Caudal Epidural Injection Research Articles

Comparison of Clinical Effects and Physical Examination of Transforaminal and Caudal Steroid Injection With Targeted Catheter in Lumbar Radiculopathy: A Single-Blind Randomized Clinical Trial.

Transforaminal and caudal epidural injections are two methods of steroid injection in lumbar radiculopathy. Using a targeted catheter with the possibility of accessing the involved spinal roots and steroid administration selectively next to them during the caudal procedure may achieve the benefits of both transforaminal and caudal procedures. The aim of this study was to investigate the clinical effects and physical examinations of transforaminal steroid injection compared to caudal through a targeted catheter in lumbar radiculopathy. Fifty patients with lumbar radiculopathy candidates for epidural steroid injection were divided into transforaminal (T) and caudal (C) groups. Steroid injection under fluoroscopic guidance was performed in group T with the transforaminal method and in group C with the caudal method using a targeted catheter for each involved spinal nerve root. Pain intensity visual analog scale (VAS), Oswestry Disability Index (ODI), daily analgesic consumption, and physical examinations on four follow-ups (before injection, second week, first and third month) were evaluated. Pain score (VAS) and functional disability index (ODI) were similar in both groups, and there was no significant difference between the two groups (p>0.05). The positive Lasègue test was significantly higher in the caudal group than in the transforaminal group only in the third month (p<0.05). Other physical examinations in both groups did not have significant differences in all the follow-ups. Moreover, there was no difference in the amount of analgesic consumption in the two groups. No complications were observed in both groups. This study showed that transforaminal and caudal steroid injection (with a targeted catheter) in patients with lumbar radiculopathy had similar effects in controlling pain and improving functional disability of patients in the short term. Cases of recurrence of positive Lasègue test in physical examinations in the long term (third month) in the caudal group may indicate the preference of the transforaminal approach. Iranian Registry of Clinical Trials (IRCT) number: IRCT20111102007984N31.

Long-term outcomes of caudal epidural steroid injection in failed back surgery syndrome patients with loss of resistance technique

Background: Failed back surgery syndrome (FBSS) is a complicated issue with various treatment approaches. This retrospective study assesses the success and safety of caudal epidural steroid injection (CESI) in FBSS patients utilizing the loss of resistance (LOR) strategy, focusing on long-term outcomes lasting up to two years. Methods: The 75 FBSS patients had CESI with triamcinolone and normal saline under local anesthesia. The visual analog score (VAS), Oswestry disability index (ODI), and patient satisfaction score (PSS) were measured at pre-intervention and 3, 6, 12, 18, and 24 months following the procedure. Result: Majority of patients (57.33%) reported bilateral sciatica, with recurrent disc herniation (54.67%) being the most prevalent MRI finding. Significant improvements (p&lt;0.001) in VAS, ODI, and PSS scores were seen in all subsequent periods. Furthermore, no significant issues reported, demonstrating the safety and effectiveness of CESI with LOR. Conclusions: CESI with the LOR technique is helpful treatment in FBSS at three, six, twelve, eighteen, and twenty-four months. It is easy to perform, less technically demanding, has low complications, and lower costs than surgery. A CESI may offer an alternative approach to managing FBSS for short-term and long-term outcomes.

The efficacy of ultrasound and fluoroscopy-guided caudal epidural prolotherapy versus steroids for chronic pain management in failed back surgery syndrome

ABSTRACT Background Caudal epidural prolotherapy injection has emerged as a successful treatment for managing chronic pain. This study is a prospective randomized, double-blinded clinical trial. It assesses and compares the effectiveness of prolotherapy versus steroid injection for pain relief in cases of failed back surgery syndrome (FBSS). It involved randomly assigning 90 patients with FBSS to one of two equal groups: steroids or prolotherapy. The VAS was used to measure pain as the primary outcome, while disability was measured by the Oswestry disability index (ODI). McGill Pain Questionnaire (MPQ) and complications were recorded as secondary outcomes. Results The VAS improved significantly from the baseline in both groups at all follow-up periods (p < 0.001). Nonetheless, after 2, 4, and 6 weeks post-injection, there was no statistically significant difference between the two groups, while at 8 weeks, 3, and 6 months, the VAS was statistically significantly lower in the steroids group than in the prolotherapy group (p < 0.001). The ODI and MPQ improved significantly from the baseline in both groups at all follow-up periods (p < 0.001). However, after 2 and 4 weeks post-injection, there was no statistically significant difference between the two groups; but, at 6 and 8 weeks, 3, and 6 months, the ODI and MPQ were statistically significantly lower in the steroid group compared to the prolotherapy group (p < 0.001). Only one patient in the steroid group suffered from pain and swelling at the injection site without a statistically significant difference between the two groups. Conclusion Caudal epidural prolotherapy injection has good efficacy in managing pain that can be similar to steroid injection but shorter in duration in cases of FBSS with comparable safety profile.

