Caudal Epidural Injection Research Articles

Caudal epidural steroid injections versus selective nerve root blocks for single-level lumbar spinal stenosis: a study protocol for a randomized controlled trial

BackgroundLumbar spinal stenosis (LSS) is a common degenerative condition associated with old age. Its incidence continues to increase with the rapidly aging population in China. Treatment for LSS usually begins with conservative treatments, as some patients refuse surgical procedures or have surgery contraindications. Caudal epidural steroid injections (CESIs) and selective nerve root blocks (SNRBs) are two commonly used conservative treatments for LSS, which have proven to be effective at relieving LSS symptoms in many studies. However, there are no randomized controlled trials comparing these two procedures. We planned the first study to assess which one of these two procedures is more effective in treating LSS. We will compare the efficacy of these two treatment methods in terms of duration of symptom relief and recurrence rate. We hope our findings will help clinicians choose an optimal treatment for LSS patients.Methods/designWe plan to conduct a 1-year randomized controlled trial that will include a total of 76 subjects. They will be randomly divided into two groups: group A (patients will receive CESIs) and group B (patients will receive SNRBs). Two days before the procedure, we will assess these patients using the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale, Oswestry Disability Index (ODI), and numeric rating scale (NRS) for pain. One day, 2 weeks, 3 months, 6 months, and 1 year after the procedure, we will assess the condition of these patients again with the NRS and ODI.DiscussionWe hope our findings will lay the foundation for the design of further comprehensive studies and help clinicians make a choice between CESIs and SNRBs for LSS patients.Trial registrationChinese Clinical Trial Registry ChiCTR1900028038. Registered on 8 December 2019

Efficacy of caudal epidural injection of steroid versus steroid and calcitonin in patients with lumbosacral spinal stenosis: A randomized clinical trial

Background: Lumbosacral spinal stenosis (LSS) is one of the most common causes of back pain and disability. Its treatment varies from surgical to conservative, and the indications for optimal management are not obviously defined. This study aimed to compare the efficacy of caudal epidural injection (CEI) of steroid with and without calcitonin in patients with LSS. Method: This is a randomized, double-blind clinical trial of 31 LSS patients diagnosed between January 1, 2017, to December 30, 2017, who were randomly allocated into two groups. Group A consisted of 17 patients who received C-arm (mobile fluoroscopy)- guided CEI of local anesthetic and steroid, and group B included 14 patients who received C-arm-guided CEI of 100 international unit calcitonin added to local anesthetic and steroid. Outcome measures included the visual analog scale (VAS) for pain during movement and walking distance, Oswestry disability index (ODI), and Quebec back pain disability scale (QBPDS) score, which were obtained from patients before the CEI as a baseline and after the second, fourth, and eighth weeks. Result: Before CEI, no significant differences were found between the two groups, neither in demographic characteristics nor in VAS, ODI, and QBPDS parameters. After CEI, VAS, ODI, and QBPDS improved from baseline through the second, fourth, and eighth weeks in both groups (p < 0.001) without any superiority between the two groups (p = 0.012, 0.078, and 0.019). Conclusion: CEI of steroid with and without adding calcitonin appears effective in the management of LSS. However, CEI of calcitonin does not appear to have any superiority when compared with steroid injection alone.

Posterior Reversible Encephalopathy Syndrome after caudal epidural steroid ınjection: A case report

AbstractBackgroundCaudal epidural injections are easy, effective, and safe methods and are good options for patients with low back pain and radicular lower extremity pain. Although various complications related to the technique of the procedure or the drugs used in the procedure have been described, Posterior Reversible Encephalopathy Syndrome (PRES) has not yet been defined for this intervention.CaseIn this case report, we describe a case of PRES, which we supported with MRI findings in our patient who developed convulsions, changes in consciousness, and vision loss after being administered with caudal epidural steroid, and whose imaging findings regressed with the regression of clinical symptoms during the treatment process.ConclusionAlthough PRES is rarely reported, it should be kept in mind that it is a complication that can develop after caudal epidural steroid injection.

