Lumbar Epidural Injections Research Articles

Kein Vorteil der epiduralen Injektion vs. oraler Medikation und Physiotherapie bei Ischialgie, unabhängig von der Beschwerdedauer

The study presented here investigated the short-term effectiveness of one-off lumbar caudal epidural injection (EI) in sciatica in relationship to the reported duration of pain. This retrospective analysis involved 106 consecutive in-patients who received either conservative treatment (Group I) or an additional EI on the first day of their treatment (Group II). Both groups were divided according to the duration of symptoms at the time of admission (less than three months, or more than six months). Propensity score matching was performed for the whole collective and the resulting subgroups. This incorporated gender, age and pain intensity at the time of admission. The target parameter were changes on a visual analogue scale (VAS) of pain intensity on days D1, D3, and D10 depending on the respective treatment. A routine evaluation of the mental variables anxiety, depression and somatisation was performed as part of the examination upon admission and their relationship to the success of treatment was later assessed. The mean age of the patients was 61.7 (± 11.6) in Group I and 63.6 (± 13.6) in Group II. 59 % of the patients were female (n = 63). The Lasègue sign was prevalent in 45 % of Group I and 51 % of Group II. The intensity of pain on the day of admission was similar in both groups (7.0 ± 1.0 for Group I, 6.7 ± 1.8 for Group II). The length of stay on the ward was also similar in both groups (10.2 ± 3.9 and 9.4 ± 3.7 d, respectively). It was found that, independent of the duration of symptoms, injection treatment was significantly more effective than conservative treatment only in the early stages (D1 and D3, p < 0.001). No differences could be found in the expression of these mental variables between treatment groups, as these factors showed no influence on the results of therapy. In the context of acute treatment a once only lumbar caudal epidural injection represents at most a short-term effectiveness for the therapy of sciatica. The results presented here indicate that neither the duration of symptoms nor the measured psychometric variables show any effect on the success of therapy.

Adjuvant Hyaluronidase to Epidural Steroid Improves the Quality of Analgesia in Failed Back Surgery Syndrome: A Prospective Randomized Clinical Trial

Background: Management of low back pain after spinal surgeries is one of the most challenging problems in pain medicine. Transforaminal lumbar epidural steroid injection has been used with inconsistent response. Most patients require multiple and frequent injections due to high recurrence of back pain. Objective: To find out whether the addition of hyaluronidase to the epidural injectate affects the quality and duration of analgesia in patients with low back pain secondary to failed back surgery syndrome. Study Design: Prospective randomized trial. Methods: The study was registered in the Government Clinical Trial registry and the protocol was reviewed and approved by the institutional review board. After obtaining an informed consent, 25 patients with low back pain due to failed back syndrome were randomly assigned to receive a transforaminal epidural injection of hyaluronidase 1500 IU (HYL) or normal saline (NSL) to a mixture of bupivacaine 0.5% (1 mL) and triamcinolone 40mg (1 mL) in a doubleblind fashion. An interventional pain specialist using fluoroscopic guidance performed all epidural injections. The patients received a comprehensive neurological examination by a non-interventional pain specialist who was blinded to the treatment during their follow-up visits, scheduled one, 2, and 4 weeks after the intervention. Numerical pain scores, analgesic requirement, and satisfaction scores were recorded during every visit. Results: There was no difference in demographic data between the 2 groups. Pain scores and total analgesic requirement were significantly lower in the HYL group at 2 and 4 weeks after blockade (P &lt; 0.01). Patient satisfaction was higher in the HYL group. Limitations: The study was limited by a relatively small sample size. Conclusion: We conclude that adding hyaluronidase to the epidural injectate was effective in the management of chronic low back pain in patients with failed back surgery syndrome demonstrated over a period of 4 weeks. Key words: Low back pain, lumbar epidural injection, steroid, hyalorunidase, bupivacaine

