Caudal Epidural Steroid Injection Research Articles

Ultrasound versus fluoroscopy-guided caudal epidural steroid injection for the treatment of chronic low back pain with radiculopathy: A randomised, controlled clinical trial

Background and Aims:Caudal epidural steroid administration is an effective treatment for chronic low back pain (LBP). Fluoroscopy guidance is the gold standard for pain procedures. Ultrasound guidance is recently being used in pain clinic procedures. We compared the fluoroscopy guidance and ultrasound guidance for caudal epidural steroid injection with respect to the time needed for correct placement of the needle and clinical effectiveness in patients with chronic LBP.Methods:Fifty patients with chronic LBP with radiculopathy, not responding to conventional medical management, were randomly allocated to receive injection depot methyl prednisolone (40 mg) through caudal route either using ultrasound guidance (Group U, n = 25) or fluoroscopy guidance (Group F, n = 25). Pre-procedural visual analogue scale (VAS) score and Oswestry Disability Index (ODI) were noted. During the procedure, the time needed for correct placement of needle was observed. Adverse events, if any, were also noted. All patients were followed up for next 2 months to evaluate Visual Analogue Scale (VAS) score and ODI at the 2nd week and again at the end of 1st and 2nd month.Results:The needle-placement time was less using ultrasound guidance as compared to fluoroscopy guidance (119 ± 7.66 vs. 222.28 ± 29.65 s, respectively, P < 0.001). Significant reduction in VAS score and ODI (clinical improvement) was noted in the follow-up time points and comparable between the groups at all time points.Conclusion:Ultrasound guidance can be a safe alternative tool for achieving faster needle placement in caudal epidural space. Clinical effectiveness (reduction of VAS and ODI scores) remains comparable between both the techniques.

An Epidurogram During Fluoroscopy-Guided Caudal Epidural Reveals an Asymptomatic Tarlov Cyst in a Patient with Lumbar Radicular Pain: A Case Report

Objective: Tarlov cysts are cerebrospinal fluid dilatations of the nerve root sheath at the dorsal root ganglion level. We report the incidental finding of a Tarlov cyst during a fluoroscopy-guided caudal epidural injection in a patient with acute lumbar radicular pain due to disc herniation. Case report: A 76-year-old male was scheduled for an epidural steroid injection (ESI) for acute L5 radicular pain caused by a paracentral disc nucleous pulposus herniation. The ESI was administered via a caudal route because the patient had back surgery at the L3-L4 for Mal de Pott tuberculoses when he was 23-years old. The epidurogram revealed a fusiform image at the sacral level and the procedure was stopped. Afterwards, an MRI showed a sacral cyst of 50 × 18 mm and a left paracentral disc herniation at L4-L5 with L5 root compression. Conclusion: The use of fluoroscopy with epidurogram during a caudal ESI allowed us to confirm epidural needle placement and to observe the cephalic flow of contrast medium into the level and side to treat. Without fluoroscopy, we would not have found this asymptomatic Tarlov cyst.

Factors Affecting Radiation Exposure during Lumbar Epidural Steroid Injection: A Prospective Study in 759 Patients.

ObjectiveTo estimate and compare radiation exposure and intervention time during lumbar epidural steroid injection (ESI) 1) under different practitioners and methods with continuous fluoroscopic monitoring, and 2) under one practitioner with different methods and monitoring.Materials and MethodsWe consecutively recruited 804 patients who underwent lumbar ESI and 759 patients who underwent 922 interventions were included for analysis in this investigation. Three different practitioners (a senior faculty member, junior faculty member, trainee) performed lumbar ESI using different methods (caudal, interlaminar, transforaminal). The senior faculty member performed lumbar ESI under two different methods of fluoroscopic monitoring (continuous [CM] and intermittent monitoring [IM]). The dose area product (DAP) fluoroscopy time, and intervention time during lumbar ESI were compared for 1) ESI methods and practitioners under CM, and 2) ESI methods and monitoring.ResultsWith CM, interaction between the effects of the practitioner and the intervention on DAP was significant (p < 0.001), but not fluoroscopy time (p = 0.672) or intervention time (p = 0.852). The significant main effects included the practitioner and intervention on DAP, fluoroscopy time, and intervention time with CM (p < 0.001). DAPs and fluoroscopy time for caudal, interlaminar, and transforaminal ESI were higher with CM than with IM (p < 0.001). Intervention time did not differ between CM and IM.ConclusionRadiation exposure is dependent on the practitioners and methods and within the established safety limits during lumbar ESIs under CM. With an experienced practitioner, IM leads to less radiation exposure than CM.

