Caudal Epidural Steroid Injection Research Articles

A Study on management of lumbar disc disease with caudal epidural steroid injection

A Study on management of lumbar disc disease with caudal epidural steroid injection

(292) Lumbar Radiculopathy in the Pregnant Patient

Lumbar radiculopathy is a common cause of low back and leg pain in many patients. While there are multiple interventions both medical and surgical for the treatment of lumbar radiculopathy, the options become limited in the pregnant patient. We present the case of a 35-year-old female at 25-week gestational age with new onset severe low back and right leg pain. The patient had a history of prior lumbar laminectomy and discectomy for similar symptoms. She presented after failed conservative management with gabapentin and acetaminophen and the pain began to interfere with her daily activities. On presentation to the clinic the patient had severe lumbosacral radiculopathy consistent with Magnetic Resonance Imaging (MRI) findings of a new large disc extrusion on the right. After a discussion of the possible interventions the decision was made to treat the lumbar radiculopathy with caudal epidural steroid injection (ESI) performed under ultrasound guidance. Though there is no set maximum radiation dose deemed safe for the fetus by the American College of Obstetricians and Gynecologists (ACOG), the consensus is to limit the radiation dose to 50mGy before 15-week gestational age and 250mGy thereafter. Ultrasound guided caudal ESI was decided to be the safest course of action to decrease the amount of radiation to the fetus and minimize the risk of dural puncture given her previous laminectomy. Success was confirmed with easy passing of an epidural catheter and a decreased pain score after the procedure. Additionally, during the management of this patient we noted the new classification system from the Food and Drug Administration (FDA) regarding medications in pregnancy. Despite most medication black box warnings maintaining the old category system of A, B, C, D and X; the new FDA system emphasizes the Pregnancy and Lactations Labeling Rule (PLLR) to guide patient discussions and medical management.

Combination of caudal epidural steroids with oral gabapentin for radicular low back pain: a prospective observational study

Introduction: The physical, socioeconomic and psychological burden of low back pain is enormous. The poor socioeconomic condition and geographical constrains confines people to limited health facilities. The objective of the study was to evaluate whether combination of caudal epidural steroids with local anaesthetics and gabapentin is effective for radicular low back pain in the rural Nepal setting.
 Methods: It was a prospective observational study including 300 patients with radicular low back pain done over a period of 6 months (13/4/2016 to 30/10/2016). All participants received caudal epidural steroid injection (6ml 2% Xylocaine with adrenaline plus Depomedroxy steroid 80mg plus 12 ml distilled water) and 200 mg gabapentin daily for three months. All patients were followed up for three months and were evaluated.
 Results: Mean age of presentation was 41.21 years (SD ± 11.02) with majority of farmers (42.31%). Mean Numerical Rating Scale at the baseline was 8.01(SD±1.00) and at the first follow up was 3.98 (SD±0.83) (p <0.001). Mean Oswestry Disability Index at baseline was7.85 (SD±0.98) and at the first follow up was 4.04 (SD±0.80) (p <0.001). Straight Leg Raising Test at baseline was less than 70° in 84.7% which improved to more than 70° in 87.9% of the patients (p-value <0.001).
 Conclusion: Caudal epidural steroids combined with gabapentin is safe, economical and technically less demanding. This treatment modality can be used with good outcomes in the rural areas with limited diagnostic and therapeutic facilities.