Effect of electroacupuncture combined with caudal epidural injection on functional rehabilitation of patients with lumbar hernia

To observe the effect of electroacupuncture (EA) combined with caudal epidural injection on subjective pain, walking capability, lumbar flexibility and muscle strength in patients with lumbar disc hernia (LDH). Sixty LDH patients were randomly allocated to the control group and the research group. The patients of the control group received ultrasound guided caudal epidural injection, and those of the research group received EA combined with ultrasound guided caudal epidural injection. Bilateral Jiaji (EX-B2) and adjunct points Guanyuanshu (BL26), Shenshu (BL23), Chengfu (BL36), Huantiao (GB30), Zhibian (BL54), etc. on the affected side were stimulated with EA (2 Hz/16 Hz, 5-8 mA) for 30 min each time, once every other day for 4 weeks, with 2 days' rest between every two weeks. The patients' pain was evaluated by using visual analogue scale (VAS), walking capability assessed by timed-up and go (TUG) test (time of walking back and forth in 3 m distance), lumbar flexibility (range of motion, ROM) detected by using an inclinometer and the strength of the lumbar flexor and extensor determined by using a push-pull dynamometer. After the treatment, self-comparison showed that the VAS score and TUG-measured time in both groups were significantly decreased (P<0.01, P<0.05), and the post-bucking ROM and extension ROM in the research group, and the lumbar flexor and extensor muscle strength in both groups were obviously increased compared with their own pre-treatment (P<0.05). Comparison between two groups showed that the VAS score and TUG-measured time of the research group were significantly lower than those of the control group (P<0.01), while the lumbar flexor's ROM as well as the extensor's strength were significantly higher in the research group than in the control group (P<0.05). For patients with LDH, EA combined with caudal epidural injection can alleviate pain, improve the walking capability, lumbar flexibility and strength of the lumbar extensor, and the therapeutic effect of the combined treatment is significantly better than that of simple caudal epidural injection.

Prediction of successful caudal epidural injection using color Doppler ultrasonography in the paramedian sagittal oblique view of the lumbosacral spine.

BackgroundUltrasound-guided caudal epidural injection (CEI) is limited in that it cannot confirm drug distribution at the target site without fluoroscopy. We hypothesized that visualization of solution flow through the inter-laminar space of the lumbosacral spine using color Doppler ultrasound alone would allow for confirmation of drug distribution. Therefore, we aimed to prospectively evaluate the usefulness of this method by comparing the color Doppler image in the paramedian sagittal oblique view of the lumbosacral spine (LS-PSOV) with the distribution of the contrast medium observed during fluoroscopy.MethodsSixty-five patients received a 10-mL CEI of solution containing contrast medium under ultrasound guidance. During injection, flow was observed in the LS-PSOV using color Doppler ultrasonography, following which it was confirmed using fluoroscopy. The presence of contrast image at L5-S1 on fluoroscopy was defined as “successful CEI.” We then calculated prediction accuracy for successful CEI using color Doppler ultrasonography in the LS-PSOV. We also investigated the correlation between the distribution levels measured via color Doppler and fluoroscopy.ResultsPrediction accuracy with color Doppler ultrasonography was 96.9%. The sensitivity, specificity, positive predictive value, and negative predictive value were 96.7%, 100%, 100%, and 60.0%, respectively. In 52 of 65 patients (80%), the highest level at which contrast image was observed was the same for both color Doppler ultrasonography and fluoroscopy.ConclusionsOur findings demonstrate that color Doppler ultrasonography in the LS-PSOV is a new method for determining whether a drug solution reaches the lumbosacral region (i.e., the main target level) without the need for fluoroscopy.

Fluoroscopy-Guided Transforaminal versus Caudal Epidural Steroid Injection for Chronic Pain After Spinal Surgery: A Retrospective Mid-Term Comparative Study.

IntroductionThis study is to compare advantages, safety and mid-term effects of fluoroscopy (FL)-guided transforaminal (TF) to caudal (CA) epidural steroid injection (ESI) for chronic pain after spinal surgery (CPSS) by assessing pain relief and improvement of functionality.MethodsPatients with radicular pain in CPSS who received FL-guided CA (n = 21) or TF (n = 28) ESI were included in this retrospective study. Complication frequencies, adverse events, treatment effects, and functional improvements for each procedure were compared at 1, 3, and 6 months following the last injection.ResultsBoth the Oswestry Disability Index (ODI) and verbal numeric pain scale scores (VNS) demonstrated improvement in both groups at all 1, 3, and 6 months following the last injection, without meaningful difference between groups (p < 0.05). Moreover, no meaningful difference was present between groups in terms of treatment success rate at every time point. The amount of time used for the injection procedure was shorter in CA group than in TF group (410.32 ± 25.73 seconds vs 640.65 ± 18.03 seconds, p < 0.05). Within 2 weeks of the injection treatment, the patient satisfactory scores were evaluated, with excellent being rated 85.7% (n = 18) among CA-ESI patients and 55.7% (n = 16) among TF-ESI patients (p < 0.05). Logistic regression analysis revealed that variables such as method of injection (CA or TF approach), sex, use of analgesics, pain duration, number of injections, and age were not significant variables for successful treatment results. There were no adverse complications after the procedure in both groups.ConclusionThe outcomes of FL-guided CA-ESI and TF-ESI for CPSS are similar in terms of pain reduction and functional improvements. CA-ESI is associated with lesser procedure time. In addition, compared with the TF-ESI, the patient experiences less discomfort during the injection, and the satisfaction with the injection treatment is confirmed to be better. Accordingly, both methods are effective; however, in the CA approach, patient satisfaction is higher and the procedure time is shorter.

