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Caudal epidural injection of local anesthetics with or without steroids is one of the most commonly used interventions in managing chronic low back and lower extremity pain. However, there has been a lack of well-designed randomized, controlled studies to determine the effectiveness of caudal epidural injections in various conditions - disc herniation and radiculitis, post-lumbar laminectomy syndrome, spinal stenosis, and chronic low back pain of disc origin without disc herniation or radiculitis. A systematic review of caudal epidural injections with or without steroids in managing chronic pain secondary to lumbar disc herniation or radiculitis, post lumbar laminectomy syndrome, spinal stenosis, and discogenic pain without disc herniation or radiculitis. To evaluate the effect of caudal epidural injections with or without steroids in managing various types of chronic low back and lower extremity pain emanating as a result of disc herniation or radiculitis, post-lumbar laminectomy syndrome, spinal stenosis, and chronic discogenic pain. A review of the literature was performed according to the Cochrane Musculoskeletal Review Group Criteria as utilized for interventional techniques for randomized trials and the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies. The level of evidence was classified as Level I, II, or III based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE from 1966 to November 2008, and manual searches of bibliographies of known primary and review articles. The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > or = 6 months). Secondary outcome measures of improvement in functional status, psychological status, return to work, and reduction in opioid intake were utilized. The evidence showed Level I for short- and long-term relief in managing chronic low back and lower extremity pain secondary to lumbar disc herniation and/or radiculitis and discogenic pain without disc herniation or radiculitis. The indicated evidence is Level II-1 or II-2 for caudal epidural injections in managing low back pain of post-lumbar laminectomy syndrome and spinal stenosis. The limitations of this study include the paucity of literature, specifically for chronic pain without disc herniation. This systematic review shows Level I evidence for relief of chronic pain secondary to disc herniation or radiculitis and discogenic pain without disc herniation or radiculitis. Further, the indicated evidence is Level II-1 or II-2 for caudal epidural injections in managing chronic pain of post lumbar laminectomy syndrome and spinal stenosis.
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... Various methods allow for access of the epidural space. Depending on the spinal segmental origin of the pain, epidural access routes include interlaminar, transforaminal, and caudal approaches, with the last method used almost solely for lumbosacral pain [2,[6][7][8]. The present systematic review focuses on the caudal route of epidural access and steroid administration with or without other adjunctive medications. ...
... Surgical hardware may also obscure transforaminal access in some individuals. The point of entry to the caudal epidural space is located below the vertebrae that are commonly decompressed and fused surgically, thereby reducing the incidence of dural puncture during epidural injection [6,9]. However, since this point of entry is distant from affected lumbar nerve roots and discs, interventionalists rely on higher volumes of injectate [6,7] or catheter use to ensure medication delivery to the targeted level(s) [10]. ...
... The point of entry to the caudal epidural space is located below the vertebrae that are commonly decompressed and fused surgically, thereby reducing the incidence of dural puncture during epidural injection [6,9]. However, since this point of entry is distant from affected lumbar nerve roots and discs, interventionalists rely on higher volumes of injectate [6,7] or catheter use to ensure medication delivery to the targeted level(s) [10]. ...
