the of age-related
resting degenera-
state [50]. It gets
thicker and stiffer with age secondary to cumulative mechanical stress [51], andelements
tive wear and tear that affects all the components of the spine including the bony also gets
of the vertebra,
buckled inside theintervertebral
spinal canal as discs, ligamentum
the disc flavum due
height decreases and to
facet joints [47].[50].
degeneration Some of
While
these conditions could result in foraminal narrowing leading to nerve
an intervertebral disc herniation can compress the nerve root from the front, ligamentum root compromise
and result
flavum in radiculopathy.
hypertrophy can causeFirstly, the most
a similar common form
compression fromofthespondylosis
back leading is interverte-
to radicu-
bral disc degeneration, which can cause significant disc height loss
lopathy [52]. In some cases of spondylosis, the nerve root can be sandwiched between and stiffness [48,49].
When this happens, the neural foraminal height also decreases,
a herniating disc from the front and a thickened and buckled ligamentum flavum from which can potentially
cause
the back exiting
(Figurenerve root
1c,d), compromise,
causing leading to radiculopathy.
severe symptoms It should also
even if the compression causedbe noted
by the
that structural changes
herniating disc is minimal. from such degenerative discs increase the risk for intervertebral
disc Similarly,
herniation.the facet joints, which are paired synovial joints that play important roles
in loadSecondly, the ligamentum
transmission and stabilityflavum, bridging the
maintenance upperspinal
during and lower lamina ofcan
movements, every spi-
also be
nal level, maintains tension when in motion and also in the resting
the cause of nerve root compromise [53]. The neural foramen is bound posteriorly by state [50]. It gets thicker
andfacet
the stiffer withformed
joint, age secondary
by the to cumulative
superior and mechanical stress [51],
inferior articular and also
processes of gets
two buckled
adjacent
inside the spinal canal as the disc height decreases due to degeneration
vertebrae [54]. Whenever there is spondylosis due to ageing or abnormal mechanics [50]. While anof
intervertebral disc herniation can compress the nerve root from the front, ligamentum fla-
vum hypertrophy can cause a similar compression from the back leading to radiculopathy
[52]. In some cases of spondylosis, the nerve root can be sandwiched between a herniating
 disc from the front and a thickened and buckled ligamentum flavum from the back (Fig-
ure 1c,d), causing severe symptoms even if the compression caused by the herniating disc
is minimal.
Similarly, the facet joints, which are paired synovial joints that play important roles
Surgeries 2022, 3 in load transmission and stability maintenance during spinal movements, can also be the 263
cause of nerve root compromise [53]. The neural foramen is bound posteriorly by the facet
joint, formed by the superior and inferior articular processes of two adjacent vertebrae
[54].
the Whenever
body, there is spondylosis
inflammation due to ageing
and hypertrophy or abnormal
of the facet mechanics
joint capsule can of the body,
occur. Besides
inflammation and hypertrophy of the facet joint capsule can occur. Besides
hypertrophy, there can also be formation of osteophytes or spurs that further enlargehypertrophy,
there can also be formation of osteophytes or spurs that further enlarge the facet joints
the facet joints [55]. Additionally, osteoarthritis of the joints can lead to the formation of
[55]. Additionally, osteoarthritis of the joints can lead to the formation of synovial cysts
synovial cysts [56]. In all such cases, there is a possibility for the degenerated and enlarged
[56]. In all such cases, there is a possibility for the degenerated and enlarged facet joint to
facet joint to cause compression of the nerve root leading to radiculopathy.
cause compression of the nerve root leading to radiculopathy.
Whatever the indication as described above, if MR imaging is clearly suggestive of the
Whatever the indication as described above, if MR imaging is clearly suggestive of
causative lesion in the foraminal-extraforaminal zone compressing the nerve root, which
the causative lesion in the foraminal-extraforaminal zone compressing the nerve root,
can be correlated to the radiculopathy, then that particular nerve root can be targeted
which can be correlated to the radiculopathy, then that particular nerve root can be tar-
with an SNRB to achieve pain relief [57]. However, the severity of the lesion will be the
geted with an SNRB to achieve pain relief [57]. However, the severity of the lesion will be
deciding factor
the deciding as toaswhether
factor the the
to whether SNRB willwill
SNRB work well
work as as
well a therapeutic intervention
a therapeutic intervention[33].
Here,
[33]. Here, it should be noted that the SNRB only reduces the inflammation, the
it should be noted that the SNRB only reduces the inflammation, but but mechanical
the me-
compression causing the inflammation will prevail and hence, in
chanical compression causing the inflammation will prevail and hence, in mostmost cases, SNRB
cases,may
not be the definite therapeutic solution.
SNRB may not be the definite therapeutic solution.