Effectiveness of Ultrasonography- and Fluoroscopy-Guided Caudal Epidural Injections in the Management of Chronic Lumbar Disc Disease: A Retrospective Comparative Study.

Lumbar disc disease is one of the common causes of lower back pain caused by a change in the structure of the normal disc. Most of the time, disc disease happens as a result of aging and the normal breakdown that occurs within the disc.Caudal epidural steroid injections are the popular treatment for patients with chronic low back pain that does not respond to conservative management. A retrospective survey was administered to 160 patients whohad received caudal epidural injections forchronic low back pain in the past, but only 74 patients who completed the scheduled follow-ups were included in the study. They were divided into two groups based on the imaging modality used for guiding the caudal epiduralsteroid injections, either ultrasonography or fluoroscopy, and thenassessed for improvement in pain on the Numeric Rating Scale (NRS), forfunctional improvement on theOswestry Disability Index (ODI), and for satisfaction on the North American Spine Society Patient Satisfaction Scale (SSPSS). Mean NRS pain scores improved significantly from baseline at 6.78 and 7.00 in the fluoroscopy and ultrasound groups, respectively, to 2.03 and 2.16 at 12 weeks post-procedure. The difference between the groups was not statistically significant (p > 0.05). The Oswestry Disability Index was completed at baseline and after 12 weeks of follow-up for both groups, and there was no significant difference between the two groups; the fluoroscopy group's mean Oswestry Disability Index scores were 52.4 at baseline and 35.6 at 12 weeks, whereas the scores for the ultrasound group were 50.3 at baseline and 37.9 at 12 weeks. Conversely, patient satisfaction as assessed using the SSPSS rose in both groups up to 12 weeks (p > 0.05). The ultrasound- and fluoroscopy-guided caudal epidural steroid injections proved equally effective in easing the pain, disability, and satisfaction levels of patients with chronic lower back pain.

(084) PERSISTENT GENITAL AROUSAL DISORDER/GENITO-PELVIC DYSESTHESIA (PGAD/GPD) SECONDARY TO TARLOV CYST-INDUCED SACRAL RADICULOPATHY

Abstract Introduction Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD) is characterized by persistent, unwanted genital arousal and/or other dysesthesia, including burning, itch and/or pain in the genito-pelvic area such as clitoris, vulva, perineal region and/or peri-anal region (pudendal nerve), umbilicus, urethra, bladder, vagina, and/or rectum (pelvic nerve) and also including the lower extremity buttock, thigh, calf, foot (sciatic nerve). Patients with PGAD/GPD are significantly bothered/distressed, and catastrophization and suicidal ideation are common. In 2012 Komisaruk reported that PGAD/GPD could result from Tarlov cyst-induced sacral radiculopathy. We developed a multidisciplinary step-care management algorithm with specialists in sexual medicine, spine surgery, sex therapy, physical therapy, and neurophysiology to diagnose and treat Tarlov cyst-induced sacral radiculopathy. Objective To utilize a multidisciplinary step-care management algorithm to identify PGAD/GPD patients with Tarlov cyst-induced sacral radiculopathy who could benefit from Tarlov cyst spine surgery and to evaluate long-term safety and efficacy of the surgery. Methods Clinical data were collected on PGAD/GPD patients who underwent Tarlov cyst spine surgery between 2016 and 2020 with at least 1-year follow-up. The management algorithm used to identify and treat Tarlov cyst-induced sacral radiculopathy involves: detailed psychosocial assessment and medical history; non-invasive diagnostic assessments for sacral radiculopathy; sacral MRI with Tarlov cyst protocol; targeted diagnostic caudal epidural injection; and if appropriate, Tarlov cyst spine surgery using minimally invasive surgery techniques. Treatment outcome was based on the validated Patient Global Impression of Improvement (PGI-I) measured at regular intervals post-operatively. Results Ten patients (8 women, 2 men), mean age 40 years (range 19-66), met inclusion criteria. Patients were discharged the same day or following morning post-operatively. No serious complications occurred. Follow-up was &amp;gt;12 months (range 13-22 months). Seven (70%) patients reported post-operative clinical improvement on PGI-I at last follow up: two patients reported “very much better”, three patients reported “much better” and two patients reported “little better”. Two patients had no improvement. Only one patient was much worse, however we believe that the PGI-I score of 6 reflected the worsening of the PGAD/GPD condition and not specifically the result of the surgical procedure. Conclusions Distressing PGAD/GPD symptoms can be caused by Tarlov cyst-induced sacral radiculopathy. A multidisciplinary step-care management algorithm allows selection of appropriate surgical candidates. To the best of our knowledge, this is the largest case series of patients with PGAD/GPD treated with Tarlov cyst spine surgery with at least 1 year follow-up. Using minimally invasive spine surgery techniques, spine surgery on the Tarlov cyst was associated with clinical improvement in 70% of select patients. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Elliquence.

