Chronic Radicular Low Back Pain Research Articles

Evaluation of the Efficacy of Caudal Epidural Neuroplasty in Patients With Lumbar Epidural Fibrosis.

Introduction Lumbar and leg pain can be caused by many factors, including scar tissue in the epidural space. Epidural fibrosis may cause chronic radicular low back pain. Adhesions in the epidural space may occur due to surgical or non-surgical reasons. Epidural adhesiolysis, i.e., neuroplasty, eliminates the pain-causing effects of scar tissue by releasing the nerve from the scar tissue or decompressing the nerve. In light of this information, this study was conducted to evaluate the effectiveness of percutaneous epidural neuroplasty interventions performed in the algology clinic in patients with lumbar epidural fibrosis who have and have not undergone lumbar surgery. Methods The sample of this retrospective study consisted of 72 patients with chronic radicular low back pain, finding fibrosis in the epidural region on contrast-enhanced magnetic resonance imaging (MRI), filling defect after epidurogram, and caudal epidural neuroplasty. Patients' visual analog scale (VAS) and Oswestry disability index (ODI) scores, pregabalin, duloxetine, and opioid doses were evaluated before and one month and six months after having neuroplasty. Results The VAS and ODI scores and pregabalin, duloxetine, and opioid doses decreased significantly in patients who had had caudal epidural neuroplasty at post-procedure endpoints compared to before the procedure (p<0.001). The paired temporal comparisons of the data of the patients who underwent epidural neuroplasty procedures before the procedure, one month after the procedure, and six months after the procedure revealed significant differences in the VAS and ODI scores (p<0.001). Additionally, the analysis of patients' VAS scores revealed that the pre-procedure VAS scores decreased significantly more one month after the procedure in patients without a history of lumbar surgery than in patients with a history of lumbar surgery. Conclusions The findings of our study demonstrated that fluoroscopy-guided percutaneous epidural neuroplasty alleviated pain and improved physical functions and quality of life. In conclusion, percutaneous epidural neuroplasty is a safe and effective treatment method for patients with lumbar epidural fibrosis.

Caudal epidural blockades for chronic pain in the lower back in working age

Introduction. Chronic back pain syndrome, which significantly restricts a person’s daily activity, can cause the formation of depressive states and is a significantly more difficult task for treatment compared to acute pain.Aim. To evaluate the efficacy and safety of caudal epidural catheterization (CEC) and local therapy with anesthetics and glucocorticoids for chronic nonspecific discogenic and chronic radicular low back pain (LBP) in young and middle-aged patients.Materials and methods. 42 patients aged from 29 to 59 years, who in the neurosurgical department of the Vologda City Hospital No. 1 in 2017–2019 underwent an operation to install a caudal epidural catheter and prolonged injection therapy of local anesthetics and glucocorticosteroids for chronic nonspecific discogenic and chronic radicular LBP.Results. There were no purulent-septic complications, hematomas of the spinal canal. In the group of patients with radicular syndrome the average values of LBP according to VAS were as follows: before CEC – 78.5 mm; 5 days after CEC – 24.1 mm; 6 months after CEC – 19.6 mm; after 12 months – 17.9 mm. In the group of patients with nonspecific discogenic LBP the average pain estimates for VAS were as follows: before CEC – 78.1 mm; 5 days after CEC – 21.7 mm; 6 months after CEC – 20.9 mm; after 12 months – 23.4 mm.Сonclusion. Our experience indicates a high long-term efficacy and safety of treatment with caudal epidural catheterization and local prolonged therapy with anesthetics and glucocorticoids for chronic radicular and chronic nonspecific discogenic pain in the lower back in young and middle-aged patients selected on the basis of a special system of criteria.

Ultrasound-guided caudal epidural steroid injection in chronic radicular low back pain: short-term electrophysiologic benefits.