3.3.Procedure
Procedure for
for SNRB
SNRB
3.1. Identifying the Affected Nerve Root
3.1. Identifying the Affected Nerve Root
In the case of disc herniation, the nerve root affected by disc herniation depends on
In the case of disc herniation, the nerve root affected by disc herniation depends on
both the level and the location of the herniation. In paracentral or posterolateral herniations,
both the level and the location of the herniation. In paracentral or posterolateral herni-
the traversing nerve root is affected. On the other hand, far lateral herniations would affect
ations, the traversing nerve root is affected. On the other hand, far lateral herniations
the exiting
would nerve
affect root. nerve
the exiting Here, root.
it should
Here, be noted be
it should that, unlike
noted that,the exiting
unlike nerve nerve
the exiting root, the
traversing
root, the traversing nerve root exits one level below the level of the compression. For ex- a
nerve root exits one level below the level of the compression. For example,
paracentral/posterolateral disc herniation
ample, a paracentral/posterolateral at L4-5 at
disc herniation would affect the
L4-5 would L5the
affect nerve root, which
L5 nerve root, is
the
which is the traversing nerve root. A far lateral disc herniation at the same level would the
traversing nerve root. A far lateral disc herniation at the same level would affect
exiting L4 exiting
affect the nerve root instead
L4 nerve root(Figure
instead2)(Figure
[58]. 2) [58].

Figure 2. Representation of L4-L5 disc level showing how the anatomy of the disc herniation would
Figure 2. Representation of L4-L5 disc level showing how the anatomy of the disc herniation would
affect the exiting or traversing nerve roots.
affect the exiting or traversing nerve roots.

The affected nerve root needs to be targeted at the point where it exits the neural
foramen. Hence, needle placement is the most important step of the procedure. Based on
expertise, different approaches can be used; however, the “oblique Scottie dog” approach is
practised widely due to its high success rates. Here, “Scottie dog” represents the appearance
of the bony vertebra in an oblique view X-ray image taken during the procedure where the
needle tip is placed below the neck of the “Scottie dog”. When a similar needle placement
is achieved without the need for an oblique view X-ray image, the procedure can be termed
the anteroposterior (AP) approach [59]. It should be noted that in both approaches, the
 foramen. Hence, needle placement is the most important step of the procedure. Based o
expertise, different approaches can be used; however, the “oblique Scottie dog” approac
is practised widely due to its high success rates. Here, “Scottie dog” represents the ap
pearance of the bony vertebra in an oblique view X-ray image taken during the procedur
where the needle tip is placed below the neck of the “Scottie dog”. When a similar needl
Surgeries 2022, 3 264
placement is achieved without the need for an oblique view X-ray image, the procedur
can be termed the anteroposterior (AP) approach [59]. It should be noted that in both ap
proaches, the needle tip is aimed for the so-called “safe zone” or “safe triangle”, while th
needle tip is aimed for the so-called “safe zone” or “safe triangle”, while the needle track
isneedle
more ortrack
lessisthe
more
same,or the
lessonly
the same, the only main
main difference difference
here is the X-rayhere
view.is This
the X-ray
zone isview. Th
zone is an inverted right-angled triangle with the pedicle as its base, lateral
an inverted right-angled triangle with the pedicle as its base, lateral vertebral border as vertebral bo
derside,
the as the side,iswhich
which is atangle
at a right a right
toangle to the
the base andbase
the and thenerve
exiting exiting nerve
root root the
forming forming th
hypotenuse (Figure 3).
hypotenuse (Figure 3).

Figure 3. Representation of safe triangle and its boundaries.

Figure 3. Representation of safe triangle and its boundaries.