Article
Objective Determine the efficacy, effectiveness, and safety of fluoroscopically- or ultrasound-guided caudal epidural steroid injections (ESIs) with or without catheter placement for the treatment of chronic low back (CLBP), radicular pain, and/or chronic post-surgical back pain (CPSBP). Design Systematic review. Population Adults ≥18 years with CLBP, radicular pain, or CPSBP ≥3 months. Intervention Fluoroscopically- or ultrasound-guided caudal ESI with or without a catheter including epidural neuroplasty. Comparison Sham, placebo procedure, active standard care treatment, or none. Outcomes The primary outcome was the proportion of individuals with reduction of pain by ≥ 50%. Secondary outcomes included functional improvement, analgesic use, subsequent spinal surgery, healthcare utilization, and mean improvement in pain. Reported adverse events were also cataloged. Methods Four reviewers independently assessed publications before January 2, 2022 in PubMed, Ovid MEDLINE, and Scopus. Quality of evidence was evaluated using the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) framework. Results Of 364 records screened, 23 publications met inclusion criteria. The success rates for the primary outcome could only be extrapolated from one study. Another study used a composite improvement scale that included pain and functional outcomes. The reported success rates in these two studies ranged from 40 to 58% at three months, 25%–67% at six months, and 58%–61% at one year. Data on secondary outcomes were limited; however, rates of functional improvement as measured by mean improvement in Oswestry Disability Index (ODI) ranged from 2% to 55%. Conclusion There is moderate-quality evidence that caudal ESIs using an in-dwelling catheter for two days is an effective treatment for pain and dysfunction associated with disc herniation with radicular pain and for CPSBP at three, six, and 12 months. There is low-quality evidence supporting the effectiveness of other caudal ESI techniques for pain and dysfunction associated with central lumbar spinal stenosis with neurogenic claudication, discogenic CLBP, and CLBP without disc herniation or radiculitis.
... [18] Caudal epidurals are considered the safest and easiest, with minimal risk of inadvertent dural puncture, even though requiring relatively high volumes. [19,20] However, the recent literature has shown that while caudal epidural injections may not be superior to either interlaminar or transforaminal, they may provide equal effectiveness. [19][20][21][22][23][24][25][26] The patient is usually placed in a prone position for fluoroscopy-guided caudal epidural injection. ...
... [19,20] However, the recent literature has shown that while caudal epidural injections may not be superior to either interlaminar or transforaminal, they may provide equal effectiveness. [19][20][21][22][23][24][25][26] The patient is usually placed in a prone position for fluoroscopy-guided caudal epidural injection. In the lateral view of fluoroscopy, the sacral hiatus could be identified as an abrupt drop-off at the end of the S4 lamina [27] [ Figure 4]. ...
Article
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Various pain generators can lead to low backpain. It includes conditions affecting the muscles, lumbar spine, joints, traversing and exiting nerve roots etc. The IASP named 2021 the year as the Global Year About Back Pain, highlighting its importance. Multiple modalities exist for the treatment of conditions causing low-back pain, including non-pharmacological therapies, drugs, percutaneous minimally invasive techniques and surgeries. This review aims at providing a cursory view of the common ailments causing low backache and its corresponding minimally invasive techniques.
... In the present study, transforaminal group showed better results in comparison of caudal group in terms of short terms, mid-term as well as follow up after one year. Various studies for e.g., by Boswell et al and Abdi et al Concluded in their systematic reviews about the discal pathology was strong for short term and moderate for long term pain relief and also their trends was compared in recent systematic reviews by Conn et al. 18,19,32 The VAS and ODI score improved in both the groups but the better results were with transforaminal group as compared to Caudal group for the same period of comparison. Also, significant results were achieved at 6 months post-last injection as shown in (Table 1). ...
Article
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p> Background: Low back pain is a common disorder. Nearly everyone is affected by it at some time during one’s life time. Corticosteroid injections showed early and moderate but unsustained improvements versus placebo in certain outcomes for lumbar radiculitis. Hence; the present study was undertaken for assessing and comparing the efficacy of transforaminal and caudal epidural steroid injections outcome for the treatment of lumbar radiculitis. Methods: The study was conducted prospectively on 60 patients (30 each) from 20-75 years of age. All the patients were divided into two groups; Group A included patients in which Transforaminal route was used while Group B included patients in which caudal route was used. Pain relief was assessed after the epidural steroid injection using visual analogue scale (VAS) and Oswestry disability index (ODI). Results: Mean VAS and mean ODI score for the patients of Group A was significantly lower in comparison to the patients of group B at post-last injection, 15 days post-last injection, 1-month post-last injection and 3 months post-last injection time interval. Conclusions: Transforaminal approach exhibited superior efficacy and should be performed with increasing frequency. Transforaminal epidural steroid injection also gave better quality of life.</p
... Although the number of prospective studies on the effects of epiduroscopy is limited, retrospective studies have major clinical and financial implications. [15][16][17] Very good results were obtained in the studies on the treatment of low back and radicular pain caused by discopathy, and it was preferred as a good treatment option. [18] Patient satisfaction rates were also shown to be high in satisfaction scale studies. ...