English

BACKGROUND Epidural steroid injections (ESIs) have been widely used for over 50 years in the treatment of back pain with or without radiculopathy. In this study, we intended to evaluate the effect of single caudal epidural steroid injection (CESI) in patients suffering from chronic lumbago-sciatica syndrome, resistant to conservative medical therapy. METHODS This was a retrospective study. CESI was performed on thirty-four patients suffering from chronic lumbago-sciatica syndrome, from April 2019 to March 2020. Single injection of caudal epidural steroid (40 mg Triamcinolone Acetonide) diluted with 10 ml. of sterile water was given guided by anatomic landmark, confirmed by “Whoosh” test and radiologically with dye. Patients were followed for 12 weeks using Numeric Rating Scale (NRS) for pain, Oswestry disability index (ODI) and North American spine society patient satisfaction index (NASS). Values were recorded before the injection and after the injection at 1 week, 3 week, 6 week and 12 week during follow-up. RESULTS Significant improvement in patient’s status was observed after CESI, as measured with NRS, ODI and NASS at one, three, six and twelve weeks as compared to pre injection (zero week) but no significant difference was observed at successive follow ups at first to third and third to six weeks. There was significant reversal of NRS and ODI Score from 6 week to 12 week follow-up. Sixty seven percent of patients were satisfied at the end of the follow-up and mild side-effects were reported in a few patients. CONCLUSIONS CESI is a safe, simple and cost-effective intervention procedure for the treatment of chronic lumbago-sciatica syndrome. It provides rapid pain relief and physical function improvement of the patient starting within a week. KEYWORDS Injections, Epidural, Sciatica, Low Back Pain

Transverse plane ultrasound-guided caudal epidural injections: sonographic anatomy and stepwise technique.

The present study aims to provide a step-by-step procedural and anatomical familiarization guide for transverse plane ultrasound (US)-guided caudal epidural (CE) injection. The study cohort consisted of 23 chronic low back pain patients (23-67years old) previously unresponsive to conservative management. A transverse plane US-guided CE injection was performed, with each procedure step documenting and emphasizing sonographic anatomy. Several Thiel's method fixed cadaveric specimen dissections were also performed to demonstrate relevant CE injection-related anatomy. The sacral hiatus location can be estimated by visually forming an equilateral triangle between the posterior superior iliac spines and the sacral apex (trigonum sacrale). Follow-up palpation locates the sacral cornua, guiding transducer placement visualizing over the paired cornua 'bull frog's eye's appearance, with the epidural space visualized as a hypoechoic line, between the eyes. Then, 2-3ml of 1% lidocaine is injected subcutaneously at the mid-point between the sacral cornua and superficial to the posterior sacrococcygeal ligament (SCL). Although keeping the cornua, superficial posterior SCL and epidural space in view, the needle is slowly advanced to the epidural space at around a 20 degree cephalad angle till the tip becomes visible. Expansion of the epidural space is monitored under the transverse sacral ligament as the injectant is slowly introduced. The present study demonstrated the anatomical landmarks necessary for the transverse ultrasound caudal epidural technique and that the cornua, superficial posterior SCL, CE space, and other relevant sacral hiatal anatomy are well visualized with this technique.

Incidence and Factors that Affect Anterior Sacral Foramen Leakage in Fluoroscopically Guided Caudal Epidural Steroid Injection