Predictors of the efficacy of epidural steroid injections for structural lumbar degenerative pathology

BackgroundLumbar epidural steroid injection (LESI) is a valuable therapeutic option when administered to the appropriate patient, for the appropriate disease process, at the appropriate time. There is considerable variability in patient-reported outcomes (PROs) after LESI, creating uncertainty as to who will benefit from the therapy and who will not. PurposeWe set out to identify patient attributes, which are important predictors for the achievement of a minimum clinically important difference (MCID) in the Oswestry Disability Index (ODI) after LESI. Study DesignA prospective cohort study was carried out. Patient SampleA total of 239 consecutive patients undergoing LESI for back-related disability, back pain (BP), and leg pain (LP) associated with degenerative pathology comprised the patient sample. Outcome MeasuresBaseline and 3-month patient self-reported ODI, numeric rating scale-BP and LP, Euro-Qol-5D, and Short Form (SF)-12 scores were recorded. MethodsA total of 239 consecutive patients undergoing LESI for degenerative pathology over a period of 2 years who were enrolled into a prospective web-based registry were included in the study. Using the previously reported anchor-based approach, an MCID threshold of 7.1% was established for ODI after LESI. Each enrolled patient was then dichotomized as a “responder” (achieving MCID) or a “non-responder.” Multiple logistic regression analysis was then performed, with the achievement of MCID serving as the outcome of interest. Candidate variables included in the regression analyses were age, gender, employment, insurance type, smoking status, preoperative ambulation, preinjection narcotic use, comorbidities, predominant LP or BP symptoms, symptom duration, diagnosis, number of levels, prior surgery, baseline PROs, type of stenosis (central, lateral recesses, or foraminal), injection route (transforaminal, interlaminar, or caudal), and number of injections. Subsequently, we also randomly selected 80% of the patients to serve as the training data for a multiple logistic regression model. Once this predictive model was built, it was validated using the remaining 20% of patients. ResultsThere were 124 (62%) patients who achieved MCID for ODI. The existence of central stenosis (p=.006), TF or IL injection route (p=.02) compared with caudal epidural steroid injection, higher baseline ODI (p=.00001), and a diagnosis of disc herniation (p=.02) increase the odds of achieving MCID for ODI at 3 months. Symptom duration for over a year (p=.006), prior surgery (p=.08), and preinjection anxiety (p=.001) decrease the odds of achieving MCID. The area under the curve (AUC) for our predictive model's receiver-operator characteristic was 0.81 when using the 80% training data set, and the AUC was 0.72 when using the 20% validation data. ConclusionWe have identified patient attributes that are important predictors for the achievement of MCID in ODI 3 months after LESI. The use of these attributes, in the form of a predictive model for LESI efficacy, has the potential to improve decision making around LESI. Spine care providers can use the information to gain insight into the likelihood that a particular patient will experience a meaningful benefit from LESI.

Anatomic Differences in the Sacral Hiatus During Caudal Epidural Injection Using Ultrasound Guidance.

The aim of this study was to clarify differences in the anatomic structure of the sacral hiatus and angle of needle insertion during caudal epidural steroid injection using ultrasound guidance in patients according to sex and age. A total of 237 patients with low back pain with or without sciatica were included. Sonograms of the sacral hiatus were obtained, and caudal epidural steroid injection using ultrasound guidance was performed in all patients. The intercornual distance, diameter of the sacral canal, thickness of the sacrococcygeal ligament, optimal angle for needle insertion, and actual angle of needle insertion were measured. Between men and women, significant differences were observed for the intercornual distance (17.7 versus 16.5 mm; P< .01) and thickness of the sacrococcygeal ligament (4.3 versus 3.9 mm; P = .02). In all patients, the thickness of the sacrococcygeal ligament (r= 0.28) and diameter of the sacral canal (r= 0.40) were positively correlated with the optimal angle for needle insertion (P < .01). In women, the thickness of the sacrococcygeal ligament (r = -0.24), diameter of the sacral canal (r = -0.27), optimal angle for needle insertion (r = -0.29), and actual angle of needle insertion (r = -0.18) were negatively correlated with age. In men, only the diameter of the sacral canal was negatively correlated with age (r = -0.30). We found that the sacral hiatus has anatomic differences between patients of different sexes and ages. Understanding these differences, especially in women, may improve the safety and reliability of caudal epidural steroid injection.

