Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 2 - Disc herniation and radiculitis

Pain physician (Impact Factor: 3.54). 12/2008; 11(6):801-815.


Background: The pathophysiology of lumbar radicular pain is a subject of ongoing research. The prevalence of sciatica or radiculitis ranges from 1.2% to 43%. Epidural injections are one of the most commonly performed interventions in the United States in managing chronic low back and lower extremity pain secondary to disc herniation and radiculitis. There is a paucity of evidence with contemporary methodology used in performing epidural injections under fluoroscopy and based on pain relief and functional status improvement. Study Design: A randomized, double-blind, equivalence trial. Setting: An interventional pain management practice, a specialty referral center, a private practice setting in the United States. Objective: To evaluate the effectiveness of caudal epidural injections with or without steroids in managing chronic low back and lower extremity pain secondary to disc herniation or radiculitis in providing effective and long-lasting pain relief and evaluate the differences between local anesthetic with or without steroids. Methods: Patients were assigned to one of 2 groups; Group I patients received caudal epidural injections with an injection of local anesthetic (lidocaine 0.5%), whereas, Group II patients received caudal epidural injections with 0.5% lidocaine 9 mL mixed with 1 mL of steroid. Randomization was performed by computer-generated random allocations sequence by simple randomization. Outcomes Assessment: 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 defined as 50% or more, whereas significant improvement in disability score was defined as a reduction of 40% or more. Results: The percentage of patients with significant pain relief of 50% or greater at 12 months was 79% in Group I and 81% in Group II. Reduction of Oswestry scores of at least 40% was seen in 83% of the patients in Group I and 91% in Group II. The overall average procedures per year were 3.9 ± 1.26 in Group I and 3.6 ± 1.08 in Group II with an average total relief per year of 35.2 ± 17.18 weeks in Group I and 35.9 ± 15.34 weeks in Group II over a period of 52 weeks. Limitations: The results of this study are limited by lack of a placebo group and a preliminary report of 42 patients in each group. Conclusion: Caudal epidural injections with or without steroids may be effective in patients with disc herniation or radiculitis with between 79% to 91% of patients showing significant pain relief and improvement in functional status.

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    ABSTRACT: The use of epidural steroids has been a cornerstone of interventional pain medicine as it has evolved as a specialty over the past few decades. These injections, which have been documented in the literature for more than 50 years, have been used for both radicular and axial pain throughout the neuroaxis. Studies have been performed that both support and distract from the evidence for these interventions. Many of the studies that have shown little or no support for the therapies have been flawed, by poor methodologies, lack of fluoroscopic guidance, and use of proceduralists with minimal training. Some clinicians have used these injections in excessive numbers in inappropriate patients. It is the goal of this paper to give guidelines for the proper use of this important therapy. Recommendations have been made on the frequency, route of administration, use of fluoroscopy, and type and dose of steroid but there does not currently exist a specific set of guidelines to address these issues. An extensive review of the available literature was performed, and evidence-based guidelines are established for the first time in an attempt to provide the interventional pain physician with specific guidelines concerning the administration of epidural steroids in patients with axial and radicular pain of spinal origin.
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    ABSTRACT: A randomized, double-blind, controlled trial. To determine the clinical effectiveness of therapeutic lumbar facet joint nerve blocks with or without steroids in managing chronic low back pain of facet joint origin. Lumbar facet joints have been shown as the source of chronic pain in 21% to 41% of low back patients with an average prevalence of 31% utilizing controlled comparative local anesthetic blocks. Intraarticular injections, medial branch blocks, and radiofrequency neurotomy of lumbar facet joint nerves have been described in the alleviation of chronic low back pain of facet joint origin. The study included 120 patients with 60 patients in each group with local anesthetic alone or local anesthetic and steroids. The inclusion criteria was based upon a positive response to diagnostic controlled, comparative local anesthetic lumbar facet joint blocks.Outcome measures included the numeric rating scale (NRS), Oswestry Disability Index (ODI), opioid intake, and work status, at baseline, 3, 6, 12, 18, and 24 months. Significant improvement with significant pain relief of >or= 50% and functional improvement of >or= 40% were observed in 85% in Group 1, and 90% in Group II, at 2-year follow-up.The patients in the study experienced significant pain relief for 82 to 84 weeks of 104 weeks, requiring approximately 5 to 6 treatments with an average relief of 19 weeks per episode of treatment. Therapeutic lumbar facet joint nerve blocks, with or without steroids, may provide a management option for chronic function-limiting low back pain of facet joint origin.
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    ABSTRACT: To assess the feasibility and safety of caudal epidural glucocorticoid injections performed with ultrasound guidance. We studied 30 patients with low back pain and nerve root pain related to disk herniation or associated with lumbar spinal stenosis. A caudal epidural injection was performed under ultrasound guidance. Prednisolone acetate, 5 ml, was administered with 10 ml of saline and 5 ml of iodinated contrast agent, providing an epidurogram. Acceptability of the procedure by the patient was assessed. Adverse events occurring immediately after the procedure and within the first month were collected. The sacral hiatus was identified in 29 (96.6%) patients. Mean distance between the two sacral cornua was 1.42 cm (range, 0.83-2.13) and mean diameter of the sacral hiatus was 0.60 cm (0,2-1.28). The injection proved feasible in 28 of the 29 patients. The epidurogram indicated that the injection was successful in 27 patients. Mean procedure duration was 15 minutes (30-10). No cerebrospinal fluid reflux occurred. Blood reflux was noted in 9/29 patients and resolved in eight upon needle repositioning. All patients deemed the procedure acceptable. No complications were recorded during the first month. Ultrasound-guided caudal glucocorticoid injection is a fast, easy-to-perform, well accepted procedure. In our study, an epidurogram confirming that the needle was in the epidural space was obtained in 27 of 28 patients.
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