Background: During the caudal epidural steroid injection (CESI), sacral foramen leakage can occur. The aim of this study was to evaluate incidence and the correlation of anterior sacral foramen leakage with several factors. Methods: We retrospectively analyzed the medical records of patients who underwent CESI. The epidural needle position and sacral foramen leakage (yes or no) in C-arm view were recorded. The following parameters were measured: 1) depth of the intervertebral disc at S1-S2, S2-S3, and S3-S4; 2) distances between the posterior borders of S1 and the apex of the sacral hiatus; and 3) depths of S1, S2 the sacral canal. Results: Ninety-one subjects were evaluated. The patients were predominately women (60%) with a mean age of 65.5 ± 11.6 years. There was leakage in 58% (53/91) of patients. One-level leakage occurred in the largest proportion of patients (27%). Age, gender, needle tip position, the depth of the intervertebral disc at S1-S2, S2-S3, and S3-S4, the distances between the posterior borders of S1 and the apex of the sacral hiatus, and the depths of S1, S2 the sacral canal were not correlated with sacral foramen leakage. Conclusion: We found leakage in 58% of patients regardless of age, gender, needle-tip position, the depth of the intervertebral disc at S1-S2, S2-S3, and S3- S4, the distances between the posterior borders of S1 and the apex of the sacral hiatus, and the depths of S1, S2 the sacral canal. Therefore, clinicians should be aware that leakage can occur in any circumstance. Keywords: incidence, factors, anterior, sacral, foramen, leakage, fluoroscopically, caudal, epidural, steroid, injection.

Role of psychological distress screening in predicting the outcomes of epidural steroid injection in chronic low back pain

BackgroundThere is a paucity of studies investigating relationship between psychological distress and effectiveness of epidural steroid injection in patients with chronic lower back pain (CLBP). AimsThis prospective cohort study assessed whether the outcome can be predicted in CLBP patients undergoing epidural injection by pre-treatment psychological stress stratification using objective screening methods. Methods96 patients with CLBP were recruited to this prospective cohort study. Preoperative level of psychological distress was measured using Modified Zung Index (MZI) and Modified Somatic Perception Questionnaire (MSPQ); pain with Visual Analogue Score (VAS) and McGill Pain Questionnaire (MPQ) and back pain related disability with Oswestry Disability Index (ODI). Fluoroscopic caudal epidural steroid injection comprising 80 mg methylprednisolone and 8 mg of lignocaine was performed. Scores were repeated at 6, 12, and 26 weeks. Successful outcome was Minimal Clinically Important Change (MCIC) in any given measure. ResultsThere were 60 (62.5%) not-distressed patients, 3(3.1%) purely somatising, 15(15.6%) depressed and 18(18.8%) with mixed distress. Preoperative VAS was 82.4, MPQ 18.2 and ODI 51.6. Average VAS and MPQ improved significantly at 6 and 26 weeks. Average magnitude of change of VAS and ODI did not differ between distressed and not-distressed. MPQ improved significantly more in the distressed. MZI was negatively associated with VAS MCIC at 6 weeks and 6 months but it failed to predict the outcome independently. MSPQ was the only individual predictor of MPQ-MCIC at any time; MSPQ≥8 could predict MPQ-MCIC at 6 months with 53%-sensitivity and 78%-specificity. None of psychological measures used showed a significant predictive value of ODI at any follow-up point ConclusionsPsychological distress may predict response only in certain outcome measures in patients suffering from nonspecific CLBP. If the interest lied primarily in pain and functional improvement, the psychological distress failed to discriminate the results at 6 months.

Comparative effectiveness of paravertebral Ozone injection and caudal epidural steroid-hyaluronidase injection in lumbosacral spinal stenosis

Background Lumbosacral spinal stenosis (LSS) is the narrowing of the lumbar spinal canal. LSS usually happens in older people who do not have the proper physical condition to undergo surgery. Therefore, minimally invasive methods such as Ozone therapy and epidural injection can be used in these patients. Objective The objective this study was to compare the effect of caudal epidural steroid-hyaluronidase injection with paravertebral intramuscular Ozone injection on reducing pain in patients with LSS. Methods A total of 30 patients suffering from LSS randomized to two groups. Group A (n = 15) received three paravertebral intramuscular infiltrations of the Ozone, Group B (n = 15) received a caudal epidural injection of steroid-hyaluronidase. The effects of the interventions were evaluated by measuring Visual analog scale (VAS), Oswestry Disability index (ODI), Quebec Back Pain Disability (QBPDS) and Roland Morris low back pain questionnaire (RMQ) before the interventions and at 2 weeks, 4 weeks, and 8 weeks after the interventions. Results Within-group changes showed significant improvement in VAS, ODI, RMQ, and QBPDS scores in both groups from pre-treatment to end of follow-up (all p < 0.05). The mean VAS score at all follow-up had significant differences between the two groups (p < 0.01). The mean ODI, RMQ, and QBPDS scores at 2-week and 4-week had significant differences between the two groups (p < 0.01). At the 8-week follow-up, there was no significant difference between groups concerning mean ODI, RMQ, and QBPDS scores (p > 0.05). Conclusion Both intramuscular injection Ozone and caudal epidural injection steroid- hyalaz significantly reduce pain. The existing data suggested 8 weeks improvements in pain severity are more significant for paravertebral Ozone injection, compared to caudal epidural steroid-hyaluronidase injection.