Declining Value of Work of Interventional Pain Physicians

threats for facets, epidurals, and spinal cord stimulation (1); certified registered nurse anesthetists (CRNAs) entering the full arena of interventional pain management (2-4); Center for Disease control supported single-dose vial policy being created without products to reasonably support it (5); Food and Drug Administration (FDA) regulating procedural standards of interventional techniques; Noridian led local coverage determinations (LCDs) prepared by Multi-Specialty Pain Workgroup (MPW) (6-8); threatened cuts of cervical epidural injections and facet joint interventions in Tennessee (9,10); empowered insurers limiting interventional pain management (IPM) services (11); usual sustained growth rate (SGR) cut fiasco (12,13); and finally the Thanksgiving gift of draconian cuts for epidural injections amounting to 33% for cervical epidural when in a facility and 56% when performed in a physicians office, and 19% for lumbar interlaminar epidural injection in a facility setting for physician fee and 49% when performed in a physicians office (14). Thus, CMS determined the work value of highly trained and skilled IPM physicians to be a whopping $42 to assess a patient preoperatively, to perform a high risk procedure of cervical epidural injection, and follow post-operatively for next 24 hours. There were successes to match these challenges. Facet joints are not on a national coverage determination (NCD) list. We provided our opinions to the FDA and they are considering them on performance of interventional procedures; the Government Accountability Office (GAO) has started a study to assess if, in fact, CRNAs are qualified to perform interventional techniques (15,16); creation of a group purchasing organization (GPO) with Henry Schein (17); published evidence-based guidelines for interventional techniques listed on Agency for Healthcare Research and Quality’s (AHRQ) National Guideline Clearinghouse (NGC) website (18); reversal of noncoverage decision on cervical epidurals and facet joint interventions in Tennessee (19,20); continuing negotiations with Cigna with evidence submission signed by 684 physicians (21); progress in negotiations with Noridian to revise LCDs based on evidence and reasonable and medically necessary; and finally with a 3 month fix for proposed 24% SGR cut (22). The above referenced challenges have led some to enter 2014 with lackluster enthusiasm, frustration, and dismay. Issues continue, most importantly draconian cuts proposed by the Centers for Medicare and Medicaid Services (CMS) for lumbar and cervical interlaminar epidural injections CPT 62310 and CPT 62311 with a physician payment of $42 for preoperative assessment, performance of the procedure intraoperatively, and post operative management. It is true a physician’s work is valued at $42 or 1.18 or 1.17 physician relative value units (RVUs) by CMS. A national rate of physician reimbursement is $72.72 when performed for each procedure in a facility setting and $108.90 for cervical epidural and $110.69 for lumbar epidural when performed in an office setting. Using simple arithmetic, the reimbursement has dropped to $36 for Health Policy Opinion

Access routes and reported decision criteria for lumbar epidural drug injections: a systematic literature review

To review lumbar epidural drug injection routes in relation to current practice and the reported criteria used for selecting a given approach. This was a HIPPA-compliant study. Employing a systematic search strategy, the MEDLINE and EMBASE databank as well as the Cochrane Library were searched for studies on epidural drug injections. The following data were noted: access route, level of injection, use of image guidance, and types and doses of injected drugs. Justifications for the use of a particular route were also noted. Data were presented using descriptive statistics. A total of 1,211 scientific studies were identified, of which 91 were finally included (7.5%). The interlaminar access route was used in 44 of 91 studies (48.4%), the transforaminal in 37 of 91 studies (40.7%), and the caudal pathway in 26 of 91 studies (28.6%). The caudal pathway was favored in the older studies whereas the transforaminal route was favored in recent studies. Decision criteria related to correct needle placement, concentration of injected drug at lesion site, technical complexity, costs, and potential complications. Injection was usually performed on the level of the lesion using local anesthetics (71 of 91 studies, 78.0%), steroids (all studies) and image guidance (71 of 91 studies, 78%). The most commonly used access routes for epidural drug injection are the interlaminar and transforaminal pathways at the level of the pathology. Transforaminal routes are being performed with increasing frequency in recent years.