Combined Ultrasound and Fluoroscopy versus Ultrasound versus Fluoroscopy-Guided Caudal Epidural Steroid Injection for the Treatment of Unilateral Lower Lumbar Radicular Pain: A Retrospective Comparative Study.

Background and Objectives: This study aimed to evaluate the mid-term effectiveness and safety of a combined ultrasound (US) and fluoroscopy (FL)-guided approach in comparison to US-guided and FL-guided caudal epidural steroid injections (CESI) for treating unilateral lower lumbar radicular pain. Materials and Methods: A total of 154 patients who underwent CESI between 2018 and 2022 were included. Patients were categorized into three groups based on the guidance method: combined US and FL (n = 51), US-guided (n = 51), and FL-guided (n = 52). The study design was retrospective case-controlled, utilizing patient charts and standardized forms to assess clinical outcomes, adverse events, complications during the procedures. Results: In all groups, Oswestry Disability Index and Verbal Numeric Scale scores improved at 1, 3, and 6 months after the last injection, with no significant differences between groups (p < 0.05). The treatment success rate at all time points was also similar among the groups. Logistic regression analysis showed that injection method, cause, sex, age, number of injections, and pain duration did not independently predict treatment success. Blood was aspirated before injection in 2% (n = 1), 13.5% (n = 7), and 4% (n = 2) of patients in the combined US and FL groups, FL-guided groups, and US-guided groups, respectively. Intravascular contrast spread was detected in one patient in the combined method groups and seven in the FL-guided groups. Conclusions: When comparing pain reduction and functional improvement, there was no significant difference between the three methods. The combined method took less time compared to using FL alone. The combined approach also showed a lower occurrence of intravascular injection compared to using FL alone. Moreover, blood vessels at the injection site can be identified with an ultrasound using the combined method. Given these advantages, it might be advisable to prioritize the combined US- and FL-guided therapy when administering CESI for patients with unilateral lumbar radicular pain.

Ultrasound-guided caudal epidural injection to treat symptoms of lumbar spinal stenosis: a retrospective study.

Lumbar spinal stenosis (LSS) occurs when bony, ligamentous, and synovial elements of the lower axial spine degenerate and overgrow, compressing neural and vascular elements in the spinal canal. Compression can cause static back pain, radicular lower extremity pain, or neurogenic claudication. Radiological and clinical findings are needed to diagnose lumbar stenosis. In this framework, caudal epidural steroid injection (ESI) is a standard treatment. The volume injected and needle positioning are the main issues that could compromise the effectiveness of the epidural injection. However, ultrasound-guided caudal epidural injections have become more common in recent years. Since Klocke and colleagues described the ultra-sound-guided caudal block in 2003, it has grown in popularity. Multiple ethnic studies have reported ultrasound-guided caudal injection success rates of 96.9-100%. Color Doppler ultrasonography can also determine if a drug solution reaches the lumbosacral region. We enrolled 42 patients with lumbar spinal stenosis, persistent lumbosciatalgia, and neurogenic claudicatio unresponsive to painkillers who were not surgical candidates. Each patient receives four weekly injections for four weeks. If the patient responds to treatment but still has pain, monthly injections are needed to reach and maintain the benefit. Treatment will be changed if the patient does not respond after 4 caudal injections. Sterile caudal epidural injections are performed with ultrasound guidance and a spinal needle 21G. Triamcinolone 40 mg, levobupivacaine 10 mg, and physiological solution 10 ml are delivered. Each patient received an average of 4 injective treatments (4±2, Means 4, SD 2). Data analysis shows that the treatment reduced pain significantly before and after therapy, which persisted after 3 months. Caudal epidural injection is one of the most common conservative treatments for chronic low back pain with radiculopathy, and lidocaine alone or with steroids is effective. In this framework, the two main literature issues about caudal epidural injection effectiveness on lumbar pain are correct. Therefore, 10 ml is suitable and effective for treating symptoms without side effects. Pain reduction of over 50% from start to finish and three-month follow-up have shown significant results in pain control and disability improvement. Finally, caudal epidural injection for lumbar spinal stenosis symptoms is effective, safe, and provides long-term pain relief.