Efficacy of epidural injection of steroid in treatment of lumber disc prolapse: article review

"Chronic low back and lower extremity pain is mainly caused by lumbar disc herniation (LDH) and radiculitis. Various surgery and nonsurgical modalities, including epidural injections, have been used to treat LDH or radiculitis. 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. To describe the indications, rationale, techniques, alternatives, contraindications, complications, and efficacy of lumbar and caudal epidural corticosteroid injections. Interventions: Three reviewers with formal training and certification in evidence-based medicine searched the literature on non–image guided lumbar interlaminar epidural steroid injections. A larger team of seven reviewers independently assessed the methodology of studies found and appraised the quality of the evidence presented. A systematic literature search was performed, in the Medline Case reports and retrospective and prospective studies were extensively reviewed to provide detailed descriptions of the clinical features of lumbar and caudal epidural corticosteroid injections. Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE , and manual searches of bibliographies of known primary and review articles. Epidural corticosteroid injections are commonly requested treatments for patients with various low-back or lower-extremity pain syndromes (or both). Most of the reports on the use of this type of treatment are retrospective and noncontrolled. These studies indicate benefit; however, the prospective controlled studies provide varied results about the efficacy of lumbar and caudal epidural corticosteroid injections. In conclusions: In patients with lumbar radicular pain secondary to disc herniation or neurogenic claudication due to spinal stenosis, interlaminar epidural steroid injections appear to have clinical effectiveness limited to short-term pain relief. Therefore, in a contemporary medical practice, these procedures should be restricted to the rare settings where fluoroscopy is not available."

The utilization of caudal hydromorphone for fast-tracking in congenital cardiac surgery in a tertiary-care Children's hospital: An audit

Study objectiveOur study sought to audit our institutional practice of routine single-shot caudal epidural hydromorphone injection in children undergoing congenital cardiothoracic surgery to assess perioperative pain control and evaluate for any caudal complications. DesignRetrospective observational study of all patients that received a caudal hydromorphone injection as part of the anesthetic for their cardiac surgical operation between January 2017 and July 2019. SettingPediatric Cardiothoracic Operating Room (OR), Cardiac Intensive Care Unit. PatientsOne hundred and twenty-seven patients that received caudal hydromorphone as part of their anesthetic for a cardiac surgical operation. InterventionsCaudal epidural injection performed immediately following induction of anesthesia utilizing only hydromorphone. MeasurementsThe primary outcome was well-controlled pain, defined as a score of <4/10 on rFLACC or verbal pain scoring. Secondary outcome measures included in-OR extubation, pain service duration (from first assessment to “sign-off”), complications related to the caudal block, intensive care unit (ICU) length of stay (LOS), and Hospital LOS. Main resultsOne hundred and nine patients were included in the final analysis. Pain was “well-controlled” on average in 96.3% of patients (105/109). Average pain in the 24-h post-block period was 1.67 (SD = 2.37), with median pain score of 0 [0–3]. Peak pain score remained <4/10 for the entire 24-h post-block period in 22% of patients. 77.1% of caudal hydromorphone patients were extubated in the operating room. The median time to heparinization post-block was 108 min, beyond the ASRA recommendation of 60 min for neuraxial procedures. There were two caudal-related complications: one subcutaneous injection, and one instance of a time to heparinization of less than 60 min (56 min). Neither caudal complication led to patient harm. ConclusionCaudal hydromorphone injection can safely contribute to achieving “well-controlled” pain in the pediatric cardiac surgical population when used as a component of a perioperative pain control plan.

Comparative study of caudal tramadol and caudal dexmedetomidine as an adjuvant with ropivacaine in paediatric infraumbilical surgeries