Needle Position Analysis in Cases of Paralysis From Transforaminal Epidurals: Consider Alternative Approaches to Traditional Technique

Background: Transforaminal technique for epidural steroid injections, unlike other approaches, is uniquely associated with permanent, bilateral, lower extremity paralysis. Objective: To review the literature and analyze the reported cases of paralysis from lumbar transforaminal epidural steroid injections to possibly establish a cause and to prevent this complication. Study Design: Eighteen cases of paralysis from transforaminal epidural injection have been reported. We could analyze the position of the needle within the neural foramen based on the available images and/or description among 10 of these 18 cases. Five cases were performed with computed tomography guidance and 12 cases were performed with fluoroscopic guidance [unknown in one case]. Additionally, other variables associated with the procedure, including the technique, were also examined. Methods: Analysis of the needle position in the neural foramen in cases of paralysis from transforaminal epidural steroid injections. This analysis is based on images and/or description provided in published reports. Results: Paralysis in these cases seems to be associated with a well performed traditional safe triangle approach with good epidural contrast spreads. Analyzed data shows that 77.7% of the time, the needle was in the superior part of the foramen. In 71.4% of the cases, the needle was in the anterior part of the foramen. This coincides with the location of the radicular artery in the foramen. In 22.2%, the needle was in the midzone (neither in the superior nor inferior zone). No level was spared as this event occurred at every foramen from T12 to S1. Ten of these events happened during a left-sided procedure and 8 during a right-sided procedure. No relation to this complication was noted when other variables like type and size of the needles, side of the injection, local anesthetic, contrast, or volume of injectate were taken into consideration. Limitations: Only 18 cases of paralysis from transforaminal epidurals have been reported. Out of these, only 10 cases included images or descriptions which could be evaluated for our study. Conclusion: In light of the anatomical and radiological evidence in the literature that radicular arteries dwell in the superior part of the foramen and along with our needle position analysis, we suggest that the traditional technique of placing the needle in the superior and anterior part of the foramen must be reexamined. Alternative, safer techniques must be considered, one of which is described. Key words: Lumbar epidural injection, lumbar transforaminal, approach, selective nerve root block, paralysis, steroid, particulate, nonparticulate, safe triangle, radicular artery, artery of Adamkiewicz

Abnormal Uterine Bleeding Following Lumbar Epidural Corticosteroid Injections and Facet Medial Branch Blocks in Both Pre- and Postmenopausal Women: A Case Series: Table 1

Epidural steroid injections (ESIs) are now increasing in popularity with regard to the management of chronic lumbar radiculopathy. While ESIs have been shown to be effective in relieving low back and radicular pain, adverse reactions have also been reported, notably abnormal vaginal bleeding. We present a case series of four women, both pre- and postmenopausal, with chronic lumbar radiculopathy and corresponding pathology who developed abnormal vaginal bleeding after receiving either ESIs or facet medial branch blocks (MBBs) for pain management. Setting. University of California, Los Angeles. Four women, both pre- and postmenopausal. We discuss the potential effects of corticosteroids on the hypothalamic-pituitary-ovarian axis and highlight our patients' risk factors for abnormal vaginal bleeding, both exogenous and endogenous, as well as focus on the technical approaches to corticosteroid administration utilized in our patients' procedures. We acknowledge that because this is a small case series, further prospective investigation is warranted regarding the above topics. Until then, it may be beneficial to consider whether patients, both pre- and postmenopausal, have risk factors for abnormal uterine bleeding prior to undergoing interventional pain management strategies, specifically ESI and MBB, and to inform all women upon consent that abnormal vaginal bleeding is a potential risk following procedures with corticosteroids.

CT-guided transforaminal cervical and lumbar epidural injections

Transforaminal injections are widely used. Serious complications including strokes and paraplegia have been reported after transforaminal injections of corticosteroids, and the Afssaps (2011) has issued a warning about their use [1]. The needle must be positioned in the posterior aspect of foramen, and its correct placement validated by an injection of contrast product. It is preferable to choose cortivazol (Altim(®)) as the corticoid for injection. This procedure is simple, reproducible, and durably effective in 60 to 70% of cases. Complications and adverse effects are rare but potentially serious: allergies, blood pressure surge, vasovagal syncope, transient exacerbation of pain, infection, stroke, and paraplegia. The aim of this course is to stress the need for rigor -in the indication, the technical performance of the procedure, and the overall management of the patient.