Evaluation of the effectiveness of caudal epidural steroid injection as an adjuvant to ganglion impar pulsed radiofrequency therapy in chronic coccygodynia

BackgroundThis study aimed to evaluate the effectiveness of adding caudal epidural steroid injection (CESI) to ganglion impar pulsed radiofrequency (GI-PRF) therapy in patients with refractory chronic coccygodynia, and to determine the effect of pain duration and trauma on treatment success. Materials and methodsForty patients who underwent GI-PRF (n = 20) or GI-PRF + CESI (n = 20) were retrospectively assessed for age, gender, pain duration, history of trauma to the coccyx, Numerical Rating Scale (NRS) pain scores pre-procedure and 1, 3, and 6 months post-procedure and satisfaction rates at 6 months post-procedure. Satisfaction was categorized as excellent, high, moderate, and low. ResultsIn both groups, NRS scores were significantly decreased at 6 months (pre-vs. 6 mo. post-procedure: GI-PRF [8 vs. 5], GI-PRF + CESI [8.5 vs. 3.5]; p < 0.001). The proportion of patients reporting excellent satisfaction was significantly higher in the GI PRF + CESI group (50 % vs. 15 %; p < 0.05). Patients with trauma history in the GI-PRF + CESI group had significantly lower median NRS values at 6 months compared to patients in both groups with negative trauma history (p < 0.02). Within the GI-PRF only group, patients with trauma history had significantly lower NRS scores at 6 months than those without a history of trauma (p = 0.012). Pain duration did not significantly impact satisfaction levels (p = 0.055). ConclusionGI-PRF therapy was effective in coccygodynia, especially in patients with positive trauma history, and adjuvant CESI increased patient satisfaction by providing better pain control.

Experience with Gore’s Block in Patients with Lower Lumbar Radiculopathy

Abstract Lower lumbar radiculopathy is one of the most common presentations in the pain clinic outpatient department (OPD). A thorough history, physical examination, neurological assessment, and imaging help in the diagnosis and management. The inability to identify the correct pain generator often causes a failure of treatment. Dr. Satishchandra Gore has proposed a new method for the diagnosis of affected lower lumbar nerve root (L5 and S1) at a peripheral level. His hypothesis is that in an inflamed nerve root, sodium channels are upregulated at both proximal and distal ends (central and peripheral). This results in tenderness at the distal peripheral end of the nerve on palpation. We can block the sodium channels at the distal portion of the same inflamed nerve, which may be able to abolish pain. This procedure is called “Gore’s Block” and the result is called “Gore’s sign.” We used this technique in 10 patients with suspected L5-S1 radiculopathy. Out of 10 patients, seven patients had pain relief after Gore’s block. These seven patients also responded well to a Caudal epidural steroid injection. Two patients did not have significant pain relief with Gore’s block and had poor responses to epidural steroid injections. One patient got therapeutic pain relief after Gore’s block, probably due to the natural resolution of the disease. Gore’s block is a simple, OPD procedure, helpful in diagnosing the level of nerve affection in lower lumbar radiculopathy. It is diagnostic and has a good correlation with epidural blocks. Whether it is therapeutic in nature needs to be further investigated.

A Comparison of Analgesic Efficacy of Triamcinolone vs Magnesium Sulfate as Adjuvants in Caudal Block in Patients with Low Back Pain: A Double-Blind Randomized Controlled Trial.