Effect of Caudal Epidural Steroid Injection in Chronic Low Back Pain due to Prolapse Intervertebral Disc

Abstract Background Low back pain (LBP) due to disc herniation is a frequent cause of back pain. It is a debilitating condition having enormous medical and socio-economic effects. Epidural injection of steroids has been used to treat LBP for many decades. Despite widespread use and numerous publications there is significant controversy with regards to the medical necessity and indications for epidural injections, hence we planned this study. Materials and methods This was a prospective follow-up study. Forty-one patients of confirmed diagnosis of prolapse intervertebral disc (PIVD) were included. Caudal epidural steroid injection (CESI) of 80 mg methylprednisolone acetate diluted in 20 ml of 0.9% saline was given. Outcome was assessed by Numeric Pain Rating Scale (NRS), Oswestry Disability Index (ODI), Straight Leg Raise (SLR) and Modified Schober Test (MST) at baseline, one, three, six and twelve weeks follow-up. Results Thirty-seven patients completed the study. Significant improvement in patient's status was observed after CESI, as measured with MST, SLR, NRS and ODI at one and three weeks post injection and the improvement were maintained till 12th week. Eighty-three per cent of patients were satisfied at the end of the study and side-effects reported were mild. Conclusion CESI is a simple, safe and cost effective intervention procedure for the treatment of chronic LBP due to PIVD. It provides rapid pain relief and improvement of physical function starting within a week of injection.

Epidural abscesses following chronic pain injections

This report will present two cases of epidural abscesses following pain interventions and review available evidence and provide preventive strategies for its avoidance. A 54-year-old man having chronic low back and leg pain with past history significant for alcohol dependence and lumbar spine surgeries received a caudal epidural steroid injection following multiple intravascular injection of contrast. Eleven days following the procedure he developed symptoms suggestive of epidural abscess. It was subsequently confirmed by magnetic resonance imaging (MRI) and underwent nonsurgical management of the abscess without any neurological deficit. A 50-year-old homeless man with history of intravenous drug abuse, alcohol abuse, hepatitis C positive, squamous cell carcinoma of the neck, and degenerative lumbar disc disease received trigger point injections to his lumbar paraspinal muscles for management of his myofascial pain syndrome. Fifteen days following the injection, he reported to the emergency (ER) room with complaints of worsening pain. An MRI revealed epidural; abscesses tracking from the paraspinal muscles. He was subsequently managed with intravenous antibiotics and recovered uneventfully. Following review of the literature, it is possible to come up with preventive strategies to mitigate the occurrence of epidural abscesses. One of the key factors is the presence of comorbid conditions including diabetes mellitus and prior spine surgery which may dictate technique for the management of pain.

MR epidurography: distribution of injectate at caudal epidural injection.

To (a) evaluate the feasibility of MR epidurography (MRE) and (b) assess the distribution of injectate using two different volumes at caudal epidural steroid injection. Twenty patients who were referred with symptomatic low back pain for caudal epidural steroid injection were assigned to have either 10 ml (9/20) or 20 ml (11/20) of injectate administered. Gadolinium was included in the injection. The patients proceeded to MRI where sagittal and coronal T1-weighted fat-saturated sequences were acquired and reviewed in the mid-sagittal and right and left parasagittal views at the level of the exit foramina. Gadolinium was observed at or above the L3/4 disc level in all 11 patients who received 20 ml (100 %), compared with only five of nine patients who received 10 ml (56 %). Injectate was seen to the L4 nerve root level in all 11 patients who received 20 ml (100 %) but only four out of nine patients who received 10 ml (44 %), not even reaching the L5 nerve root level in four further of these nine patients (44 %). Overall, there was a trend to visualize gadolinium at higher levels of the epidural space with higher volumes injected. Firstly, MR epidurography is a safe technique that allows excellent visualization of the distribution of gadolinium in the epidural space following injection via the caudal hiatus. Secondly, a volume of 10 ml is unlikely to treat L5/S1 disease in almost half of patients at caudal epidural steroid injection and at least 20 ml of injectate is likely required for any medication to reach the desired level.