Anatomical differences in sacral hiatus during caudal epidural injection with ultrasonography guidance and its effects on success rate

To investigate the anatomical differences of sacral hiatus, pain levels and success rates during caudal epidural steroid injection (CESE) using ultrasonography. In the study, 255 patients (148 male and 107 female) with lower lumbar back pain and sciatica were included. These patients were applied caudal epidural steroid injection by ultrasonography. Sonograms were obtained by ultrasonography (USG) guideline. Patients' pain levels were assessed by the Visual Analogue Scale (VAS) during the CESE procedure performed on USG guided, and success rates were saved. The intercornual distance, sacral distance and sacrococcygeal ligament thickness were measured. There was no statistically significant difference between the demographic data of the patients (p>0.05). There was a significant difference between male and female patients concerning intercornual distance (15.8 versus 16.6 mm; p=0.004) and sacrococcygeal ligament thickness (4.1 mm vs. 3.7 mm; p=0.018). There was no significant difference between patients about KESE success rate, VAS values and sacral distance (p>0.05). We found that sacral hiatus has anatomical differences between male and female patients. According to current evidence, the success rate of caudal epidural steroid injection increased when the anatomical structures of sacral hiatus are shown correctly in USG guided.

Influence of needle-insertion depth on epidural spread and clinical outcomes in caudal epidural injections: a randomized clinical trial.

BackgroundA caudal epidural steroid injection (CESI) is a commonly used method to improve symptoms of lumbosacral pain. We compared the achievement of successful epidurograms and patient-reported clinical outcomes following different needle-insertion depths during CESI.MethodsFor the conventional method group, the needle was advanced into the sacral canal. For the alternative method group, the needle was positioned immediately after penetration of the sacrococcygeal ligament. Epidural filling patterns and vascular uptake during fluoroscopy were determined to verify successful epidural injection. Procedural pain scores were investigated immediately after the procedure. Pain scores and patient global impression of symptom change were evaluated at 1-month follow-up.ResultsAssessments were completed by 127 patients (conventional method, n=64; alternative method, n=63). The incidence of intravascular injection was significantly lower in the alternative method group than in the conventional method group (3.2% vs 20.3%, P=0.005). Procedural pain during needle insertion was significantly lower in the alternative method group (3.7±1.3 vs 5.3±1.2, P<0.001). Epidural contrast filling patterns were similar in both groups. One-month follow-up pain scores and patient global impression of symptom change were comparable in both groups.ConclusionCompared with the conventional method, the alternative method for CESI could achieve similar epidural spread and symptom improvement. The alternative technique exhibited clinical benefits of a lower rate of intravascular injection and less procedural pain.

Determination of the Optimal Angle for Needle Insertion During Caudal Epidural Steroid Injection in Adults Using Ultrasound Imaging

Background: Lumbar back pain is a common disease, which reduces life quality. Caudal epidural steroid injection (CESI) is frequently preferred to relieve lumbar back pain. However, various major complications can be observed due to CESI. A new technique of needle angle should be improved to prevent complications such as intraosseous, intrathecal or intravascular injection during CESI. Objectives: Caudal epidural steroid injection is one of the methods frequently used to treat chronic lumbar back pain. The current study aimed at examining the anatomy of the sacral hiatus and determining the optimal angle of the needle for CESI. Methods: The current clinical trial was performed in Diyarbakir Selahaddin Eyyubi State Hospital from January to June in 2017. The study included 150 adult patients (first group = 92 males (%61.3), second group = 58 females (%38.7) aged 18 - 78 years applied to the Algology Polyclinic with ASA-PS classes I and II (the American Society of Anesthesiologists (ASA) physical status classification system). Measurements were taken during the CESI applied under ultrasonography (USG) guidance of the intercornual distance, the sacral space, and the optimal needle entry angle. Results: The intercornual distance was significantly higher in group one (mean ± standard deviation (SD): 16.6 ± 2.04) than group two (mean ± SD: 15.8 ± 2.51) (P 0.79). The most appropriate entry angle for the needle in the application of CESI was mean 71.04° in the whole patient group, as 71.9° in group one and 69.7° in group two. There was no significant difference between the genders in terms of the mean optimal angle (P > 0.091). Also, no significant difference was observed among the patients in terms of the demographic data (P > 0.05). Conclusions: The results of the current study revealed that the optimal needle angle for CESI applied under USG guidance was 71.04°, different from traditional method and the injection procedure could be safely made directly to the epidural space without changing the angle after entry of the needle to the epidural space.