Objective:To assess the short-term efficacy of ultrasound-guided caudal epidural steroid injections (ESIs) in improving pain, and nerve function as measured by electrophysiological testing in chronic radicular low back pain.Methods:Patients diagnosed with chronic radicular low back pain were randomized into one of two groups. The injection group (n = 20) underwent a single ultrasound-guided Caudal ESI of 1 ml of 40 mg ml−1 Triamcinolone Acetonide (Kenacort-A), with local anesthetic. The control group (n = 20) underwent a 12-session physiotherapy program. Both groups were evaluated before and 2 weeks after the intervention using visual analog scale for pain and electrophysiological testing comprising peroneal and tibial terminal motor latencies and F-response latencies and chronodispersion.Results:Both groups showed significant pain reduction on the visual analog scale after the intervention. The injection group showed a significant reduction in F wave chronodispersion post-treatment (<0.01). In the control group, there were no significant differences in F wave parameters pre- and post-treatment (p > 0.05).Conclusion:Caudal ESIs were shown to provide short-term improvement of nerve function as evident by improvement in the electrophysiological parameters sensitive to radiculopathy. It was found to be superior to standard physical therapy in this regard.Advances in knowledge:This work shows a novel electrophysiologic evidence of the short-term efficacy ultrasound-guided caudal ESI.

Effectiveness of intradiscal injection of radiopaque gelified ethanol (DiscoGel®) versus percutaneous laser disc decompression in patients with chronic radicular low back pain.

BackgroundLow back pain secondary to discopathy is a common pain disorder. Multiple minimally invasive therapeutic modalities have been proposed; however, to date no study has compared percutaneous laser disc decompression (PLDD) with intradiscal injection of radiopaque gelified ethanol (DiscoGel®). We are introducing the first study on patient-reported outcomes of DiscoGel® vs. PLDD for radiculopathy.MethodsSeventy-two patients were randomly selected from either a previous strategy of PLDD or DiscoGel®, which had been performed in our center during 2016–2017. Participants were asked about their numeric rating scale (NRS) scores, Oswestry disability index (ODI) scores, and progression to secondary treatment.ResultsThe mean NRS scores in the total cohort before intervention was 8.0, and was reduced to 4.3 in the DiscoGel® group and 4.2 in the PLDD group after 12 months, which was statistically significant. The mean ODI score before intervention was 81.25% which was reduced to 41.14% in the DiscoGel® group and 52.86% in the PLDD group after 12 months, which was statistically significant. Between-group comparison of NRS scores after two follow-ups were not statistically different (P = 0.62) but the ODI score in DiscoGel® was statistically lower (P = 0.001). Six cases (16.67%) from each group reported undergoing surgery after the follow-up period which was not statistically different.ConclusionsBoth techniques were equivalent in pain reduction but DiscoGel® had a greater effect on decreasing disability after 12 months, although the rate of progression to secondary treatments and/or surgery was almost equal in the two groups.

The effect of exercise therapy, dry needling, and nonfunctional electrical stimulation on radicular pain: a case report

A 43-year-old male, office worker with history of chronic radicular low back pain radiating into the left leg was admitted to a sports medicine research center, neuroscience institute. During the past year, he visited a physiotherapist and orthopedic experts. Magnetic resonance imaging revealed a protruded disc at L4–5 level. Additionally, electromyography indicated that there was bilateral moderate irritation at the L5–S1 root. We designed a management package including exercise therapy, dry needling, and nonfunctional electrical stimulation for four sessions. Outcomes included pain intensity, pain with lumbar flexion, with the numerical rating scale (NRS), visual analogue scale (VAS), and function measured with the Oswestry Disability Index before and after the intervention. After 4 treatment sessions, the patient reported a reduction in pain intensity from a 9 to 2 on the NRS and from 90 to 30 on the VAS. In addition, the patient was able to perform lumbar flexion fully without pain.

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.