Chronic low back pain (CLBP) is a common issue among older adults. Radicular pain syndromes are often managed with caudal epidural injections. Our study aimed to compare the effects of triamcinolone and magnesium sulfate, used as adjuvants to local anesthetics in caudal blocks, on pain levels and quality of life in patients with LBP. A total of 40 patients undergoing caudal block were randomized to two groups,received 10 mL caudal epidural injection of either injection 9 mL of ropivacaine 0.1% and 1 mL of triamcinolone; 40 mg (Group T, n = 20) or magnesium sulfate; 200 mg (group M, n = 20). Improvements in the pain score measured with the Visual Analog Scale (VAS) and functional ability measured with the Oswestry Disability Index (ODI) were the primary and secondary outcome measures, respectively. Before, one month and three months after the caudl block, the VAS and ODI scores were evaluated. The VAS and ODI scores did not exhibit a significant difference between the 2 groups at all post-injection time points, except for the VAS score at 3 months, which showed a statistically lower value in group M compared to group T (P = 0.046). However, when comparing within the same group, both groups showed significantly improved VAS and ODI scores at all post-injection time points compared to the pre-injection scores (P < 0.0001). The addition of magnesium or triamcinolone to a local anesthetic in caudal epidural injections does not result in any discernible difference. However, this combination may lead to improvements in pain levels and quality of life, and these improvements can be sustained for up to 3 months.

Study of caudal ropivacaine with or without dexmedetomidine for postoperative analgesia in paediatric genitourinary infraumbilical surgery: a double-blinded randomized controlled trial.

Various studies have described the use of Dexmedetomidine with local anaesthetic drugs in caudal blocks for the management of postoperative pain in children. This study was designed to determine the analgesic effect of caudal Dexmedetomidine with Ropivacaine in paediatric genitourinary infraumbilical surgeries. Postoperative analgesic effects of caudal Ropivacaine with or without Dexmedetomidine in paediatric genitourinary infraumbilical were evaluated. This study was a prospective, interventional, comparative study conducted after ethical approval from the institute. Informed expressed consent was taken from each patient's guardians. The sample size was calculated to be 31 in each group. The two groups were randomly assigned and the intervention involved caudal epidural injection with either Ropivacaine combined with Dexmedetomidine or Ropivacaine with Normal Saline. Children receiving Ropivacaine with Dexmedetomidine had a significantly prolonged duration of analgesia compared to those receiving Ropivacaine alone (840.35 ± 149.97 vs. 412.90 ± 93.46 min, P < 0.001). Postoperative rFLACC scores were consistently lower in the Dexmedetomidine group, indicating better pain control (P < 0.05 at 6, 12, and 24 h). Total analgesic consumption was lower in the Dexmedetomidine group (500.67 ± 212.92 vs. 741.75 ± 268.06mg, P < 0.01). No significant differences in adverse effects were observed between the groups. The addition of Dexmedetomidine to Ropivacaine in caudal epidural significantly prolongs analgesia, improves pain control, and reduces analgesic consumption in paediatric genitourinary infraumbilical surgeries.

Hybrid Technique for Caudal Epidural Steroid Injection in Morbid Obese Patient

Incidence of back pain related to disc prolapse is higher in morbid obesepatients. Treatment options including epidural injections and surgery is difficult in such patients. Here we are discussing a case of successful Hybrid technique for caudal epidural steroid injection in a morbidly obese patient.

ORAL OPIOID ANALGESICS VS SPINAL STEROID INJECTIONS IN THE TREATMENT OF LOW BACK PAIN: A COMPREHENSIVE SYSTEMATIC REVIEW

Introduction: Low back pain (LBP) affects a significant portion of the population worldwide, with distinct treatment needs for acute and chronic cases. Despite widespread opioid use, evidence for their efficacy in LBP remains uncertain, highlighting the need for alternative interventions. Minimally invasive procedures like epidural steroid injections offer potential relief for conditions like lumbar disc herniation, but their effectiveness is debated. To address these complexities, we conducted a comprehensive review encompassing various treatment modalities beyond medication, aiming to optimize outcomes and improve quality of life for individuals with LBP. Method: The researchers in this study followed the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines to ensure that their work met the required standards. This was done to ensure the precision and reliability of the conclusions derived from the research. Result: Our search produced 13 results. After looking at the titles and summaries, we found 8 papers that fit our criteria. At first, we excluded several articles because they were written in review style and case reports. But after reading the full papers carefully, we included four papers in our final analysis. These papers included retrospective analysis, a randomized, double blind, placebo controlled cross-over study, noninterventional, retrospective 12-week study using anonymized clinical practice data from the German Pain eRegistry, and a retrospective analysis of anonymized, propensity score–matched data. Conclusion: Favorable post-injection outcomes suggest the blind method for caudal epidural injections is safe and effective, suitable for patients not eligible for surgery or unresponsive to conservative treatments. Interlaminar epidural steroid injections effectively reduce VAS and ODI scores in patients with chronic low back pain and multi-level disc disease, but further research is needed to standardize administration protocols and optimize treatment outcomes, including addressing BMI's impact. The analgesic efficacy of periradicular meloxicam injections for acute/subacute low back pain, indicating a potential new treatment option, while real-world data suggest NBX oromucosal spray may be superior to typical oral LAO analgesics for severe peripheral NBP, pending confirmation in large RCTs.