The Effectiveness of Lumbar Interlaminar Epidural Injections in Managing Chronic Low Back and Lower Extremity Pain

Background: Intervertebral disc herniation, spinal stenosis, intervertebral disc degeneration without disc herniation, and post lumbar surgery syndrome are the most common diagnoses of chronic persistent low back and lower extremity symptoms, resulting in significant economic, societal, and health care impact. Epidural injections are one of the most commonly performed interventions in the United States in managing chronic low back pain. However the evidence is highly variable among different techniques utilized – namely interlaminar, caudal, and transforaminal – and for various conditions, namely – intervertebral disc herniation, spinal stenosis, and discogenic pain without disc herniation or radiculitis. Multiple systematic reviews conducted in the evaluation of the effectiveness of interlaminar epidural injections have been marred with controversy. Consequently, the debate continues with regards to the effectiveness, indications, and medical necessity of interlaminar epidural injections. Study Design: A systematic review of lumbar interlaminar epidural injections with or without steroids. Objective: To evaluate the effect of lumbar interlaminar epidural injections with or without steroids in managing various types of chronic low back and lower extremity pain emanating as a result of disc herniation or radiculitis, spinal stenosis, and chronic discogenic pain. Methods: The available literature on lumbar interlaminar epidural injections with or without steroids in managing various types of chronic low back pain with or without lower extremity pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, or limited based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to December 2011, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term &gt; 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. Results: Overall, 82 lumbar interlaminar trials were identified. All non-randomized studies without fluoroscopy and randomized trials not meeting the inclusion criteria were excluded. Overall, 15 randomized trials and 11 non-randomized studies were included in the analysis. Analysis was derived mainly from fluoroscopically-guided randomized trials and non-randomized studies. The evidence is good for radiculitis secondary to disc herniation with local anesthetics and steroids, fair with local anesthetic only; whereas it is fair for radiculitis secondary to spinal stenosis with local anesthetic and steroids, and fair for axial pain without disc herniation with local anesthetic with or without steroids, with fluoroscopically-guided epidural injections. Limitations: The limitations of this study include that we were unable to perform meta-analysis for disc herniation, and the paucity of evidence for discogenic pain and spinal stenosis. Further, methodological criteria have been highly variable along with sample sizes. The studies were heterogenous. Conclusion: The evidence based on this systematic review is good for lumbar epidural injections under fluoroscopy for radiculitis secondary to disc herniation with local anesthetic and steroids, fair with local anesthetic only; whereas it is fair for radiculitis secondary to spinal stenosis with local anesthetic and steroids, and fair for axial pain without disc herniation with local anesthetic with or without steroids. Key words: Chronic low back pain, lower extremity pain, disc herniation, radiculitis, spinal stenosis, discogenic pain, lumbar interlaminar epidural injections, fluoroscopy

Effective Dose of CT-Guided Epidural and Periradicular Injections of the Lumbar Spine: A Retrospective Study

Spinal injection procedures can be performed blindly or, more accurately, with fluoroscopic or computed tomography (CT) guidance. Radiographic guidance for selective nerve root blocks and epidural injections allows an accurate needle placement, reduces the procedure time and is more secure for the patient, especially in patients with marked degenerative changes and scoliosis, resulting in a narrowing of the interlaminar space. Limiting factors remain the availability of scanners and the radiation dose. Interventional CT scan protocols in axial CT-acquisition mode for epidural and periradicular injections help to limit the radiation dose without a significant decrease of image quality. The purpose of this retrospective study was to analyze the effective radiation dosage patients are exposed during CT-guided epidural lumbar and periradicular injections. A total amount of n=1870 datasets from 18 months were analyzed after multiplying the dose length product with conversion factor k for each lumbar segment. For lumbar epidural injections (n=1286), a mean effective dose of 1.34 mSv (CI 95%, 1.30-1.38), for periradicular injections (n=584) a mean effective dose of 1.38 mSv (CI 95%, 1.32-1.44) were calculated.

Performing Fluoroscopically Guided Interlaminar Lumbar Epidural Injections

The purpose of this video article is to provide a step-by-step guide for performing fluoroscopically guided interlaminar lumbar epidural injections, emphasizing the anatomy of the epidural space, anatomic landmarks to aid in needle placement, techniques, and ways of minimizing potential complications. Low back pain and radiculopathy afflict millions of people each year with enormous socioeconomic ramifications and individual disability. This condition has a prevalence of at least 13% and is the second most common symptom-related cause for office visits in the United States. Epidural injections have become the most commonly performed intervention in the management of chronic low back pain in the United States.