Ultrasound-Guided vs. Fluoroscopy-Guided Caudal Epidural Steroid Injection for the Treatment of Unilateral Lower Lumbar Radicular Pain

Ultrasound-Guided vs. Fluoroscopy-Guided Caudal Epidural Steroid Injection for the Treatment of Unilateral Lower Lumbar Radicular Pain

Caudal vs Transforaminal Epidural Steroid Injections as Short-Term (6 Months) Pain Relief in Lumbar Spinal Stenosis Patients with Sciatica

The aim of this study is to evaluate prospectively the efficacy of caudal epidural steroid injection (CESI) and transforaminal epidural steroid injection (TFESI) in lumbar spinal stenosis patients with sciatic pain. Prospective clinical study. Thirty-one patients (average age 62 years) from two hospitals, with single dermotomal distribution of sciatic pain due to spinal stenosis were included in the study. Patients underwent epidural steroid injections done by the same injectionist. Eleven patients from one hospital were included in the CESI group, while the TFESI group consisted of 20 comparable patients from the second site. Primary outcome measure was the complete relief or at least 50% reduction of pain (visual analog scale [VAS]) at 6 months postinjection. Secondary outcome measures were the improvement of function (of at least 15 points of Oswestry Disability Index [ODI]) at 6 months and the changes of VAS and ODI and at 2 weeks, at 3 months, and at 6 months postinjection. A significantly greater number of stenosis patients showed pain relief at 6 months postinjection with TFSI (90%) than with CESI (54.54%). All patients with TFSI showed improvement of function at 6 months while only three (27.27%) patients with caudal epidural improved functionally. Out of the total 31 patients, two patients from group A underwent a second CESI at 15 days postinjection and decompressive spine surgery between 3 and 6 months postinjection. The effectiveness of transforaminal steroid injection for the stenosis patients with sciatica was superior to caudal at 6 months postinjection.

Radiation Exposure for Fluoroscopy-guided Lumbosacral Epidural Steroid Injections

A retrospective investigation. We evaluated and compared the radiation exposure caused by using the fluoroscopy-guided transforaminal and caudal approaches of lumbosacral epidural steroid injection (ESI). Only a few studies focused on the radiation exposure to patients who underwent lumbosacral ESI for pain management. A total of 228 patients (83 males, 145 females; mean age, 63.3 y) who received lumbosacral ESI were included. Transforaminal ESI was performed in 181 patients (67 males, 114 females; mean age, 61.3 y) and caudal ESI was used in 47 patients (16 males, 31 females; mean age, 69.7 y). All ESIs were performed under a single-plane fluoroscopic guidance by 1 musculoskeletal radiologist. The kerma-area product (KAP) and fluoroscopy time were recorded in all patients. Both measurements were correlated and compared for each approach. KAP was 3.02-1048.2 μGy m (mean, 101.7 μGy m; median, 67.8 μGy m) for transforaminal ESI and 16.0-604.5 μGy m (mean, 101.8 μGy m; median, 54.6 μGy m) for caudal ESI. The fluoroscopy time was 11-161 seconds for transforaminal ESI (mean, 36.0 s; median, 29 s) and 4-78 seconds (mean, 18.2 s; median, 13 s) for caudal ESI. KAP and fluoroscopy time were positively correlated for each approach (P<0.001). Fluoroscopy time was significantly longer for transforaminal ESI (correlation coefficient=-0.77, P=0.000). After correction for the fluoroscopy time, KAP was less in transforaminal ESI than in caudal ESI (correlation coefficient=0.74, P=0.000). The longer the fluoroscopy time, the greater the KAP in both transforaminal and caudal ESIs. The fluoroscopy time for transforaminal ESI was longer than that for caudal ESI. However, KAP of transforaminal ESI was less than that of the caudal ESI, after being corrected for the length of fluoroscopy time.

