Complications of fluoroscopically guided caudal epidural injections

Comparison Between Relative Efficacy of Erector Spinae Plane Block and Caudal Epidural Block for Postoperative Analgesia in Lumbar Fusion Surgery- A Prospective Randomized Controlled Study

STUDY DESIGN

Prospective, randomized controlled double-blinded study.

OBJECTIVE

To compare the relative efficacy of ultrasound-guided ESPB and CEB for postoperative analgesia after a single-level lumbar fusion surgery and compared it with conventional multimodal analgesia.

METHODS

81 patients requiring single-level lumbar fusion surgery were randomly allocated into 3 groups (ESPB group, CEB group, and the control group). Demographic and surgical data (blood loss, duration of surgery, perioperative total opioid consumption, muscle relaxants used) were assessed. Postoperatively, the surgical site pain, alertness scale, satisfaction score, time to mobilization, and complications were recorded.

RESULTS

The total opioid consumption in the first 24 hours was significantly lower in both the block groups than in the control group (103.70 ± 13.34 vs 105 ± 16.01 vs 142.59 ± 40.91mcg; P < .001). The total muscle relaxant consumption was also significantly less in block groups compared to controls (50.93 ± 1.98 vs 52.04 ± 3.47 vs 55.00 ± 5.29 mg; P < .001). The intraoperative blood loss was significantly less in both the block group (327.78 ± 40.03 mL, 380.74 ± 77.80 mL) than the control group (498.89 ± 71.22 mL) (P < .001). Among the block groups, the immediate postoperative pain relief was better in the CEB group, however, the ESPB group had a longer duration of postoperative pain relief.

CONCLUSION

Both ESPB and CEB produce adequate postoperative analgesia after lumbar fusion however the duration of action was significantly longer in the ESPB group with relatively shorter surgical time and lesser blood loss compared to the CEB group.

Flushing After Lumbar Epidural Steroid Injection with Dexamethasone

PURPOSE OF REVIEW

Epidural steroid injections are an accepted treatment for low back pain and radicular symptoms. While epidural steroid injections are routinely performed without complications, side effects can be seen, including flushing. Flushing has been studied using various steroid preparations, including dexamethasone, but at significantly higher doses. This was a prospective cohort study that examines the rate of flushing in ESIs with a lower dose (4 mg) of dexamethasone. Subjects undergoing lumbar epidural steroid injection were asked about the presence of flushing following the procedure prior to discharge and again at 48 h after. A total of 80 participants received fluoroscopically guided interlaminar and transforaminal epidural injections. All participants received 4 mg of dexamethasone. Of the 80 subjects, 52 were female, and 28 were male. Seventy-one underwent a transforaminal epidural injection and 9 underwent an interlaminar epidural injection. Four (5%) subjects experienced flushing-1 subject experienced immediate post-procedural flushing and 3 experienced flushing within 48 h. All 4 subjects (100%) were female. All 4 subjects received transforaminal injections (100%).

RECENT FINDINGS

There is a gap of knowledge about the flushing after lumbar epidural steroid injection with dexamethasone. Flushing is a known and common side effect of epidural steroid injections, varying in frequency based on type of steroid as well as dose. We found 5% incidence in flushing reaction with 4 mg of dexamethasone.

Retrospective study assessing the efficacy of i.v. dexamethasone, SNRB, and nonsteroidal treatment for radiculopathy