3.2.The
3.2. TheAnteroposterior
Anteroposterior Approach
Approach
This
This approach
approach requires
requires the patient
the patient to lieto lie down
down proneprone on a radiolucent
on a radiolucent operating operating
table. tabl
After preparation and draping of the patient, the C-arm machine is brought in and tilted
After preparation and draping of the patient, the C-arm machine is brought in and tilte
cephalocaudally (compensating for lordosis) to get a true AP image with the affected disc
cephalocaudally (compensating for lordosis) to get a true AP image with the affected dis
level endplates parallel to each other. The vertebra corresponding to the target nerve root
levelisendplates
level identified on parallel
the APtoview.
eachThe
other.
entryThe vertebra
point corresponding
is marked to thelateral
a few centimetres targettonerve roo
level
the is identified
lateral border of the on pedicle
the APon view. The entry
the affected sidepoint
whichisis marked
followedaby few centimetres
local anaesthetic lateral t
the lateral border of the pedicle on the affected side which
infiltration of the skin. An 18-gauge needle is directed diagonally to a point justis followed by local
belowanaestheti
infiltration
and lateral to of
thethe skin. on
pedicle Anthe18-gauge
affectedneedle
side whichis directed diagonally
corresponds to a point
to the lateral side just below an
of the
lateral
“safe to the
zone” pedicle
[33,59]. Theon the affected
drawback here side which
is that corresponds
the nerve root at thisto zone
the lateral side of the “saf
is completely
zone” [33,59].
covered by the parsTheintrarticularis.
drawback here is that
Hence, theresistance
a bony nerve root at this
might zone
be felt is completely
when advancing covere
the needle [33]. In such circumstances, the needle can be walked over
by the pars intrarticularis. Hence, a bony resistance might be felt when advancing the bone laterally to th
an ideal point where the bony resistance disappears. In order to prevent X-ray exposure
needle [33]. In such circumstances, the needle can be walked over the bone laterally to a
to the administrator’s hand, the needle is held using a long sponge holder or any other
ideal pointthat
instrument where the bony
can hold resistance
it without disappears.
interfering with the In order position
needle’s to prevent X-ray
on the exposure t
C-arm
image. Advancing the needle, a bit further, would help its tip enter the neural foramen at other in
the administrator’s hand, the needle is held using a long sponge holder or any
strument
the that can
safe triangle hold
(Figure it without
4a). This needsinterfering with the
to be confirmed withneedle’s
a lateralposition
view X-ray onimage
the C-arm im
age. Advancing
(Figure 4b). Once athe needle, aplacement
satisfactory bit further, would help
is achieved its AP
in both tip and
enter the neural
lateral foramen at th
view images,
safe triangle
Iohexol (Figure to
dye is injected 4a). This needs
confirm placementto be(Figure
confirmed with a lateral
4c), followed view X-rayofimage
by a combination a (Fig
ure 4b). Once a satisfactory placement is achieved in both AP and lateral view image
steroid and local anaesthetic.
 Surgeries 2022, 3, FOR PEER REVIEW 7

Surgeries 2022, 3 265

Iohexol dye is injected to confirm placement (Figure 4c), followed by a combination of a
steroid and local anaesthetic.

Figure 4. C-arm images during the SNRB procedure. (a) Antero-posterior (AP) view of needle place-
Figure 4. C-arm
ment during images during the
the AP approach, (b)SNRB procedure.
Lateral (a) Antero-posterior
view showing (AP)
needle tip positioned inview of needle
the foramen, (c)placement
AP view following injection of Iohexol dye showing appropriate spread along the L5 nerve
during the AP approach, (b) Lateral view showing needle tip positioned in the foramen, (c) AP viewroot, (d)
Oblique view showing needle placement below the neck of the Scottie dog during the Scottie dog
following injection of Iohexol dye showing appropriate spread along the L5 nerve root, (d) Oblique view
approach, (e) AP view of needle placement in the S1 foramen, (f) Spread of dye along the S1 nerve
showing
root. needle placement below the neck of the Scottie dog during the Scottie dog approach, (e) AP
view of needle placement in the S1 foramen, (f) Spread of dye along the S1 nerve root.
3.3. The Oblique Scottie Dog Approach
3.3. The Oblique Scottierequires
This approach Dog Approach
similar patient positioning on a radiolucent table. The C-arm
is positioned
This approach for arequires
true AP view, as previously
similar described. Maintaining
patient positioning the cephalocaudal
on a radiolucent table. The C-arm
tilt, the C-arm
is positioned for isa positioned to takeas
true AP view, anpreviously
oblique viewdescribed.
X-ray imageMaintaining
of the affected level. Here,
the cephalocaudal
the vertebra corresponding to the nerve root that has to be targeted (for example, the L5
tilt, the C-arm is positioned to take an oblique view X-ray image of the affected level. Here,
vertebra in cases where the L5 nerve root is to be targeted) needs to be visualised as a
the vertebra corresponding to the nerve root that has to be targeted (for example, the L5
“Scottie dog” in the oblique view image [57,59]. Once satisfactory C-arm positioning is
vertebra in cases
obtained, the site where the L5
of injection nerve root to
(corresponding is the
to be
necktargeted) needs
of the “Scottie to be
dog”) visualised as a
is marked,
and dog”
“Scottie the skin inisthe
infiltrated
obliquewith a local
view anaesthetic
image [57,59]. agent.
OnceThen, an 18-gaugeC-arm
satisfactory spinal needle
positioning is
is inserted
obtained, the andsite advanced to a (corresponding
of injection point just below thetoneck theof the “Scottie
neck dog”.
of the “Scottie dog”) is marked,
and the skin Throughout the advancement
is infiltrated with a local of the needle, it isagent.
anaesthetic maintained
Then,inan an18-gauge
“end on” position
spinal needle is
alongand
inserted withadvanced
the direction to of the X-ray
a point justbeam
belowso that
the the
neckneedle appears
of the as a dog”.
“Scottie single point in
the C-arm image (Figure 4d) [59]. In a subsequent lateral view X-ray image, the needle tip
Throughout the advancement of the needle, it is maintained in an “end on” position
position is confirmed to be at the level of the neural foramen. Once a satisfactory place-
along with
ment theneedle
of the direction of theinX-ray
is obtained beam and
both oblique so that the
lateral needle
views, appears
the C-arm as a single point in
is re-positioned
the C-arm
for an AP image
view (Figure
image and 4d) [59]. In a subsequent
a radiopaque dye (Iohexol) lateral view
is injected X-ray
through theimage,
needle the
with-needle tip
out disturbing
position is confirmed its placement.
to be at theThelevel
accuracy andneural
of the the success rates ofOnce
foramen. the oblique Scottie dog
a satisfactory placement
of the approach
needleare said to be high,
is obtained in bothandoblique
appropriate
andspread
lateralof views,
the dye the
along the targeted
C-arm nerve
is re-positioned for
an AP is visualised
view image in most
andcases [59]. Following
a radiopaque dyethis, a combination
(Iohexol) of a steroid
is injected and the
through localneedle
anaes- without
thetic is its
disturbing injected. While the
placement. local
The anaesthetic
accuracy andgives
theimmediate
success ratestemporary
of thepain relief, the
oblique Scottie dog
steroid acts to reduce inflammation of the affected nerve root and helps with prolonged
approach are said to be high, and appropriate spread of the dye along the targeted nerve is
pain relief.
visualised in most cases [59]. Following this, a combination of a steroid and local anaesthetic
is injected. While the local anaesthetic gives immediate temporary pain relief, the steroid
acts to reduce inflammation of the affected nerve root and helps with prolonged pain relief.