Background and Aims: Caudal anaesthesia is one of the most commonly used regional anaesthetic technique in providing peri- and post-operative analgesia. It can serve as the sole anesthetic or can be an adjuvant to general anaesthesia. The aim of this study was to compare the clinical efficacy of the caudal block of 0.25% Ropivacaine with Tramadol or Dexmedetomidine as an adjuvant in paediatric infraumbilical surgeries. Methods: In this prospective, randomised, double-blinded comparative study, sixty children of either gender, in the age group of 1-8 years and scheduled for elective infra umbilical surgeries were randomly divided into two groups of thirty each. Children in Group D received a caudal epidural injection of 1ml/kg 0.25% ropivacaine with 2µg/kg dexmedetomidine while Group T received a caudal epidural injection of 1ml/kg ropivacaine with 2mg/kg tramadol. The primary outcome variable was the duration of time to rescue analgesia. The secondary outcome variables were onset of action, residual motor block, sedation score and adverse effects. Results: Results were statistically analysed using student’s t- test. Mean time of rescue analgesia in group D was 718.00 ± 100.06 min i.e. 11 hours 58 minutes and in group T was 467.33± 68.94 min i.e. 7 hours 47 minutes. (P<0.001). Pain scores measured at regular intervals post operatively were lower in D group as compared to T group. Rescue analgesia requirement was more in group T as compared to group D. Haemodynamic changes and side effects were comparable between the groups Conclusion: Caudal dexmedetomidine with Ropivacaine provides longer duration of post-operative analgesia as compared to caudal Tramadol with Ropivacaine.

Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines

BACKGROUND: Chronic spinal pain is the most prevalent chronic disease with employment of multiple modes of interventional techniques including epidural interventions. Multiple randomized controlled trials (RCTs), observational studies, systematic reviews, and guidelines have been published. The recent review of the utilization patterns and expenditures show that there has been a decline in utilization of epidural injections with decrease in inflation adjusted costs from 2009 to 2018. The American Society of Interventional Pain Physicians (ASIPP) published guidelines for interventional techniques in 2013, and guidelines for facet joint interventions in 2020. Consequently, these guidelines have been prepared to update previously existing guidelines. OBJECTIVE: To provide evidence-based guidance in performing therapeutic epidural procedures, including caudal, interlaminar in lumbar, cervical, and thoracic spinal regions, transforaminal in lumbar spine, and percutaneous adhesiolysis in the lumbar spine. METHODS: The methodology utilized included the development of objective and key questions with utilization of trustworthy standards. The literature pertaining to all aspects of epidural interventions was viewed with best evidence synthesis of available literature and recommendations were provided. RESULTS: In preparation of the guidelines, extensive literature review was performed. In addition to review of multiple manuscripts in reference to utilization, expenditures, anatomical and pathophysiological considerations, pharmacological and harmful effects of drugs and procedures, for evidence synthesis we have included 47 systematic reviews and 43 RCTs covering all epidural interventions to meet the objectives. The evidence recommendations are as follows: Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections, with or without steroids, and results of previous systematic reviews, the evidence is Level I for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term effectiveness. The evidence for percutaneous adhesiolysis in managing disc herniation based on one high-quality, placebo-controlled RCT is Level II with moderate to strong recommendation for long-term improvement in patients nonresponsive to conservative management and fluoroscopically guided epidural injections. For thoracic disc herniation, based on one relevant, high-quality RCT of thoracic epidural with fluoroscopic guidance, with or without steroids, the evidence is Level II with moderate to strong recommendation for long-term effectiveness. Spinal stenosis: The evidence based on one high-quality RCT in each category the evidence is Level III to II for fluoroscopically guided caudal epidural injections with moderate to strong recommendation and Level II for fluoroscopically guided lumbar and cervical interlaminar epidural injections with moderate to strong recommendation for long-term effectiveness. The evidence for lumbar transforaminal epidural injections is Level IV to III with moderate recommendation with fluoroscopically guided lumbar transforaminal epidural injections for long-term improvement. The evidence for percutaneous adhesiolysis in lumbar stenosis based on relevant, moderate to high quality RCTs, observational studies, and systematic reviews is Level II with moderate to strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. Axial discogenic pain: The evidence for axial discogenic pain without facet joint pain or sacroiliac joint pain in the lumbar and cervical spine with fluoroscopically guided caudal, lumbar and cervical interlaminar epidural injections, based on one relevant high quality RCT in each category is Level II with moderate to strong recommendation for long-term improvement, with or without steroids. Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality RCT with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement. For percutaneous adhesiolysis, based on multiple moderate to high-quality RCTs and systematic reviews, the evidence is Level I with strong recommendation for long-term improvement after failure of conservative management and fluoroscopically guided epidural injections. LIMITATIONS: The limitations of these guidelines include a continued paucity of high-quality studies for some techniques and various conditions including spinal stenosis, post-surgery syndrome, and discogenic pain. CONCLUSIONS: These epidural intervention guidelines including percutaneous adhesiolysis were prepared with a comprehensive review of the literature with methodologic quality assessment and determination of level of evidence with strength of recommendations. KEY WORDS: Chronic spinal pain, interventional techniques, epidural procedures, caudal epidural, lumbar interlaminar epidural, cervical interlaminar epidural, thoracic interlaminar epidural, lumbar transforaminal epidural, percutaneous adhesiolysis DISCLAIMER: These guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a “standard of care.” There was no external funding in the preparation of this manuscript.