Endovascular treatment for acute paraplegia after epidural steroid injection in a patient with spinal dural arteriovenous malformation

Spinal dural arteriovenous fistulas (SDAVFs) are the most common type of spinal arteriovenous malformations. Type 1 spinal arteriovenous malformations are defined by the presence of radiculomeningeal feeders that drain into intradural veins. Patients with these lesions frequently present with chronic myelopathy, which is most often caused by venous hypertension. The authors present the case of a 69-year-old man with acute paraparesis following a lumbar epidural injection, resulting from a previously undiagnosed SDAVF. The patient initially reported right lower-extremity weakness and paresthesias and was referred to an orthopedic practice. His pain and weakness were exacerbated with ambulation. Reevaluation at 4 months was remarkable for groin, mild low-back, and buttock pain. The patient received a right L5-S1 interlaminar epidural steroid injection and became acutely weak. He presented to the emergency department 3 hours after the injection. Once MRI of the lumbar and thoracic spine had been performed, the neurosurgery service was consulted, and it was decided to proceed with emergent spinal angiography with the intent to embolize the fistula. An emergent spinal angiogram was obtained, revealing 2 arterial pedicles emanating from the right T-5 and T-6 radicular arteries. Transarterial embolization was thought to be the most rapid way to potentially obliterate the fistula. The patient exhibited immediate improvement in neurological function, and by 6 hours postprocedure, his neurological function was near normal. He was ambulatory and released to home 3 days after the embolization procedure.

Effectiveness of Therapeutic Lumbar Transforaminal Epidural Steroid Injections in Managing Lumbar Spinal Pain

Background: Among the multiple interventions used in managing chronic spinal pain, lumbar epidural injections have been used extensively to treat lumbar radicular pain. Among caudal, interlaminar, and transforaminal, transforaminal epidural injections have gained rapid and widespread acceptance for the treatment of lumbar and lower extremity pain. The potential advantages of transforaminal over interlaminar and caudal, include targeted delivery of a steroid to the site of pathology, presumably onto an inflamed nerve root. However, there are only a few well-designed, randomized, controlled studies on the effectiveness of steroid injections. Consequently, multiple systematic reviews with diverse opinions have been published. Study Design: A systematic review of therapeutic transforaminal epidural injection therapy for low back and lower extremity pain. Objective: To evaluate the effect of therapeutic transforaminal lumbar epidural steroid injections in managing low back and lower extremity pain. Methods: The available literature on lumbar transforaminal epidural injections in managing chronic low back and lower extremity pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and by the Newcastle-Ottawa Scale criteria for observational studies. Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to December 2011, and manual searches of the bibliographies of known primary and review articles. The level of evidence was classified as good, fair, or poor based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Outcome Measures: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term &gt; 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. Results: For this systematic review, 70 studies were identified. Of these, 43 studies were excluded and a total of 27 studies met inclusion criteria for methodological quality assessment with 15 randomized trials (with 2 duplicate publications) and 10 non-randomized studies. For lumbar disc herniation, the evidence is good for transforaminal epidural with local anesthetic and steroids, whereas it was fair for local anesthetics alone and the ability of transforaminal epidural injections to prevent surgery. For spinal stenosis, the available evidence is fair for local anesthetic and steroids. The evidence for axial low back pain and post lumbar surgery syndrome is poor, inadequate, limited, or unavailable. Limitations: The limitations of this systematic review include the paucity of literature. Conclusion: In summary, the evidence is good for radiculitis secondary to disc herniation with local anesthetics and steroids and fair with local anesthetic only; it is fair for radiculitis secondary to spinal stenosis with local anesthetic and steroids; and limited for axial pain and post surgery syndrome using local anesthetic with or without steroids. Key words: Spinal pain, chronic low back pain, lower extremity pain, transforaminal epidural steroids, radiculopathy, sciatica, steroids, local anesthetic

