Patient-Specific Virtual Reality Rehearsal for Technically Challenging Lumbar Transforaminal Epidural Steroid Injection: A Pilot Randomized Controlled Trial.

Purpose: Lumbar transforaminal epidural steroid injection (TFESI) can be technically challenging in patients with complex spinal anatomy. This pilot study aimed to evaluate whether patient-specific three-dimensional (3D) virtual reality (VR) rehearsal generated from pre-procedural CT images improves procedural performance during anatomically challenging lumbar TFESI. Patients and Methods: This prospective, single-center, randomized controlled trial included 30 patients scheduled for technically challenging lumbar TFESI. Participants were randomly assigned to either the control group (n = 15) or the VR group (n = 15). In the VR group, patient-specific 3D models were generated from pre-procedural lumbar CT images and the operator performed VR rehearsal one day before the procedure. In the control group, pre-procedural CT images and, when available, magnetic resonance imaging findings were reviewed before the procedure. All procedures were performed by a single experienced pain specialist. The primary outcomes were procedure time and the number of fluoroscopic image acquisitions. Secondary outcomes included needle-bone contacts, intravascular contrast uptake, patient satisfaction, and procedure completion. Results: All patients received the allocated intervention and were included in the final analysis. Procedure time was shorter in the VR group than in the control group (215.7 ± 46.8 sec vs 254.5 ± 50.3 sec; mean difference, -38.9 sec; 95% CI, -75.2 to -2.5; p = 0.037). The number of fluoroscopic image acquisitions was also lower in the VR group (10.27 ± 2.74 vs 13.27 ± 3.65 images; mean difference, -3.00 images; 95% CI, -5.41 to -0.59; p = 0.017). The number of needle-bone contacts was numerically lower in the VR group, although this difference was not statistically significant (1.3 ± 1.1 vs 2.1 ± 1.3, p = 0.081). Patient satisfaction and intravascular contrast uptake did not differ significantly between groups. All procedures were completed as planned. Conclusion: In this pilot study, patient-specific VR rehearsal before technically challenging lumbar TFESI was associated with shorter procedure time and fewer fluoroscopic image acquisitions. These preliminary findings support further evaluation of patient-specific VR rehearsal as a useful pre-procedural planning tool for anatomically challenging TFESI cases.