Clinical Outcomes of Interlaminar Percutaneous Endoscopic Decompression for Degenerative Lumbar Spondylolisthesis with Spinal Stenosis.

The use of traditional open decompression alone in degenerative spondylolisthesis can lead to the development of postoperative spinal instability, whereas percutaneous endoscopic decompression can preserve the attachment of intervertebral muscles, facet joint capsules, and ligaments that stabilize the spine. The study’s aim was to determine clinical as well as radiologic outcomes associated with interlaminar percutaneous endoscopic decompression in patients with stable degenerative spondylolisthesis. For this study, 28 patients with stable degenerative spondylolisthesis who underwent percutaneous endoscopic decompression were enrolled. The clinical outcomes in terms of the visual analogue scale (VAS) and Oswestry disability index (ODI) were evaluated. Radiologic outcomes were determined by measuring the ratio of disc height and the vertebral slippage percentage using lateral standing radiographs. The average follow-up period was 25.24 months. VAS and ODI were significantly improved at the final follow-up. In terms of ratio of disc height and vertebral slippage percentage found no significant difference between the preoperative and postoperative periods. One patient underwent further caudal epidural steroid injection. One patient underwent fusion because their radicular pain did not improve. Interlaminar percutaneous endoscopic decompression is an effective procedure with favorable outcomes in selected patients with stable degenerative spondylolisthesis.

The Synergistic Effect of Combined Transforaminal and Caudal Epidural Steroid Injection in Recurrent Lumbar Disc Herniations.

BackgroundRecurrent lumbar disc herniation (RLDH) is one of the most common causes of chronic low back and leg pain. Although surgical treatment has high success rates in primary lumbar disc herniations, recurrence is not an uncommon clinic condition after the surgery. Considering the recurrent surgeries have lower success rates and higher risks, such as dural tear and nerve injury, alternative treatment modalities are needed for RLDH patients. Epidural steroid injections (ESI), particularly transforaminal steroid injection (TFESI) and caudal steroid injection (CESI), which are the alternative treatments to surgery, have not shown reasonable results in RLDH separately. In this study, we aimed to investigate the effects of combined TFESI and CESI (TFESI + CESI) treatment, which has been found successful in primary lumbar disc herniation (PLDH) and on pain control and quality of life in RLDH patients for the first time.Materials and methodsA total of 71 patients, who had ESI treatment as only TFESI or TFESI + CESI because of RLDH in our clinic between March 2017 and February 2020, were investigated retrospectively. The visual analog scale (VAS) leg, VAS back, and Oswestry disability index (ODI) were used to assess leg pain, low back pain, and limitation of daily routine activities. Each assessment was done before the intervention and repeated at the third week, the third month, and the sixth month of injection, and the results were noted.ResultsOut of 71 patients, 38 were female and 33 male. Patients were divided into two subgroups according to the applied ESI methods as only TFESI (n = 32) and TFESI + CESI (n = 39). In the only TFESI group, the mean VAS leg score was 7.84, 4.63, 5.40, and 6.19 before, at the third week, the third month, and the sixth month of the injection, respectively. Also, in this group, the mean VAS back score was 8.06, 4.16, 4.88, and 5.97; the mean ODI score was 55.81, 34.31, 37.5, and 49.04 in the same respect. In the TFESI + CESI group, the mean VAS leg score was 8.20, 2.87, 3.64, 4.23; mean VAS back score 8.03, 3.05, 3.90, 4.08; mean ODI score 56.56, 28.05, 30.21, 33.64 before, at the third week, third month, and sixth month of the injection, respectively. The mean of the initial VAS leg, VAS back, and ODI scores was not found to be statistically significantly different between the two groups. The mean of all VAS leg, VAS back, and ODI scores was found to be lower in the TFESI + CESI group than the only TFESI group at each third-week, third-month, and sixth-month controls, and these differences were statistically significant. (p<0.0001 at each controls for VAS leg; p = 0.001 at third week, p = 0.002 at third month and p <0.0001 at sixth month for VAS back; p= 0.0003 at third week, p<0.0001 at third month, p<0.0001 at sixth month for ODI)ConclusionOur study demonstrates that TFESI + CESI treatment is an effective non-surgical treatment for RLDH. Considering the higher risks and lower success rates of recurrent surgeries, TFESI + CESI can be a potential treatment option for RLDH patients.