Comparing the Efficacy of Transforaminal and Caudal Epidural Injections of Calcitonin in Treating Degenerative Spinal Canal Stenosis: A Double-Blind Randomized Clinical Trial.

Lumbar spinal stenosis (LSS) is the most common indication for lumbar surgery in elderly patients. Epidural injections of calcitonin are effective in managing LSS. This study aimed to compare the efficacy of transforaminal and caudal injections of calcitonin in patients with LSS. In this double-blind randomized clinical trial, LSS patients were divided into two equal groups (N = 20). The first group received 50 IU (international units) of calcitonin via caudal epidural injection (CEI), and the second group received 50 IU of calcitonin via transforaminal epidural injection (TEI). The Visual Analogue Scale (VAS) and Oswestry Low Back Pain Disability Questionnaire (ODI) were used to assess the patient's pain and ability to stand, respectively. Visual Analogue Scale and ODI scores were recorded and analyzed. The results showed that caudal and TEIs of calcitonin significantly improved pain and ability to stand during follow-up compared to before intervention (P < 0.05). Additionally, CEI of calcitonin after 6 months significantly reduced pain in LSS patients compared to TEI of calcitonin (P < 0.05). However, no significant difference was observed between the two epidural injection techniques in improving the patient's ability to stand (P > 0.05). The results of the study indicate that epidural injection of calcitonin in long-term follow-up (6 months) had a significant effect on improving pain intensity and mobility in patients with LSS, and its effect on pain in the TEI method was significantly greater than that in the CEI method.

(148) “Zebras” in Sexual Medicine from Cauda Equina Pathology

Abstract Introduction Unrelenting, bothersome sexual medicine problems in individuals with a vulva or penis sometimes do not respond to conventional therapies, frustrating both patient and provider. These distressing problems can be categorized as a genito-pelvic dysesthesia (GPD), including genito-pelvic (penile, scrotal, clitoral, vulvar, vestibular, vaginal, bladder, rectal) pain, persistent genital arousal disorder (PGAD), sleep related prolonged erections (SRPE) and hard-flaccid syndrome (HFS), currently considered as “zebras” in sexual medicine. We recently published a study on 20 patients with PGAD/GPD who underwent a multi-disciplinary management algorithm, were determined to have lumbosacral annular tear induced sacral radiculopathy, and with one year follow-up post-spine surgery, 80% revealed improvement in symptoms. Objective To apply our (spine-sexual medicine) multi-disciplinary management algorithm to sexual medicine “zebras”. Methods Patients who presented between July 1, 2021, and June 30, 2023, to our sexual medicine clinic were included in the study cohort. The management algorithm was as follows: biopsychosocial history, multiple validated instruments, physical examination, neurogenital testing, regional anesthesia testing, lumbosacral MRI, and when appropriate, a caudal epidural or transforaminal epidural spinal injection. Those with clinically significant symptom reduction from the spinal injection were offered appropriate spine surgery. Patient Global Impression of Improvement (PGI-I) was assessed post-operatively (1 = very much better, 2 = much better, 3 = better, 4 = no change, 5 = worse, 6 = much worse and 7 = very much worse. Results Our study cohort consisted of 24 patients, 14 with a vulva and 10 with a penis, mean age 42 years (range 25-69) who presented to our clinic over a period of two years. The patients' GPD complaints included genital pain (13), PGAD (6), SRPE (2), HFS (1), bladder pain (1) and rectal pain (1). All patients had results of neurogenital and regional anesthesia tests consistent with sacral radiculopathy, then underwent a diagnostic focal lidocaine spinal injection. Each had a positive response to either a transforaminal epidural spinal injection and underwent lumbar endoscopic spine surgery (n = 21) or a caudal epidural and underwent Tarlov cyst surgery (n = 3). PGI-I scores after surgery indicative of improvement (PGI-I = 1, 2, 3) at one week was 10/22 (45%), at 6 weeks was 9/17 (53%) at 3 months was 9/16 (56%) and at 6 months was 5/6 (83%). Conclusions Patients presenting with sexual medicine complaints not successfully managed by routine treatment strategies often experienced delay in diagnosis and excessive healthcare-seeking behavior resulting in significant distress. In our experience, GPD can result from triggers in the cauda equina, far from the location of the presenting genito-pelvic symptom(s). Our cohort of sexual medicine “zebras” who underwent our multi-disciplinary management algorithm were diagnosed with sacral radiculopathy. These patients opted for spine surgery and reported improvement of symptoms that continued to get better over time. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Eliquence.