The Effect of Hyaluronidase in Interlaminar Lumbar Epidural Injection for Failed Back Surgery Syndrome

ObjectiveTo evaluate the effect of hyaluronidase in patients with failed back surgery syndrome (FBSS) treated with interlaminar lumbar epidural injection (ILEI).MethodSixty patients suffering from severe low back pain and sciatica were randomly allocated into three groups. Group T received ILEI with 2 ml triamcinolone 40 mg/ml and 5 ml bupivacaine 0.25%. Group H received ILEI with 1500 IU hyaluronidase and 5 ml bupivacaine 0.25%. Group TH received interlaminar lumbar epidural injection (ILEI) with 1500 IU hyaluronidase, 2 ml triamcinolone 40 mg/ml and 5 ml bupivacaine 0.25%. The effect was evaluated using Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) at pre-injection, 2 weeks, 6 weeks and 12 weeks after ILEI.ResultsAfter 2 weeks and after 6 weeks, patients in both Group T and Group TH had significant effectiveness more than Group H in decrease of VAS and ODI. After 12 weeks, only patients in Group TH had significant effectiveness in decrease of VAS and ODI (p<0.05). In every period, Group TH had the most effectivess in decrease of VAS and ODI after ILEI.ConclusionILEI for FBSS with triamcinolone and hyaluronidase is considered to have more long term effectiveness to reduce pain and improve function after ILEI than injection with triamcinolone alone or hyaluronidase alone.

A case of convexity subarachnoid haemorrhage from intracranial hypotension treated with epidural blood patch

The majority of subarachnoid haemorrhages (SAH) are of aneurysmal origin, and nontraumatic convexity SAH is rare. We describe one patient who had a convexity SAH caused by cortical veins thrombosis (CVT) secondary to intracranial hypotension (IH). We discuss possible pathophysiologic mechanisms and its treatment. A 52-year-old female presented with left hemiparesis and tonic–clonic seizures, following lumbar epidural injections of local anaesthetics and steroids because of chronic low back. Brain CT showed right fronto-parietal convexity SAH. Brain MRI revealed diffuse pachymeningeal enhancement and confirmed the SAH. Cerebral angiography showed no/low flow signal in few frontal and parietal cortical veins in the correspondence of the SAH. A restoration of flow signal in this area was revealed after 2 months. The patient was treated with lumbar epidural blood patch with recovery. Convexity SAH caused by CVT from IH may be treated only with lumbar epidural blood patch which eliminates by itself the determinants of CVT (vein dilatation and slow vein drainage).

Placebo response to interventional pain procedures and effect on patient outcome

Considerable debate exists over the effectiveness of numerous procedures performed in current interventional pain practice. Our goal was to review all current prospective, randomized, placebo-controlled trials pertaining to the most commonly performed interventional pain procedures and to present these results in the form of a comprehensive review article. A review of the literature was performed with extensive PubMed searches and no date restrictions. A review of various reference sections within articles was also done. All prospective, randomized, placebo-controlled trials acquired that pertained to the most commonly performed intervention pain medicine techniques were included in the review. Lumbar and transforaminal epidural steroid injections appear superior to placebo. Radiofrequency denervation and steroid injections for sacroiliac joint pain appear superior to placebo. Radiofrequency denervation for lumbar and cervical facetogenic pain appears superior to placebo. Intradiscal electrothermal therapy for discogenic low back pain may be more effective than placebo in a select group of patients. Alcohol neurolytic celiac plexus block appears superior to placebo in the treatment of pancreatic cancer pain. Current data do not support superiority over placebo for lumbar facet joint steroid injections, lumbar intradiscal steroid therapy, or vertebroplasty for treatment of osteoporotic fractures. A continued lack of prospective, randomized, placebo-controlled trials pertaining to interventional pain medicine still persists. The above results can only serve as a guide in current practice, as only tentative conclusions can be reached based on the current data.

