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Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 3--Post surgery syndrome.

Pain Management Center of Paducah, Paducah, KY 42003, USA.
Pain physician (Impact Factor: 4.77). 01/2008; 11(6):817-31.
Source: PubMed

ABSTRACT Post surgery syndrome resulting in persistent pain following lumbar spine surgery is common. Speculated causes of post lumbar surgery syndrome include stenosis, degeneration of adjacent segments, internal disc disruption, recurrent disc herniation, retained disc fragment, epidural or intraneural fibrosis, radiculopathy, and various other causes. Epidural injections are most commonly used in post surgery syndrome. There is lack of evidence for the effectiveness of epidural injections in managing chronic low back pain with or without lower extremity pain secondary to post surgery syndrome.
A randomized, double-blind, equivalence trial.
An interventional pain management practice, a specialty referral center, a private practice setting in the United States.
To evaluate the effectiveness of caudal epidural injections in patients with chronic low back and lower extremity pain after surgical intervention with post lumbar surgery syndrome.
Patients were randomly assigned to one of 2 groups; Group I patients received caudal epidural injections with local anesthetic (lidocaine 0.5%), whereas Group II patients received caudal epidural injections with 0.5% lidocaine 9 mL mixed with 1 mL of 6 mg non-particulate Celestone. Randomization was performed by computer-generated random allocation sequence by simple randomization.
Multiple outcome measures were utilized which included the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake with assessment at 3 months, 6 months, and 12 months post-treatment. Significant pain relief was described as 50% or more, whereas significant improvement in the disability score was defined as a reduction of 40% or more.
Significant pain relief (> or =50%) was recorded in 60% to 70% of the patients with no significant differences noted with or without steroid over a period of one-year. In addition, functional assessment measured by the ODI also showed significant improvement with at least 40% reduction in Oswestry scores in 40% to 55% of the patients. The average procedures per year were 3.4 with an average total relief per year of 31.7 +/- 19.10 weeks in Group I and 26.2 +/- 18.34 weeks in Group II over a period of 52 weeks.
The results of this study are limited by the lack of a placebo group and the preliminary report size of only 20 patients in each group.
Caudal epidural injections in chronic function-limiting low back pain in post surgery syndrome without facet joint pain demonstrated effectiveness with over 55% of the patients showing improvement in functional status with significant pain relief in 60% to 70%.

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    ABSTRACT: INTRODUCTION Low back pain (LBP) is a common problem. Approximately 80% Americans experience LBP dur-ing their lifetime. An estimated 15-20% develop protracted pain, and 2-8% has chronic pain. Ev-ery year, 3-4% of the population is temporarily disabled, and 1% of the working-age population is disabled totally and permanently because of LBP. LBP is second only to the common cold as a cause of lost work time; it is the fifth most frequent cause for hospitalization and the third most com-mon reason to undergo a surgical procedure. In United States acute LBP (also called lumbago) is the fifth most common reason for physician visits. About nine out of ten adults experience back pain at some point in their life, and five out of ten working adults have back pain every year. 1 Productivity losses from chronic LBP ap-proach $28 billion annually in the United States. The most common area affected is low back be-cause the lower back supports most of body weight. 2-4 LBP is defined as chronic after 3 months because most normal connective tissues heal within 6-12 weeks unless patho-anatomic instability per-sists. A slowed rate of tissue repair in the relatively avascular intervertebral disc may impair the reso-lution of chronic LBP. Traumatic or degenerative conditions of the spine are the most common causes of chronic LBP. A number of anatomic struc-tures of the lumbar spine have been considered as the origin of lower back pain. 5-9 Many studies have shown significant im-provement with caudal epidural injections with or without steroids in patients with chronic LBP. 10,11,12 In our set up, caudal epidural blocks are routinely used to support non-operative treatment for chronic LBP and our anecdotal perception is that a considerable proportion of patients report sub-stantial pain relief after this procedure. However, there is a paucity of studies exploring the predic-tion of the therapeutic efficacy of a caudal epidu-ral block. Selecting patients with chronic LBP who would benefit from a caudal epidural block would save health care costs. The aim of this study was to find the short and medium-term therapeutic efficacy of caudal epidural bupivacaine and steroid injections in chronic LBP. ABSTRACT Background: Low back pain is a common problem. The aim of this study was to find the therapeutic efficacy of caudal epidural injections in chronic low back pain.
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    ABSTRACT: Study Design Prospective study. Purpose We compared the effects of two methods of epidural steroid injection in patients with recurrent disc herniation. Overview of Literature To our knowledge, there is no previous report of such a comparison in these patients. Methods The study was performed with 30 patients with relapsed lumbar disc herniation whose pain was not relieved by conservative remedies. The patients were divided into two groups, each of 15 patients, and entered the study for caudal or transforaminal injections. The degree of pain, ability to stand and walk, and the Prolo function score were evaluated in both groups before the injection and 2 months and 6 months after the injection. Results The degrees of pain reduction in the caudal injection group in the second and sixth months were 0.6 and 1.63, respectively, and in the transforaminal injection group were 1.33 and 1.56, respectively. The difference between the two methods was not statistically significant. Similarly, no other evaluated criterion showed a significant difference between the methods. Conclusions In the current study, the caudal and transforaminal steroid injection methods showed similar outcomes in the treatment of relapsed lumbar disc herniation. However, more detailed patient categorizing may help in finding possible subgroups with differences.
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    ABSTRACT: On behalf of the American Society of Interventional Pain Physicians (ASIPP), the board and membership, the Executive Committee thanks Washington State Health Care Authority for providing us with an opportunity to present public comments for key questions on spinal injections. ASIPP is a not-for-profit professional organization comprised of over 4,500 interventional pain physicians and other practitioners who are dedicated to ensuring safe, appropriate, and equal access to essential pain management services for patients across the country suffering with chronic and acute pain. There are approximately 7,000 appropriately trained and qualified physicians practicing interventional pain management in the United States. Interventional pain management is defined as the discipline of medicine devoted to the diagnosis and treatment of pain related disorders principally with the application of interventional techniques in managing sub acute, chronic, persistent, and intractable pain, independently or in conjunction with other modalities of treatment (1). Interventional pain management techniques are minimally invasive procedures, including percutaneous precision needle placement, with placement of drugs in targeted areas or ablation of targeted nerves; and some surgical techniques such as laser or endoscopic diskectomy, intrathecal infusion pumps and spinal cord stimulators, for the diagnosis and management of chronic, persistent or intractable pain (2).

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