Demographic Characteristics and Pain Treatments of Patients Applying to the Algology Polyclinic of Firat University Medical Faculty

Aim: The aim of this study is to retrospectively evaluate the patients who were admitted to the Algology polyclinic with pain, focusing on their sociodemographic characteristics, types of pain, and pain management. Materials and Methods: In this study, the pain assessment forms of patients who presented to our Algology polyclinic with pain complaints between January 2022 and December 2022 were examined. The sociodemographic characteristics of the patients, pain properties, and treatments administered were retrospectively evaluated. Results: Within one-year period, a total of 2001 patients have been admitted to our clinic. 75.5% of the patients were between the ages of 15 and 64. The average age of men was found to be significantly lower than the average age of women. 71.7% of the patients were overweight or obese, with obesity being more prevalent in women. Additionally, 69.8% of the patients had at least one comorbidity, with cardiovascular disease (CVD) and diabetes mellitus (DM) being the most common. The most common causes of pain were low back pain, neck pain, myofascial pain, and knee pain. The Visual Analog Scale (VAS) score was found to be 6.64. Interventional pain treatment was applied to 53.3% of the patients, with the most common methods were caudal epidural injection, cervical epidural injection, and ozone trigger point injection. Conclusion: Close examination of patients' responses to treatment and knowledge of sociodemographic characteristics are important. In addition to well-planned medical treatment for pain, we believe that interventional pain treatment can alleviate patients' pain, improve their quality of life, and potentially prevent work loss due to chronic pain.

Efficacy of caudal epidural steroid injection in the Management of low backache with radiculopathy

Efficacy of caudal epidural steroid injection in the Management of low backache with radiculopathy

Intercepting Intracept: A Case Report of Idiopathic Arachnoiditis

Introduction: Determining the exact diagnoses for low back is challenging due to the myriad of causative factors. Consequently, rare diagnoses like arachnoiditis are often overlooked, causing patients with this condition to be ineffectively treated. Arachnoiditis involves inflammation of the arachnoid membrane enveloping the spinal cord, can is caused by diverse etiological factors, including infections, trauma, spinal cord contamination, tumors, and genetic predispositions. Case: In this case report, the author describe a 43-year-old female with a past medical history of anxiety and depression who presented with chronic back pain. The patient had previously undergone trials of various neuropathic and nociceptive modulating medications as well as transforaminal and caudal epidural corticosteroid injections, yielding minimal relief. On the evaluation, the patient’s lumbar spine MRI revealed findings suggestive arachnoiditis, a diagnosis that had also been missed on a previous MRI a year prior. Given this, the patient was advised to not undergo the Intercept procedure which had been previously recommended by another provider. Discussion: Given its resemblance to other neurologic conditions, the diagnosis of arachnoiditis involves a comprehensive approach with history, physical examination, and imaging modalities such as MRI or CT myelography serving as critical components. In this case, the patient did not have any history of infection or trauma, making the diagnosis more elusive, and requiring the team to pay more heed to the imaging finding. Although her imaging served supportive evidence or arachnoiditis, it is important to recognize its correlation with clinical findings and the severity of symptoms is not always consistent. Management of arachnoiditis requires a multi-faceted approach with steroids, neuropathic modulating medications, muscle relaxants, cognitive behavioral therapy, and physical therapy. Conclusion: This case report underscores the diagnostic challenges and clinical intricacies associated with spinal arachnoiditis. The presented patient's atypical symptoms and protracted diagnostic journey highlight the importance of ongoing vigilance and comprehensive evaluation in chronic pain management. Further research should investigate effective treatment modalities for this chronic and debilitating condition that is overlooked, given its similarity to other diagnoses and rare prevalence.

Practice Patterns of Physicians who Perform Caudal Epidural Steroid Injections.