Effect of fluoroscopically guided caudal epidural steroid injection in degenerative lumbar spinal stenosis–A randomized controlled trial

Degenerative lumbar spinal stenosis (DLSS) is a common source of pain and disability in the elderly population. Epidural steroid injections are often used to treat lumbosacral radiculopathy in DLSS. There is paucity of clinical trials comparing caudal epidural steroid injections plus local anaesthetics with conservative treatment. Moderate and high-quality evidence for nonoperative treatment is lacking and thus prohibits recommendations for guiding clinical practice. So, the aim of this study was to compare the effects of conservative treatment (physical therapy) and caudal epidural steroid injection with physical therapy in patients of DLSS (grade A and B). An Open Label, Parallel randomized controlled trial was conducted from January 2016–August 2017 and patients fulfilling the inclusion criteria were enrolled after written informed consent. The Trial was registered under the Clinical Trial Registry of India (CTRI). Patients were randomized in two groups–32 in Intervention Group A (caudal epidural steroid injection with physical therapy) and 32 in Control Group B (physical therapy only) with concealed allocation method. The outcome was assessed by Numerical Pain Rating Scale (NPRS), Oswestry Disability Index (ODI), standing tolerance test and walking tolerance test at 3, 6, 12 and 24 weeks. Significant improvement in NPRS, ODI and standing tolerance test was observed at 3, 6 and 12 weeks (Group A > > Group B). Equivocal effect in NPRS and ODI was seen at 24 weeks (Group A ∼ Group B). Improvement in mean claudication distance was seen at each follow up from baseline (Group A > > Group B). The probability of improvement in intervention group (A) was more than in control group (B). Epidural steroid administration improved pain, physical ability and claudication distance (> 200 meters) at 12 weeks aiding an early return to routine activities. Physical therapy also shows clinical improvement in patients of DLSS and can be an appropriate treatment modality.

Correlation of functional results of caudal epidural steroid injections with duration of symptoms in PIVD

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Low backache and sciatica is a common complaint signifying some underlying pathology; it may be a soft tissue strain or disc protrusion, or conditions such as neoplasm or ankylosing spondylitis besides others. We aim to assess the functional outcome of epidural steroid injection in patients with low backache and sciatica as well as the effect of pre operative duration of symptoms in Indian population presenting to our centre, on the post procedure outcome, if any.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; 50 patients were evaluated with complaints of low backache and radiculopathy. They were subjected to following questionnaires including the ODI and VAS, and the scores were evaluated before and after the intervention, and at every follow up.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Patients commonly affected were from 4th and 5th decade. The commonest intervertebral disc involved was L4-5 (44%) followed by L5-S1 (30%). Significant Functional status improvement according to ODI scoring was observed in all follow up visits. Similarly significant reduction in pain intensity according to VAS scoring was observed in all follow up visits. On comparing the improvement in functional status (ODI) and pain (VAS) between the 3 groups, it is seen that patients in group A had the highest rate of improvement, while patients in group C had the least improvement.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Caudal epidural injections are safe, effective and less expensive modality of treatment without any significant complications. The lesser the duration of symptoms i.e. earlier the patient presents, better are the results with caudal epidural injection.&lt;/p&gt;&lt;p&gt; &lt;/p&gt;

Efficacy of Caudal Epidural Steroid Injection with Targeted Indwelling Catheter and Manipulation in Managing Patients with Lumbar Disk Herniation and Radiculopathy: A Prospective, Randomized, Single-Blind Controlled Trial.