Use of magnetic resonance imaging to identify outcome predictors of caudal epidural steroid injections for lower lumbar radicular pain caused by a herniated disc.

ObjectiveWe used lumbar magnetic resonance image (MRI) findings to determine possible outcome predictors of a caudal epidural steroid injection (CESI) for radicular pain caused by a herniated lumbar disc (HLD).MethodsNinety-one patients with radicular pain whose MRI indicated a HLD were enrolled between September 2010 and July 2013. The CESIs were performed using ultrasound (US). A responder was defined as having complete relief or at least a 50% reduction of pain as assessed by the visual analog scale (VAS) and functional status on the Roland Morris Disability Questionnaire (RMDQ); responder (VAS n=61, RMDQ n=51), and non-responder (VAS n=30, RMDQ n=40). MRI findings were analyzed and compared between the two groups with regard to HLD level, HLD type (protrusion or exclusion), HLD zone (central, subarticular, foraminal, and extraforaminal), HLD volume (mild, moderate, or severe), relationship between HLD and nerve root (no contact, contact, displaced, or compressed), disc height loss (none, less than half, or more than half ), and disc degeneration grade (homogeneous disc structure or inhomogeneous disc structure-clear nucleus and height of intervertebral disc).ResultsA centrally located herniated disc was more common in the responder group than that in the non-responder group. Treatment of centrally located herniated discs showed satisfactory results. (VAS p=0.025, RMDQ p=0.040). Other factors, such as HLD level, HLD type, HLD volume, relationship to nerve root, disc height loss, and disc degeneration grade, were not critical.ConclusionThe HLD zone was significant for pain reduction after CESI. A centrally located herniated disc was a predictor of a good clinical outcome.

CAUDAL EPIDURAL INJECTIONS FOR LUMBAR PROLAPSED INTER VERTEBRAL DISC: ASSESSMENT WITH URDU VERSION OF OSWESTRY DISABILITY INDEX

Background/Aims: Oswestry Disability index is an established tool for assessment of Spinal Disability. It has been translated into many languages and but observational study was translation, application and validation of Urdu version of the Oswestry Disability Index (Urdu ODI) for our specific cultural background. Methods: Urdu version of ODI was developed and applied for outcome assessment in 50 patients, suffering from lumbar prolapsed inter vertebral discs and treated with caudal epidural steroid injection. All patients having mechanical low backache with radiculopathy and single level disc prolapse at L-4-5 or L5-S1 on Magnetic Resonance Imaging (MRI) were included in the study. Single Steroid Injection with local anesthetic was injected into sacral caudal epidural space through sacral hiatus. A Performa was made for each patient and records were kept in a custom built Microsoft access database. Outcome was assessed using Urdu ODI and validation by comparing with Numeric rating Scale 0-10 at each visit. Results: Fifty patients received caudal epidural injections, 23 (46%) were male and 27 (54%) were female. The mean age was 34 years, with the range being 21-55. Low mechanical backache with right sided radiculopathy was in 29 (58%) and left sided in 21 (42%) patients. The commonest involved disc was L4-5 in 28 (56%) and L5-S1 in 22 (44%) patients Pain was assessed with Numeric Rating Scale (NRS) of ten points. This was mean 7.35, range 9-6 at presentation and mean improvement was 4.15 with range 5-3 at fist week, 3.80 with range 5-2 at first month and 3.05 with range 4-1 after six months. Functional disability assessment was done using Urdu ODI. The mean Urdu ODI at the time of presentation was 66.23% with range 81%-48%. The mean functional status was found to be 38.64% with range 26%-45% at the end of the first week, 43.65% with range 31%-48% after one month and 44.85% with range 28%-48% after six months. So there was mean improvement in score of Urdu ODI: 41.65% at the end of the first week, 34.09% after the first month and 32.28% after the end of six months. Pain at injection site was the only complication in 4 (8%) patients. Conclusion: Urdu ODI is useful tool for assessment of spinal disability in Pakistani population. This will meet the local cultural and literacy requirement. Caudal epidural injection can be injected in Out Patient Clinics safely with good outcome avoiding surgery in majority of the cases. To our knowledge this is the first Urdu translation and validation of ODI. Key Words: Oswestry Disability Index, ODI, Urdu Oswestry Disability Index, Urdu ODI, Caudal Epidural Injection