3.4. SNRB Targeting S1

Targeting the S1 nerve root is completely different from the rest of the lumbar nerve
roots [60]. Here, while the patient is lying down prone on the radiolucent table, the S1
foramen needs to be visualised in the C-arm image; the C-arm needs to be tilted cephalo-
caudally until the S1 foramen, both the dorsal and ventral aspects, appear overlapped. This
is required for the needle to approach the dorsal S1 foramen without encountering any
bony structures. Once the S1 foramen is clearly visualized, the site is marked on the surface
Surgeries 2022, 3 266

and local anaesthesia infiltration is given. Then, a spinal needle is advanced up to the
dorsal S1 foramen in line with the beam of the X-ray. Once the needle tip is at the required
position as confirmed by a lateral view C-arm image (Figure 4e), Iohexol dye is injected,
and it should spread along the spinal nerve and subsequently flow into the epidural space
medial to the S1 pedicle (Figure 4f).

3.5. Ultrasonogram (USG) Guided SNRB

USG-guided SNRB for lumbar levels is recently gaining popularity due to the avoid-
ance of excessive radiation to the patient as only confirmatory X-ray images are required
during the procedure [61]. The technique could be quite demanding for first users of
ultrasound as there might be difficulty in visualizing the final needle tip due to shadowing
of the foraminal area with bony structures in the ultrasound image [62]. Currently, two
approaches have been described: The axial approach, where the ultrasound transducer is
placed perpendicular to the long axis of the body and the parasagittal approach, where
the ultrasound transducer is placed parallel to the long axis of the body with the needle
orientation being in-plane for both approaches [62]. The probe used is generally a curvi-
linear probe, which best suits the visualization of deep structures [63]. Probably due to
the difficulty in visualizing the needle tip in an axial scan, authors have used different
final ultrasound images showing the various bony elements of the vertebra during the
placement of the needle; however, studies describing the parasagittal scan are consistent
in identifying the plane between adjacent transverse processes [62]. Nevertheless, a final
X-ray is required to confirm the level, placement, and spread of dye [64]. Even though the
current evidence is not adequate to propose USG as an alternative to the use of X-rays,
further randomized trials comparing both techniques hold the key to determining if this
could be true.