Lumbar disk herniation (LDH) is considered a common cause of lumbosacral radiculopathy. Epidural steroid injection is a common method to treat inflammation associated with low back-related leg pain. Spinal manipulations are widely used, and systematic reviews have also shown that these manipulations are more effective than placebos. Due to the absence of clinical evidence, we designed a prospective, randomized, single-blind controlled trial in patients with LDH with radiculopathy, aiming to detect the safety and clinical efficacy of targeted indwelling catheter combined with "4-step" manipulative therapy in patients with LDH. Patient visits were performed at baseline and days 1, 3, 7, and 28 after treatment. Clinical outcomes were measured using visual analog scale for back and leg pain, Oswestry Disability Index (ODI), and clinical symptom scores of the Japanese Orthopedic Association (JAO). The study included 85 eligible patients. They were categorized with a randomization schedule into a Catheter Group (N= 43) and No-Catheter Group (N= 42). Between the measurement points, there was a statistically significant difference in the visual analog scale (back) at days 1, 3, and 7 of follow-up after treatment between the 2 groups. The change was statistically different at days 1 and 3, and a higher change was observed in the Catheter Group compared with the No-Catheter Group. There was a statistically significant difference in change of JOA and ODI scores at day 1 of follow-up after treatment between the 2 groups, and a greater change was seen in the Catheter Group at days 1 and 3 compared with the No-Catheter Group. The small sample size was small, and the follow-up time was short. The study also lacked documents of adjuvant therapies, like individual patient exercise routines and analgesic drug therapy. Both methods were effective in reducing pain intensity and functional disability compared with pretreatment. The Catheter Group showed a more significant decrease in visual analog scale and greater changes in JOA and ODI scores of short/term follow-up, compared with the No-Catheter Group. The therapy project was safe.

The influence of adjunctive caudal epidural steroid injection on the therapeutic effect of transforaminal epidural steroid injection.

Epidural steroid injection is widely used to treat the short and long-term symptoms of low back and radicular pain. To the best of our knowledge, the influence of transforaminal epidural steroid injection (TFSI) combined with caudal epidural steroid injection (CESI) on pain intensity, patient satisfaction, and quality of life in lumbar radiculopathy has not been examined. To evaluate the short and long-term efficacy of TFSI, and TFSI combined with CESI (TFSI + CESI) in patients with lumbar radiculopathy. We retrospectively examined the records of 104 patients with lumbar radicular pain and L4/5 and/or L5/S1 intervertebral disc disease who underwent TFSI or TFSI + CESI. We compared the pain intensity using a Visual Numeric Scale (VNS), North American Spine Society (NASS) pain satisfaction index, and EuroQol five dimensions (EQ-5D) quality of life scores before intervention, and after 1, 6 and 12 months. In the TFSI group, the mean pre-treatment VNS score was 9.2, which improved to 4.9 after 1 month and to 7.2 after 12 months. In the TFSI + CESI group, the mean pre-treatment VNS score was 9.4, which improved to 2.6 and 4.6 after 1 and 12 months, respectively. Improvement in the VNS scores was significantly higher in the TFSI + CESI group (P < 0.0001 for each). Mean EQ-5D quality of life index in the TFSI group improved from 0.59 in the pre-treatment phase to 0.76 after 12 months of intervention, while it improved from 0.62 in the pre-treatment phase to 0.84 at 12 months of intervention in the TFSI + CESI group. The EQ-5D scores were significantly better in the TFSI + CESI group at 1, 6, and 12 months after the procedure (P = 0.004, 0.036, and 0.042, for 1, 6, and 12 months, respectively). The NASS scores were significantly better in the TFSI + CESI group at 6 and 12 months after the intervention (P = 0.025 and 0.001 for 6 months and 12 months, respectively). In patients with lower lumbar radiculopathy, a combined TFSI + CESI technique offers superior short and long-term pain relief, quality of life, and long-term patient satisfaction, than when TFSI is performed alone.

Tardive dyskinesia and dexmedetomidine

SummaryA 52‐year‐old female patient presented for a caudal epidurogram and epidural steroid injection. Patient compliance was limited by severe tardive dyskinesia secondary to previous chlorpromazine treatment. Based on a report of effectiveness in propofol‐induced dyskinesias, an infusion of dexmedetomidine was used which effectively controlled the movements within a few minutes. The patient remained alert and comfortable throughout. This report highlights the pharmacology and clinical application of dexmedetomidine in this clinical scenario, and proposes potential mechanisms underlying this therapeutic effect.