Caudal epidural steroid injection in the treatment of chronic discogenic low back pain. Comparative, prospective and randomized study

ObjectiveThere is no consensus on the treatment of chronic low back pain of disk origin in the medical literature. The few prospective, randomized, controlled studies evaluating the effectiveness of caudal epidural steroid injections (CESI) have obtained contradictory results. The aim of this study is to evaluate the efficacy of CEI in reducing pain and improving the associated disability. Material and methodThis is a prospective, randomized, case-control study of a group of 46 patients with chronic low back disk pain. Patients were randomly allocated into 2 groups to either receive fluoroscopy guided CESI (CESI-group), or oral non-steroidal anti-inflammatory drugs (NSAID-group). All patients were clinically evaluated at 4, 12, and 24 weeks, and according to the indications of the Spanish Society for Study of Diseases of the Spine (GEER). ResultsLumbar pain, measured by the visual analog scale (VAS) and the Oswestry Low Back Pain Disability Questionnaire (ODQ), did not improve significantly during follow-up in any of the two study groups (p>0.05). Younger patients, women, patients with shorter duration of symptoms, low physical job demand, without leg pain, and sport-active, included in CESI-group showed a trend toward better results, but none reached statistical significance (p>0.05). ConclusionsThe present study has not demonstrated the superiority of CESI over NSAIDs in treating chronic low back pain of disk origin. While CESI could show some improvement in patients with degenerative lumbar disk disease, we consider it should be used with caution, informing patients about realistic expectations on the success of treatment.

Infiltración esteroidea epidural por vía caudal en el tratamiento del dolor lumbar crónico de origen discal. Estudio comparativo, prospectivo y aleatorizado

ObjectiveThere is no consensus on the treatment of chronic low back pain of disc origin in the medical literature. The few prospective, randomized, controlled studies evaluating the effectiveness of caudal epidural steroid injections (CESI) have obtained contradictory results. The aim of this study is to evaluate the efficacy of CEI in reducing pain and improving the associated disability. Material and methodThis is a prospective, randomized, case-control study of a group of 46 patients with chronic low back disc pain. Patients were randomly allocated into 2 groups to either receive fluoroscopy guided CESI (CESI-group), or oral non-steroidal anti-inflammatory drugs (NSAID-group). All patients were clinically evaluated at 4, 12, and 24 weeks, and according to the indications of the Spanish Society for Study of Diseases of the Spine (GEER). ResultsLumbar pain, measured by the visual analog scale (VAS) and the Oswestry Low Back Pain Disability Questionnaire (ODQ), did not improve significantly during follow-up in any of the two study groups (P>.05). Younger patients, women, patients with shorter duration of symptoms, low physical job demand, without leg pain, and sport-active, included in CESI-group showed a trend towards better results, but none reached statistical significance (P>.05). ConclusionsThe present study has not demonstrated the superiority of CESI over NSAIDs in treating chronic low back pain of disc origin. While CESI could show some improvement in patients with degenerative lumbar disc disease, we consider it should be used with caution, informing patients about realistic expectations on the success of treatment.

Ultrasound-Guided vs. Fluoroscopy-Guided Caudal Epidural Steroid Injection for the Treatment of Unilateral Lower Lumbar Radicular Pain

The aim of this study was to compare the short-term effects and advantages of ultrasound-guided caudal epidural steroid injections with fluoroscopy-guided epidural steroid injections for unilateral radicular pain in the lower lumbar spine. A total of 120 patients with unilateral radicular pain were enrolled and randomly assigned to either the fluoroscopy or the ultrasound group. Complication frequencies during the procedures, treatment effects, functional improvement, and adverse events were compared after the procedures. The verbal numerical rating scale and the Oswestry Disability Index improved 2 and 12 wks after the injections in both groups. Statistical differences were not observed in the verbal numerical rating scale, the Oswestry Disability Index, or the effectiveness of the procedure between the groups. Two cases of intravascular injections were observed in the fluoroscopy group, without the prevalence of complication between the groups. The ultrasound approach with color Doppler mode may avoid intravascular injection-induced complications. The results showed similar improvements in short-term pain relief, function, and patient satisfaction with both ultrasound and fluoroscopic guidance.