Single Shot Epidural Injection for Cervical and Lumbosaccral Radiculopathies: A Preliminary Study

BackgroundEpidural steroid injection is an established treatment modality for intervertebral disc prolapse leading to radiculopathy. In cases where two levels of radiculopathy are present, two separate injections are warranted. Herein, we present our experience of management of such cases with a single epidural injection of local anaesthetic, tramadol and methylprednisolone, and table tilt for management of both radiculopathies.Methods50 patients of either sex aged between 35-65 years presenting with features of cervical and lumbar radiculopathic pain were included and were subjected to single lumbar epidural injection of local anaesthetic, tramadol and methylprednisolone, in the lateral position. The table was then tilted in the trendelberg position with a tilt of 25 degrees, and patients were maintained for 10 minutes before being turned supine. All patients were administered 3 such injections with an interval of 2 weeks between subsequent injections, and pain relief was assessed with a visual analogue scale. Immediate complications after the block were assessed.ResultsImmediate and post procedural complications observed were nausea and vomiting (20%), painful injection site (4%), hypotension (10%) and high block (4%). Pain relief was assessed after the three injections by three grades: 37 (74%) had complete resolution of symptoms; 18% had partial relief and 8% did not benefit from the procedure.ConclusionsThis technique may be used as an alternative technique for pain relief in patients with unilateral cervical and lumbar radiculopathies.

Preliminary Results of a Randomized, DoubleBlind, Controlled Trial of Fluoroscopic Lumbar Interlaminar Epidural Injections in Managing Chronic Lumbar Discogenic Pain Without Disc Herniation or Radiculitis

Background: Low back pain without disc herniation is the most common problem among chronic pain disorders. Epidural injections are commonly used interventions in managing chronic low back pain without disc herniation. However, little evidence exists regarding the effectiveness, indications, and medical necessity of lumbar epidural injections in managing axial low back pain without disc herniation or radiculitis. Study Design: A randomized, double-blind, controlled trial. Setting: An interventional pain management practice, a specialty referral center, a private practice setting in the United States. Objectives: To evaluate the ability to provide effective and long-lasting pain relief with lumbar interlaminar epidural injections with local anesthetic with or without steroids in managing chronic low back pain not caused by disc herniation or radiculitis. Methods: Patients were randomly assigned to one of 2 groups with Group I patients receiving local anesthetic only, whereas Group II patients received local anesthetic mixed with non-particulate betamethasone. Seventy patients were included in this analysis. Randomization was performed by computer-generated random allocation sequence by simple randomization. Outcomes Assessment: Outcome measures included the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake. The assessments were done at baseline, 3 months, 6 months, and 12 months post-treatment. Significant pain relief and/or improvement in disability were defined as at least 50% improvement. Results: Significant pain relief (≥ 50%) was demonstrated in 74% of patients in Group I and 63% in Group II. Functional status improvement (reduction of ≥ 50%) in the ODI scores was seen in 71% of patients in Group I and 60% of patients in Group II. The overall average procedures per year were approximately 4. Limitations: The results of this study are limited by the lack of a placebo group and that it is a preliminary report of 35 patients in each group with a total of 70 patients. Conclusion: Lumbar interlaminar epidural injections of local anesthetic with or without steroids was effective in 63% and 74% of patients with chronic function-limiting low back pain without facet joint pain, disc herniation, and/or radiculitis. Key words: Chronic low back pain, lumbar interlaminar epidural injections, discogenic pain, disc herniation, radiculitis, local anesthetic, steroids, controlled comparative local anesthetic blocks

Lumbar epidural injection in the management of lumbar radicular pain. A prospective study of 90 patients followed up for a 6 months

Lumbar epidural injection in the management of lumbar radicular pain. A prospective study of 90 patients followed up for a 6 months

End-Stage Disorders of the Hip Presenting With Posterior Pelvic Girdle and Lateral Thigh Pain: Two Case Reports