Predictive Factors of the Effectiveness of Caudal Epidural Steroid Injections in Managing Patients With Chronic Low Back Pain and Radiculopathy.

Retrospective clinical outcome analysis. To evaluate and determine whether demographic, comorbid factors, or physical examination findings may predict the outcome of caudal epidural steroid injections in managing patients with chronic low back pain and radiculopathy SUMMARY OF BACKGROUND DATA:: The caudal epidural approach is commonly utilized with patients who are on anticoagulation or who have had prior lumbar surgery to treat L5 or S1 radiculopathies. A retrospective review of 136 patients undergoing an initial caudal epidural steroid injection for radiculopathy from January 1, 2006 to August 30, 2013. The patients were assessed before their injections for their pain levels: visual analog scale, presence of lumbar paraspinal and sciatic notch sensitivity, pain with provocative maneuvers, motor weakness, and sensory loss. The patients were then reassessed following their injection for their visual analog scale pain levels, percentage improvement, and duration of pain relief. Stepwise regression was used to determine whether demographic, comorbid factors, or physical examination signs were predictive of percentage improvement or length of relief following an injection. Among these variables, duration of symptoms was found to be negatively significantly related with a P-value of 0.032 for percentage of improvement. For each week of the duration of symptoms, the percentage of improvement decreased by 0.07%. Regarding physical examination findings, presence of pain with lumbar extension was negatively and significantly related to length of relief duration with a P-value of 0.0124. The mean length of relief duration is 38.37 weeks for individuals without painful lumbar extension and 14.68 weeks for individuals with painful lumbar extension CONCLUSIONS:: The mean length of relief following a caudal injection is reduced by 62% in patients who exhibit pain with lumbar extension.

Caudal Epidural Steroid Injections in Discojenic Pain: Review Article

Introduction: 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 aimed to evaluate the effects of caudal epidural steroid injections( CESIs) in patients suffering from discogenic pain, resistent to conservative medical therapy.Methods: Systematic review of 270 CESIs performed patientsdata’suffering from discogenic pain from January to December 2016 were evaluated.The pain’s exact region was marked as left, right,and bilateral. Patients who had operated before were recorded. According to the source of the discogenic pain, patients were divided into two like; upper lumbar pain (L1-4), lower lumbar pain (L4-S1). Visual analogue scale (VAS) values were recorded before the injection,after the injection andat 1, 3, 6th months during the control visits.Results: A total of 270 patients with discogenic pain were included in the study. 172 of them were male (63.7 %), while 98 of them female (36.3%). VAS scores in all recorded times after injection were found significantly lower compared the values of preinjection (p < 0.05). VAS values in Pain Group L4-S1 were found lower than Pain Group L1-4 for all recorded times. According to the regions of pain, VAS values didn’t differ.VAS scores compared between the patients operated before and the nonoperated patients didn’t differ significantly.Discussions: CESIs are effective in patients suffering from discogenic back pain resistant to conservative and medical therapy. It is a safe and effective method with low complication rates.

Inadvertent Dural Puncture in Interventional Pain Management (Caudal Epidural Block)

Caudal epidural steroid injection (CESI) is one of the most common interventions in management of lumbar radicular pain of the patients who fail to respond to conservative treatment. Complications related to caudal epidural injections are rare. However, occasional complications may become worrisome. This report presents the inadvertent dural puncture during caudal epidural injections in two patients who were suffering from spinal-related radicular pain.

A Randomized Controlled Clinical Trial to Determine the Effectiveness of Caudal Epidural Steroid Injection in Lumbosacral Sciatica.