Article
Objective: To compare the efficacy of the transforaminal approach (TFA) versus the interlaminar approach (ILA) for CT-guided epidural steroid injection (CTESI) in the treatment of persistent lumbosacral radicular pain (LRP > 6 weeks) with long-term follow-up. Methods: Patients were prospectively assessed for pain by visual analogue scale (VAS) and functional disability (Oswestry Disability Index, (ODI)) before treatment, then 6 weeks (6W), 6 months (6 M), and 5 years (5Y) after CTESI. Results: Overall, n = 237 patients (TFA, n = 71 and ILA, n = 166) were included, and 96 patients had 5 years of follow-up. Both groups showed a statistically significant improvement in VAS and ODI values at 6W (TFA, n = 60 and ILA, n = 146, P < 0.001 for both), at 6 M (TFA, n = 34 and ILA, n = 96, P < 0.001 for both), and at 5Y (TFA, n = 32 and ILA, n = 64, P < 0.001 for both). No significant differences were observed between the two approaches in VAS or ODI decreases at 6W (P = 0.38 and P = 0.33 respectively), 6 M (P = 0.13 and P = 0.51 respectively), or 5Y (P = 0.15 and P = 0.57 respectively). No major complications were noted. Conclusion: Outcomes after CTESI by ILA approaches are similar to those by TFA for the treatment of persistent LRP.
Article
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Study design Systematic Review. Objectives The aim of this systematic review is to evaluate the efficacy of non-invasive procedures in relieving chronic pain due to Failed Back Surgery Syndrome (FBSS). Methods Since patients who suffered from FBBS are often non-responders to analgesics, we compared Visual Analogical Scale for low back and leg pain, Oswestry Disability Index, trial success rate, adverse events and complications between conservative treatment groups and control groups. Results The included studies were 15. Spinal Cord Stimulation (SCS) was performed in 11 trials; 4 studies assessed the efficacy of different epidural injections; one study evaluated repetitive Transcranial Magnetic Stimulation. All the studies reported back and leg pain relief after treatment with SCS, with a significant superiority in high frequences (HFS) group, compared to low frequences (LFS) group. Moreover, disability decreased with each non-invasive treatment evaluated. Epidural injections of steroids and hyaluronidase have shown controversial results. Adverse events were described in 7 studies: lead migration, hardware-related events, infection and incisional pain were the most reported. Finally, trial success rate showed better outcomes for HFS. Conclusions Our systematic review highlights the efficacy of conservative treatments in FBSS patients, with an improvement in pain scores and a decrease in disability index, especially after SCS with HFS. However, due to the lack of homogeneity among trials and population characteristics, further studies are needed to confirm the effectiveness of non-invasive interventions in patients affected by FBSS.