CASE 1 A 44-year-old white man with an 8-year history of low back, posterior pelvic girdle, and posterior thigh pain presented to a physiatrist with the recent progression of pain to bilateral posterior thighs. Eight years before his presentation to the physiatrist, his medical history included a diskectomy of an L5–S1 disk protrusion and a short period of physical therapy with symptom improvement. He continued to have some pain into the left posterior pelvic girdle and posterior thigh to the knee but without associated paresthesias. During the next 7 years his pain and functional decline continued. During that time he was seen by several neurosurgeons, chiropractors, and a neurologist. For pain modification he was prescribed multiple anti-inflammatory medications, antidepressants, and antiseizure medications. The anti-inflammatories did give him some relief. Three additional magnetic resonance imaging (MRI) scans of his lumbar spine were performed during the intervening years that showed moderate-to-severe degenerative changes of the intervertebral disks at L4 –L5 and L5–S1 without significant central or neuroforaminal narrowing. He was offered spinal fusion by one surgeon, but the patient declined. He went for a second surgical opinion and was prescribed lumbar epidural injections. The lumbar epidural injections were performed but failed to relieve his symptoms and caused severe discomfort. Finally, 8 years after his initial presentation he was seen by a neurologist who referred him to physical therapy. The physical examination performed by the physical therapist by using the movement system impairment syndrome [1] method of examination is summarized in Table 1. The physical therapist then referred the patient to a multidisciplinary hip clinic at the same university. At the time the patient was seen in the multidisciplinary hip clinic by the physiatry service, he reported being unable to walk greater than 100 yards without having to stop. He was having difficulty performing his job responsibilities as an environmental engineer, which often required him to walk over uneven terrain. He had stopped many activities that he previously enjoyed, including riding horses and motorcycles. The physical examination revealed an alert pleasant man who indicated his area of maximal pain to be across the posterior pelvic girdle. He ambulated with a wide based gait and had a positive Trendelenburg on the left. He was unable to do a single-leg stance on either side without pain and loss of balance. Strength testing of bilateral lower extremities for hip flexion, knee extension, ankle dorsiflexion, and extension of the great toe was 5/5. Hip abduction was 3/5. Hip extension was 2/5. Reflexes were 1 at the patella and hamstring. Hip range of motion (ROM) is listed in Table 1. Passive ROM reproduced his posterior pelvic girdle pain and lateral thigh pain bilaterally. His pain was also reproduced with log roll and resisted straight leg raise. He had some groin pain bilaterally with end range hip flexion but the patient stated that this was not the pain he experienced outside of the

The Preliminary Results of a Comparative Effectiveness Evaluation of Adhesiolysis and Caudal Epidural Injections in Managing Chronic Low Back Pain Secondary to Spinal Stenosis: A Randomized, Equivalence Controlled Trial

Lumbar surgery and epidural injections for spinal stenosis are the most commonly performed interventions in the United States. However, there is only moderate evidence to the effectiveness of surgery and caudal epidural injections. The next sequential step is adhesiolysis and hypertonic neurolysis with targeted delivery. There have not been any randomized trials evaluating the effectiveness of percutaneous adhesiolysis and targeted delivery of local anesthetic, steroid and hypertonic sodium chloride solution in lumbar spinal stenosis. A randomized, equivalence, controlled trial. An interventional pain management practice, a specialty referral center, a private practice setting in the United States. To evaluate the effectiveness of percutaneous epidural adhesiolysis in patients with chronic low back and lower extremity pain with lumbar central spinal stenosis and compare with fluoroscopically directed caudal epidural injections. Patients were randomly assigned to one of 2 groups with 25 patients in each group. Group I patients received caudal epidural injections with catheterization up to S3 with local anesthetic, 0.9% sodium chloride solution, non-particulate betamethasone and served as the control group. Group II patients received percutaneous adhesiolysis with targeted delivery and injection of lidocaine, 10% hypertonic sodium chloride solution, and non-particulate Betamethasone and formed the intervention group. Randomization was performed by computer-generated random allocation sequence by simple randomization. Multiple outcome measures were utilized including the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake with assessment at 3, 6, and 12 months post treatment. Significant pain relief was described as 50% or more, whereas significant improvement in the disability score was defined as a reduction of 40% or more. This evaluation showed significant pain relief (>or= 50%) in 76% of the patients at one year follow-up in the adhesiolysis group compared to 4% of the patients in the control group. The results of this study are limited by the lack of a placebo group, the fact that it is a preliminary report, and there are only 25 patients in each group. With significant pain relief in 76% of patients, percutaneous adhesiolysis utilizing local anesthetic, steroids and hypertonic sodium chloride solution may be effective in patients with chronic function-limiting low back and lower extremity pain with spinal stenosis.