Caudal epidural steroid injection have been a part of nonsurgical management of lumbosacral sciatica since last half a century but various randomized controlled trials fail to provide convincing evidence in favour of its effectiveness. To assess the efficacy of caudal epidural steroid injection in patients of lumbosacral sciatica in comparison to placebo. The study consisted of patients of sciatica caused by lumbosacral disc prolapse (observed on Magnetic Resonance Imaging (MRI) scan). Caudal epidural injections of 80 mg methyl prednisolone were injected in 47 patients in one group. The other group consisted of 46 patients who were injected isotonic saline as placebo. Self-evaluation was the main judgment criterion at 4th week using a descriptive four item scale (recovery, marked improvement, slight improvement, or worse). Patients rating the improvement as "recovery" or "marked improvement" were considered as success. Patients rating the improvement as "slight improvement" or "worse" were considered as failure. Only paracetamol were authorized and patients requiring Non Steroidal Anti-inflammatory Drugs (NSAIDs) before 4th week were also considered as failure. On analysis per protocol, at 4 weeks, the two groups differed significantly with respect to the primary outcome: among the 93 patients, 8/46 (17%) in the placebo group and 32/47 (68%) in the steroid group (p=0.000) were considered as success (difference 50.7%; 95% CI for the difference 33.4 to 67.99). But at the end of the study (week 12) there was no significant difference in primary outcome between the groups: 22/46 (48%) patients in the placebo group and 28/47 (60%) in the steroid group (p=0.25) were considered as success (difference 11.8%; 95% CI for the difference -8.38 to 31.9). Caudal epidural steroid injections provide no additional improvement over placebo in the long term natural history of lumbosacral sciatica. However, it can be an important component of short term management of painful sciatica.

Caudal epidural steroids in management of lumbar radiculopathy

Introduction: Practice of epidural steroid injections have been used in the past in for lumbar radiculopathy. We observed and analysed outcomes of caudal epidural steroid injections in the management of lumbar radiculopathy due to disc herniations. Methods: In this study, 45 patients with lumbar radiculopathy due to disc herniation between the ages of 18-50 confirmed by MRI were included in the study. All patients were given a suspension of Methyl prednisolone along with local anaesthetic through caudal epidural route and the results were analysed. Results: Majority of the patients [64.5%] had significant pain relief measured by VAPS, ODI and SLRT and could avoid surgery. 13 patients opted for surgery due to failure of epidural steroid injections. None of the patient had deterioration of pain or disability as compared to pre-injection status. Conclusion: Patient with predominant radicular pain due to lumbar disc herniation can be considered for treatment with caudal epidural steroids prior to being considered for operative intervention. Caudal epidural steroids offer a cost effective and low risk alternative to surgery.

Abstract PR302

Background:In refractory pain, interventional procedures have been used successfully.(1) Objectives:To study and compare the efficacy of inter-laminar steroid injection and caudal epidural steroid injection in chronic radicular low back pain. Materials & Methods:After institutional ethics approval and written informed consent, a prospective, interventional assessor blinded study involving 60 patients (nmaster no.2, α error= 5%, power of study-80%). Aged 18-65years. Numeric rating scale (NRS) of radicular low back pain of 4 at rest for 12weeks in whom conservative therapy failed. Allocated either Group I (inter-laminar à conventional epidural injection in sitting position with 18G Tuohy’s needle consisting of 60mg Triamcinolone, 0.5ml of 0.5% Bupivacaine and 4ml of normal saline) or Group C (Caudalà fluoroscopy guided caudal epidural injection in prone position with 23G Quincke’s needle consisting of 80mg of Triamcinolone, 0.5ml of 0.5% Bupivacaine and 5.5ml of normal saline) by computer generated numbers. Intervention was done as a day care procedure under strict aseptic precautions and patient was discharged 2hours after observation. Cold fomentation was advised for 2 days. Analgesics in the form of Tapentadol, Paracetamol and gabapentin were continued. On day 3, they were referred to physiotherapist for back strengthening exercises. On the 1st, 3rd and 6th weeks after the procedure and they were assessed by NRS for pain, Rolland Morris low back pain and disability questionnaire, analgesic requirement and return to routine work. Results: Pain relief seen immediately after the procedure and at 1st week after the procedure were comparable in both groups but at the 3rd and 6th weeks after the procedure, Group C showed significantly better pain relief(Table 1)Table 1 -: ResultsConclusion: 1.Steroids administered by both conventional inter-laminar and fluoroscopic guided caudal techniques are effective for chronic radicular low back pain, 2.Over time, the effect of inter-laminar injection wears off while that of caudal injection stays consistent even at the 6th week, 3.Efficacy of caudal approach is better, 4.In absence of pain physician anaesthetist can treat low back pain.