Unintentional intrathecal placement during attempted caudal epidural steroid injection with directed catheter allows for excellent relief in refractory lumbar radiculopathy: a case report

Unintentional intrathecal placement during attempted caudal epidural steroid injection with directed catheter allows for excellent relief in refractory lumbar radiculopathy: a case report

Arachnoiditis Following Caudal Epidural Injections for the Lumbo-Sacral Radicular Pain

Caudal epidural steroid injection is a very common intervention in treatment of low back pain and sciatica symptoms. Although extensively used, it is not devoid of complications. A few reports of chemical and infective arachnoiditis exist following lumbar epidural anaesthesia, but none following a caudal epidural steroid injection.We report a case of arachnoiditis following caudal epidural steroid injections for lumbar radiculopathy. The patient presented with contralateral sciatica, worsening low back pain and urinary retention few days following the injection, followed by worsening motor functions in L4/L5/S1 myotomes with resultant dense foot drop. Gadolinium-enhanced magnetic resonance imaging suggested infective arachnoiditis with diffuse enhancement and clumping of the nerve roots within the lumbar and sacral thecal sac. As the number of injections in the management of back pain and lumbo-sacral radicular pain is increasing annually, it is imperative to have a thorough understanding of this potentially dangerous complication and educate the patients appropriately.

The Role of Caudal Epidural Steroid Injections in Management of Low Back Pain

The role of caudal epidural steroid injection in management of low back pain is controversial. This is a prospective study done on 50 patients who reported to orthopaedic OPD over a period of 2 years. Patients were classified on the basis of MRI diagnosis. All the injections were given by same surgeon after a trial of conservative treatment for at least six weeks. A combination of drugs containing methylprednisolone, lignocaine 2% and normal saline was injected through sacral hiatus. Patients were assessed at 24 hours, one week, three weeks and three months interval. No major complications were observed except for dural leak, headache and injection site pain. We believe that CEI is mainly effective in treating patients with acute low back pain refractory to conservative treatment, patients with disc degeneration and discogenic grade I -II low back pain. The patients with chronic pain usually do not respond to CEI on long term follow up. Such patients must be referred to back school condition programs before taking up for surgery.

Survey of European Pain Medicine Practice

This survey was undertaken to explore the variation in the functional constitution of pain clinics in Europe. In addition, we also explored the amount of training which doctors practicing pain medicine typically receive. Approximate hospital charges for common pain interventions and the source of funding were also surveyed. Members of the British Pain Society (Interventional Pain Medicine-Special Interest Group) and other pain physicians in Europe responded through the online questionnaire tool “Survey Monkey.” About 215 requests were sent; 82 pain practitioners from 13 countries in Europe responded. This survey indicates that chronic pain interventions are primarily funded either through government or insurance companies. The primary chronic pain service members continue to be anesthesiologists, combined with specialist nurses and physiotherapists. There appears to be some consistency, both with regard to working in a multidisciplinary team, and the training required to become a pain specialist. More than half of the respondents reported the cost of common interventions like caudal epidural steroid injection (ESI) , transforaminal ESI, 3 level medial branch blocks, and 6 level facet joint injections to fall under the €500 range ($645). Two thirds of the respondents reported the cost of 4-joint radiofrequency lumbar denervation to be less than €1,500 ($1,935). Good practice should ensure an adequate duration of training, and development of a pain faculty to ensure standards of assessments across the continent. A more detailed, large scale survey is perhaps required to map the availability of chronic pain services and understand the health economics in pain medicine across Europe. Key words: Chronic pain, Europe, survey, charges for pain interventions, advanced training, multidisciplinary pain team, pain specialists