Caudal epidural steroid injections (ESIs) are commonly employed in the management of low back pain and radiculopathy. Despite their widespread use, practice patterns among physicians performing caudal ESIs can vary significantly. This study aims to identify variability in injection techniques utilized by physicians during caudal ESIs, focusing on steroid use, needle selection, and catheter use. This study also looks at major permanent neurological injuries related to caudal ESIs. A survey was distributed to a cohort of physicians who regularly perform ESIs. The survey comprised questions regarding the type of needle primarily used, steroid selection, the use of catheters, and major neurological injuries from caudal ESIs. The respondents included a diverse group of pain management physicians from various specialties and practice settings. The results revealed a predominant preference for the use of particulate steroids (72.41%) when performing caudal ESIs. Additionally, physicians primarily prefer to use spinal needles (72.41%) compared to other needle types. A majority of physicians (65.12%) reported that they never use a catheter when performing caudal ESIs to access higher pathology. Finally, all physician responders (100%) reported that they have never caused a permanent neurological injury when performing a caudal ESI. This survey provides initial data among physicians who perform caudal ESIs. Our results demonstrate the majority of physicians favor using particulate steroids and a spinal needle, with fewer opting to use a catheter during these procedures. There were no reported major permanent neurological injuries, demonstrating that caudal ESIs are a safe interventional option for managing lumbosacral pain complaints.

Comparative Evaluation of Caudal Epidural Method to Ultrasound-Guided S1 Transforamen Block in Patient's Lumbar Discectomy with Failed Back Syndrome Symptoms: A Double-Blind Clinical Trial.

Post-lumbar surgery syndrome (PLSS) refers to persistent or recurrent pain following spinal surgery with an unknown cause. It is commonly associated with epidural fibrosis (EF). Some studies suggest that epidural steroid injection (ESI) can effectively alleviate pain in PLSS, particularly when targeting the S1 nerve root using S1 transforaminal epidural steroid injection (S1-TFESI). A key factor in a successful block is accurately visualizing the first dorsal sacral foramen, and the needle's destination is the dorsal S1 foramen. Although S1-TFESI is often performed under fluoroscopy through the transforaminal route, an alternative to reduce radiation exposure is ultrasound guidance. This study aimed to compare the efficacy of ultrasound-guided caudal epidural steroid injection (CESI) and S1-TFESI in PLSS patients. A randomized double-blinded clinical trial was conducted involving 52 PLSS patients who were randomly assigned to either the CESI group or the S1-TFESI group. The patients were positioned prone. A linear transducer with a curve at a low frequency (2 - 5 MHz) was used to visualize the area. An aseptically prepared puncture site was used to insert a 2- to 5-MHz curved ultrasound probe with an ultrasound gel to identify the articular processes of the lower lumbar vertebrae and the posterior sacral surface. The probe was then positioned longitudinally to the para-sacral area, about 2 cm lateral to the midline. The articular process represented the L5/S1 level at the farthest caudal side, and the S1 posterior sacral foramen was represented by the concavity at the posterior sacral surface that was somewhat caudal. The probe was angled caudally to provide enough room for the needle to enter the S1 foramen. The injection site for the needle tip was the S1 foramen. A combination of triamcinolone (40 mg, 1 mL), normal saline (2 mL), and ropivacaine (0.2%) was administered. For TFS1 ESI, 5 mL of the combination was used. For CESI, the sacral hiatus was palpated in the prone position, and a linear high-frequency transducer was placed transversely to obtain a transverse view of the sacral hiatus. A combination of triamcinolone 40 mg and ropivacaine (0.2%) totaling 10 mL was employed. The Numerical Rating Scale (NRS) and Oswestry Disability Index (ODI) were used to assess patients' preoperative and postoperative conditions, and adverse events were recorded. Follow-up was conducted one week and one month after the procedures. In both groups, NRS and ODI scores decreased at different time points after treatment, compared to baseline (P < 0.001). The CESI group had lower median ODI scores after one week and one month, although this difference did not reach statistical significance (P = 0.334). Despite similar baseline NRS ratings, the CESI group had statistically significantly lower mean NRS scores at one week and one month (P < 0.001). The current study demonstrated that both CESI and TFESI treatments for PLSS following lumbar discectomy are effective and safe. These procedures can alleviate pain and reduce disability. Although the success rates of the two procedures are comparable, CESI appears to be more successful in reducing pain at the one-week and one-month follow-up.