(461) Inadvertent filum terminale needle placement during caudal epidural steroid injection: a case report

Caudal epidural steroid injections (ESI) are a commonly utilized and efficacious means in which to treat radicular leg symptoms arising from the lumbo-sacral spine. Touhe needles are placed via fluoroscopic guidance with utilization of live fluoroscopy to ensure epidural administration. This is a case report of direct needle and catheter placements into and through the filum terminale during a caudal approach to the epidural space. The patient, a 69-year-old woman who suffered from chronic low back and leg pain from lumbosacral radiculopathy, failed back surgery syndrome and lumbar facet arthropathy presented to the outpatient pain clinic for repeat caudal ESI. Her initial caudal ESI, 2 years prior, resulted in pain relief for 2 months. Due to her previous robust response to the caudal ESI the patient was scheduled for a repeat injection. Under AP and lateral fluoroscopic guidance a Coude needle was introduced into the caudal epidural space without advancement beyond S4. An epimed catheter was inserted and tracked to the L4 level. The needle and catheter placement were confirmed via intrathecal contrast spread to be in the filum terminale with flow cephalad into the thecal space, which resulted in the abortion of the procedure. This case illustrates a rare incidence of catheter placement directly into the filum terminale during a routine caudal ESI. Despite a relatively safe and routine intervention, care must be taken to ensure proper placement of needle, catheter and injectate. While contrast is injected to ensure appropriate epidural spread, we present, to the best of our knowledge, the first occasion of a needle being inserted directly into the filum terminale during a caudal ESI.

A Rare Complication after Caudal Epidural Steroid Injection: Persistent Hiccup

Lumbar caudal epidural steroid injection (LKES ) is one of the non-surgical treatment of back pain. In this case report; we presented persistent hiccup after lomber caudal epidural steroid injection for chronic low back pain and treatment of this case. Key words: Steroid, persistent hiccup, lomber injection, low back pain

Selective nerve root blocks vs. caudal epidural injection for single level prolapsed lumbar intervertebral disc - A prospective randomized study.

Chronic lumbar radiculopathy has a lifetime prevalence of 5.3% in men and 3.7% in women. It usually resolves spontaneously, but up to 30% cases will have pronounced symptoms even after one year. A prospective randomized single-blind study was conducted to compare the efficacy of caudal epidural steroid injection and selective nerve root block in management of pain and disability in cases of lumbar disc herniation. Eighty patients with confirmed single-level lumbar disc herniation were equally divided in two groups: (a) caudal epidural and (b) selective nerve root block group, by a computer-generated random allocation method. The caudal group received three injections of steroid mixed with local anesthetics while selective nerve root block group received single injection of steroid mixed with local anesthetic agent. Patients were assessed for pain relief and reduction in disability. In SNRB group, pain reduced by more than 50% up till 6 months, while in caudal group more than 50% reduction of pain was maintained till 1 year. The reduction in ODI in SNRB group was 52.8% till 3 months, 48.6% till 6 months, and 46.7% at 1 year, while in caudal group the improvement was 59.6%, 64.6%, 65.1%, and 65.4% at corresponding follow-up periods, respectively. Caudal epidural block is an easy and safe method with better pain relief and improvement in functional disability than selective nerve root block. Selective nerve root block injection is technically more demanding and has to be given by a skilled anesthetist.