The comparison between steroid and hypertonic saline 10% with steroid in transforaminal epidural injection in patients with unilateral foraminal stenosis

Introduction: Chronic radicular low back pain is a common disease that limits patient’s daily activity. Epidural steroid injection (ESI) is becoming the mainstay of therapies for radicular low back pain due to contained bulged disc. Aim: To determine the effect of adding hypertonic saline to epidural steroid injections to provide pain relief for chronic radiculopathy back pain secondary to foraminal stenosis. Method: In a randomized clinical trial, 50 patients with unilateral radicular low back pain due to unilateral foraminal stenosis were enrolled. Epidural steroid injections were performed using transforminal approach. In hypertonic saline group 80 mg of triamcinolone plus 2 ml of 10% hypertonic saline, and in control group 80 mg of triamcinolone plus 2 ml of normal saline were injected. Outcome measures were numerical rating scale (NRS), Oswestry disability index (ODI), and proportion of responder patients (NRS<3) were measured at baseline, 1, 3, and 6 months post-procedure. Results: Comparison of pain score between two groups showed that pain score was not significantly different at 1(p=0.24), 3 (p=0.31) and 6 (p=0.38) month. significant pain relief (NRS<3) in 76% of patients within 1 months. Percent of patient with NRS<3 was 48% and 32% in hypertonic and 40% and 32% in steroid group at 3 and 6 month respectively. Conclusion: hypertonic saline added to steroid did not significantly increase pain relief effect of epidural steroid injection.

The effectiveness of transforaminal epidural steroid injection in patients with radicular low back pain due to lumbar disc herniation two years after treatment.

The aim of this retrospective study was to investigate the therapeutic effect of transforaminal epidural steroid injection in patients with chronic low back pain and radicular leg pain due to lumbar disc herniation. This study included 80 patients (32 female and 48 male; mean age: 45.8 years [range: 25-65 years]) that received fluoroscopically guided transforaminal epidural steroid injections for chronic radicular low back pain due to lumbar disc herniation. All of the patients had diagnostic MRI findings and did not respond to conservative treatment. All injections were performed by the same physician at the interventional pain unit of a tertiary hospital. The effectiveness of transforaminal epidural steroid injections was assessed via a standardized telephone questionnaire administered 2 years after the first injection. Mean duration of radicular low back pain was 24.50 ± 18.25 months. Most of the epidural injections were administered at the L5 and S1 levels. The most effective post-injection period was the first 5.11 ± 3.07 months. Mean duration of injection effect was 12.46 ± 7.24 months. The response rate to the epidural steroid injections was 72%. There was negative correlation between the duration of treatment effect and the duration of pre-treatment symptoms. Additionally, clinical improvement of radicular low back pain increased significantly as the duration of pre-treatment symptoms decreased. Based on the present findings, we think that transforaminal epidural steroid injections can be used as an alternative treatment for managing chronic radicular low back pain.

Alternative Approach To Needle Placement In Spinal Cord Stimulator Trial/Implantation

Neuromodulation with spinal cord stimulation is a proven, cost effective treatment for the management of chronic radicular low back pain from failed low back surgery syndrome and other neuropathic pain conditions. The traditionally instructed method for percutaneous spinal cord stimulator lead placement promotes the use of a “loss of resistance” technique under anteroposterior fluoroscopic guidance to assure midline lead placement and proper entry into the epidural space. Loss of resistance is a reliable method to locate the epidural space in most clinical situations. However, in certain circumstances such as a congenital underdeveloped ligamentum flavum or defects of the ligamentum flavum, sometimes occurring after lumbar spine surgery, it might become difficult to use a loss of resistance technique to locate the epidural space. In this case, the level of resistance might not be clear. Further, a false loss of resistance might occur between changes in fascial planes that might lead to the uncertainty of needle depth. This paper introduces an alternative method for needle placement for spinal cord stimulator (SCS) trials and implantation without using the traditional loss of resistance technique. The technique allows for precise visual monitoring of the Tuohy needle tip under fluoroscopy to gauge needle depth as it enters into the tissue and the epidural space based on anatomic structural landmarks. This method allows for multiple lead placement or single lead insertion multiple times in the same interlaminar space. This is an alternative approach to the loss of resistance technique based on the fluoroscopic landmarks. Theoretically, this should be a safer approach for accessing the epidural space; however, further studies are needed to evaluate its safety. Key words: spinal cord stimulator, loss of resistance, epidural access, lumbar radicular symptoms of lower limbs, neuromodulation, posterior column stimulator