The relationship between the grading of lumbar spinal stenosis and pain improvement after caudal epidural steroid injection.

Objective: This study aimed to determine the relation of severity of lumbar spinal stenosis and pain improvement after caudal epidural injection.&#x0D; Material and Methods: 70 patients of neurogenic claudication were included from July 2019 to June 2020. MRI lumbosacral spine was done of all patients to categorize the degree of spinal stenosis on T2-W axial. All patients were given caudal epidural steroid injection as a day case procedure. Follow-up was done at 3 &amp; 8 weeks and pain improvement was assessed by using Ronald satisfaction score.&#x0D; Results: Mean age was 37.9 ± 7.8 years. 48.6% patients were male and 51.6% were female. The improvement was observed in 28 patients (40%) at 3 weeks and in 46 patients (65.7%) at 8 weeks. There was no statistically significant relationship between lumbar&#x0D; spinal stenosis and pain improvements at 3 weeks (p value 0.30) and 8 weeks (p value 0.32).&#x0D; Conclusion: The grade of lumbar spinal stenosis has no significant effect on pain improvement after caudal epidural steroid injection.&#x0D; Keywords: LSS (Lumbar spinal stenosis), caudal epidural steroid injection (ESI), neurogenic claudication, MRI (Magnetic resonance imaging), T2W (T2 weighted) images.

Clinical outcome of caudal epidural steroid injection in lumbosacral radiculopathy

This is a prospective, non-randomized, single-blind study conducted in twenty-three patients of both sexes, with either L5 or S1 or both L5 and S1 radiculopathy, secondary to disc pathology at L4L5 and L5S1 suffering from chronic leg pain for three months or more. The objective of this study was to analyze the difference in the efficacy of administering caudal epidural corticosteroid in the patients with single and double level disc pathology, in terms of improvement of walking distance and relief of leg pain-decrease in Visual Analog Score (VAS). All the patients were evaluated clinically and radiologically, including magnetic resonance imaging of the spine. The patients were divided into two groups i.e., Group I – with single level pathology at either L4L5 or L5S1 and Group II – with double level pathology. Injection Dexamethasone 8mg mixed with injection Bupivacaine 0.5% and distilled water was injected by the caudal route to all patients under fluoroscopy. The pre-injection, 3 weeks, 3 months and 6 months post-injection Visual Analogue Score (VAS) and walking distance were analysed. There was significant reduction of VAS & improvement of walking distance at 3 weeks, 3 months and 6 months post Caudal Epidural Steroid Injection (CESI) in both the groups. There is no statistical correlation in both the groups in terms of clinical efficacy of the corticosteroid with respect to the number of levels of disc pathology. No major adverse event was reported in this series. Caudal Epidural Steroid Injection is a safe and reproducible modality for the treatment of lumbosacral radiculopathy. We would recommend CESI in L5 and S1 radiculopathy, secondary to disc pathology and maybe repeated after 3 months.

Ultrasound-guided epidural block in axial spondyloarthritis patients with limited spine mobility: a randomized controlled trial.

BackgroundEvaluation of the effectiveness of caudal epidural injection on pain, spine mobility, disease activity, and activity of daily living in axial spondyloarthritis (SpA) patients.MethodsA total sample of 47 patients were registered in this study. They were randomly assigned into 2 groups; Group I received caudal epidural injections, ultrasound-guided, with 1% lidocaine hydrochloride mixed with triamcinolone, whereas Group II did not receive any injections. All participants fulfilled the ASAS criteria for axial SpA. Outcome measures were as follows visual analogue scale, Oswestry disability index (ODI), modified Schober test, lateral lumbar flexion, and Ankylosing Spondylitis Disease Activity Score (ASDAS) with assessment at baseline, 2 weeks, and 8 weeks post-treatment. This clinical trial was registered on clinicaltrials.gov under the number NCT04143165.ResultsThere was a significant difference between both groups regarding pain, ODI, spine mobility and ASDAS scores in favor of group I. This effect was at its maximum after 2 weeks. Despite the decline of this effect after 2 months, the difference between the groups remained significant. Higher disease activity, younger age, and shorter disease duration were associated with better outcomes.ConclusionsEpidural injection of lidocaine and triamcinolone is a cost effective and a practical technique for controlling pain, as well as improving the function of the spine and disease activity scores in axial SpA patients with acceptable complications and relatively sustained effect.