4. The Pharmacological Formulae

Various authors have reported the use of different steroids, both particulate (triam-
cinolone acetonide, methylprednisolone acetate and betamethasone acetate) and nonpar-
ticulate (betamethasone sodium phosphate and dexamethasone sodium phosphate) in
combination with local anaesthetic agents, such as lidocaine or bupivacaine [65–68]. Even
though nonparticulate corticosteroids are preferred for cervical epidural steroid injections,
authors utilise both particulate and non-particulate preparations when it comes to lumbar
selective nerve root blocks without serious neurological complications [69]. The reported
benefits of particulate corticosteroids with regard to treatment efficacy and duration of relief
may outweigh their risk, especially at the lumbar levels and in those who do not respond
to nonparticulate soluble preparations [67,70]. However, there could be adverse effects due
to the preservatives and drug vehicles used in the different formulations of corticosteroids
and hence they are always to be used with caution. In addition, it should be noted that
local anaesthetic agents could cause central nervous system disruption, or cardiotoxicity, if
there is any unwanted intravascular or intrathecal injection in large doses [71]. However,
during routine selective nerve root blocks, the concentrations used and exposure durations
are unlikely to cause such toxicity [69].

5. Outcomes Following SNRB

Multiple reports have shown varied therapeutic efficiencies for SNRBs [33,34,57,72].
This is because outcomes following SNRB depend on various factors, especially the severity
of nerve root compromise, selection of patients and the pharmacological formulation used.
In addition, due to the heterogeneity among studies, reported data including appropriate
dosage, number of procedures required and adverse effects vary. Only well-designed,
large, randomized studies can provide a clear consensus regarding these aspects. However,
the current literature does provide evidence for both short-term and long-term relief of
radicular pain following SNRBs [73]. A systematic review by Roberts et al. showed that
SNRBs are not only superior to placebo but also to interlaminar epidural steroid injections
Surgeries 2022, 3 267

and caudal epidural steroid injections in treating radicular pain [74]. Another review by
Bhatia et al. showed that while there was an analgesic benefit at 3 months, there was no
impact on the incidence of surgery among those who took SNRBs [75]. Hence, it is often
portrayed as more of an intermediate treatment modality that offers temporary pain relief
for a few months without altering the long-term prognosis, especially in those with a severe
pathology compressing the nerve root [33].

6. Complications of SNRB
Some of the large studies, as that of Manchikanti et al. [76], Karaman et al. [77] and
McGrath et al. [78], which assessed 1310, 1305 and 4104 injections, respectively, have
reported mostly transient minor complications, such as intravascular penetration, bleeding,
local hematoma, bruising, vasovagal reaction, nerve root irritation, facet joint or disc entry,
facial flushing, impotency, increased pain and numbness, injection site pain, flushing
headache and weakness [79]. McGrath et al. also concluded that transforaminal injections
result in fewer minor complications, as mentioned above, than interlaminar injections.
However, reports do exist of major complications, which are extremely rare, such as
paraplegia, epidural abscess, epidural hematoma, and dural puncture [80–87]. Based on
this data, it can be understood that SNRB is a well-tolerated management strategy for
lumbar radiculopathy; even though minor side effects seem to happen more frequently,
major complications are rare and hence the procedure can be considered safe, especially in
expert hands and when due safety precautions are taken [77].

7. Conclusions
Selective nerve root block is both a useful diagnostic tool and a therapeutic procedure
that has been growing in popularity in the clinical field. It can be effective in treating
lumbar radiculopathy caused by a wide variety of conditions. The procedure itself can
be approached in many ways, as deemed appropriate by respective clinicians. This can
include different methods of visualisation of the spine with placement of the needle and
different drug combinations. As with all procedures, SNRB comes with its own set of
possible complications. However, major complications are extremely rare, and the benefits
largely outweigh the risks. In future, SNRBs may become more popular with further
advancements, such as better standardisation, and optimisation of its process to ensure
maximum periods of effectiveness.

Author Contributions: Conceptualization, J.C.R.Y., S.T.C., J.Y.-L.O. and A.-K.K.-P.; methodology,

J.C.R.Y., S.T.C. and A.-K.K.-P.; resources, J.C.R.Y. and S.T.C.; data curation, J.C.R.Y., S.T.C. and A.-K.K.-
P.; writing—original draft preparation, J.C.R.Y., S.T.C. and A.-K.K.-P.; writing—review and editing,
J.Y.-L.O. and A.-K.K.-P.; supervision, J.Y.-L.O. and A.-K.K.-P.; project administration, J.Y.-L.O. and
A.-K.K.-P. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Written informed consent was obtained from patients whose X-ray
and MRI images are shown here.
Data Availability Statement: Not applicable.
Acknowledgments: The authors sincerely thank Esther Ivorra-Molla for help with preparing the figures.
Conflicts of Interest: The authors declare no conflict of interest.

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