Chapter
Caudal canal injections are commonly performed to access the epidural space when there is lumbosacral radicular or discogenic pain attributable to the lumbosacral nerves when other approaches are not suitable due to difficult anatomy. It is imperative that an accurate placement of the needle is key to a successful procedure. The relevant anatomy and sonoanatomy are described, and a stepwise approach into the caudal canal is discussed.KeywordsInjectionsEpiduralAnesthesiaCaudalUltrasonographyLow back painSciaticaSpinal stenosis
Article
Objective The goal of this study is to assess the clinical effectiveness and prognostic potential of simultaneous bilateral lumbar transforaminal epidural steroid injections (TFESIs) in patients with bilateral radicular back pain with previous history of lumbar laminectomy and/or fusion surgery. Design Retrospective case series. Setting Single physiatrist in an academic setting. Subjects 23 patients with previous lumbar surgery who received bilateral TFESIs. Methods Cumulative bilateral radicular back pain was assessed with a pain numerical rating scale (NRS, 0-10) prior to receiving bilateral TFESI and at minimum 2 weeks follow-up. Responders included patients who experienced any NRS pain reduction post-procedure and non-responders were patients who reported no change in pain. A minimal clinically important difference (MCID) was defined as NRS change ≥2.0 to identify the proportion of responders who experienced a clinically significant reduction in pain. Other outcome measures included subsequent repeat bilateral TFESI, operations at the level of injections, and operative outcomes of these patients. Results There was a statistically significant (P<0.0001) reduction of 2.2 in mean NRS at average 3.7 weeks follow-up. With the MCID defined as NRS pain reduction ≥2, 13 of 16 responders (56%; CI 36.8-74.4%) achieved a clinically significant reduction in pain. Nine patients (39.1%) went on to receive repeat bilateral TFESIs and 9 patients (39.1%) underwent surgical interventions involving the same spinal level as the injections. Eight of the 9 patients who underwent repeat bilateral TFESIs met follow-up criteria and each responded to repeat injections with an average NRS pain reduction of 2.2. Of the 9 surgical patients, 5 responded to the previous injections and each reported improvements in pain and function after their operations (PPV= 100%). Of the 4 surgical patients who were non-responders to the injections, 2 reported improvements in pain and function post-operatively and the remaining 2 reported no change or worsening outcomes (NPV= 50%). Conclusion This study suggests bilateral TFESIs are clinically effective in short-term management of bilateral radicular back pain in patients with previous lumbar surgery, and they reveal potential prognostic information for subsequent surgical intervention.
Article
Study Design. A case report of distant discitis and vertebral osteomyelitis involving skip levels after caudal epidural steroid injection. Objectives. To report and investigate the occurrence of distant infective discitis and vertebral osteomyelitis involving skip levels after epidural injection. Summary of the Background Data. Distant discitis and vertebral osteomyelitis is a serious but rare complication after epidural injection. A case involving skip levels and without the occurrence of epidural abscess formation has apparently not been previously reported in the literature. Methods. An elderly woman presenting with clinical, radiologic, and magnetic resonance imaging evidence of spinal canal stenosis involving L3/4 and L4/5 levels and degenerative spondylolisthesis of the L4/5 level was given an epidural injection of steroids and lignocaine via the caudal route. A month later, she presented with worsened low back pain, elevated serum acute phase reactants, and plain radiographic evidence of L4/ 5 infective discitis. Magnetic resonance imaging and microbiologic examination of computed tomographically guided biopsy specimens confirmed infective discitis involving L2/3 and L4/ 5 intervertebral levels, together with adjacent vertebral osteomyelitis. Results. The patient was successfully treated with antibiotics targeted at Pseudomonas aeruginosa, which was isolated in the culture of the biopsy specimens. Follow-up improvements in the clinical condition, serum acute phase reactants levels, radiographs, and magnetic resonance imaging were noted. Conclusions. Distant discitis and vertebral osteomyelitis involving skip levels and without the occurrence of epidural abscess formation is a serious but rare complication after epidural injection.
Article
This prospective outcome study documents the efficacy of the caudal epidural administration of steroids in combination with local anesthetics in 53 patients suffering from pain secondary to radiographically documented lumbar herniated disc. All patients had lumbar disc herniation documented by magnetic resonance imaging. The finding of herniated disc was then positively correlated with positive electromyography, neurological findings on physicial examination, and the neuroanatomic distribution of the patient's pain. Patients received up to four caudal epidural blocks containing methylprednisolone and bupivicaine. At 6-months follow-up, the 51 patients who remained in the study reported a 70.8 per cent decrease in their original pain symtomatology. No complications related to the caudal epidural blocks were identified. The results of this study suggest that the caudal epidural administration of steroids in combination with local anesthetics is highly effective in the treatment of radicular pain secondary to lumbar herniated disc and that this technique is safe. Also more than three epidural blocks may be required to obtain adequate pain relief in such patients.