Retrospective study. The purpose of this study was to investigate the clinical symptomatology of discopathies before and 7 days after treatment with one of the following: intravenous dexamethasone, selective nerve root block (SNRB), and systemic treatment with different nonsteroidal antiinflammatory drugs (NSAIDs). Radiculopathy is a clinical condition in which dysfunction of one or more nerves occurs due to mechanical compression and/or chemical irritation of the nerve roots. Most often located in the lumbar spine, radiculopathy remains one of the most common complaints in primary health. Some patients responded well to conservative treatment. However, those who show no improvement may benefit from more invasive treatment options, such as intravenous corticosteroids, spinal injections, and surgical procedures. We conducted a retrospective study of 81 male and female patients aged 18 years and above who had radicular pain and were referred to our facility over a 7-year period. Of the 100 patients assessed for eligibility, 19 patients were not included in the study due to malignancy or surgical intervention, 32 patients received intravenous dexamethasone, 24 patients received SNRB, and 25 received various NSAIDs as the control group. The visual analog scale, straight leg raise test and neurological deficits were assessed to evaluate the patients before and after receiving treatment. All patients underwent spinal computed tomography to confirm the diagnosis of disc herniation. Pearson chi-squared test, Kruskal-Wallis test, and Mann-Whitney test were used to evaluate the results. Visual analog scale scores and the ability to perform straight leg raise test significantly improved after treatment with dexamethasone, SNRB, and NSAIDs. However, clinical improvement was significantly better in both the dexamethasone and SNRB groups than in the control group. Motor deficits improved significantly after dexamethasone treatment alone. Dexamethasone and SNRB are useful and safe treatment options for treating patients with acute radicular pain. Randomized, double-blinded, control studies are warranted.

Basivertebral Nerve Ablation

Low back pain is one of the most prevalent musculoskeletal ailments in the United States. Intraosseous radiofrequency ablation of the basivertebral nerve is an effective and durable therapy for low back pain and can be offered to patients who have chronic low back pain of greater than 6 months of duration, failure to respond to noninvasive therapies for 6 months, with either Modic Type I or Type II changes at L3-S1. This article reviews the anatomy and physiology, patient selection, technique, and evidence regarding basivertebral nerve ablation.

Comparison of Whitacre needle and Chiba needle on the incidence of intravascular injection during caudal epidural injections: A single-blind, randomized clinical consort study

Caudal epidural injection (CEI) is effective for lumbar spinal pain. However, accidental intravascular injection reduces therapeutic efficacy of CEI and leads to fatal complications such as hematoma, and neurologic deficit. Whitacre needle has been reported to be effective for reducing intravascular injection during transforaminal epidural injection, compared with Quincke needle. The bevel of Chiba needle is shorter than that of Quincke needle. In this study we compared Whitacre needle and Chiba needle on incidence of intravascular injection during CEI.This was a single-blind, randomized clinical consort study. After institutional Review Board approval, a total of 164 patients underwent CEI were randomly allocated to one of 2 group (Whitacre needle or Chiba needle group). Intravascular injection was assessed with real-time fluoroscopy. In addition, total procedure time was measured. Data were compared between groups, and P < .05 was consideredstatistically significant.There were no differences between groups in terms of patient demographic and clinical characteristics. There was no significant difference on incidence of intravascular injection between Whitacre and Chiba needle group (11% vs 19.5%, P = .192). However, the procedure time is significantly longer in the Whitacre than Chiba needle group (172.8 ± 53.8 sec vs 147.1 ± 61.1 sec, P = .005).Based on current study, our results indicated that Whitacre needle was not effective to decrease the incidence of intravascular injection during CEI, compared to Chiba needle.

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.

Recent Preoperative Lumbar Epidural Steroid Injection Is an Independent Risk Factor for Incidental Durotomy During Lumbar Discectomy

STUDY DESIGN

Retrospective review.

OBJECTIVE

To investigate the association between lumbar epidural steroid injection (LESI) and incidental durotomy (ID) in patients with a diagnosis of disc herniation undergoing a primary discectomy.

METHODS

A Medicare patient database was queried for patients between the ages of 65 and 85 years who underwent a primary lumbar discectomy for a diagnosis of lumbar disc herniation or degeneration from 2008 to 2014. Our main cohort of 64 849 patients was then divided into 2 groups: patients who experienced a dural tear (N = 2369) and our matched (age, gender, and history of diabetes) control cohort of patients who did not (N = 62 480). All patients who had a history of LESI were further identified and stratified into 4 subgroups by duration between LESI and discectomy (<3 months, 3-6 months, 6 months to 1 year, and overall), and a comparison of the relative incidence of ID was made among these subgroups. A multivariate logistic regression analysis was employed to determine the relationship between LESI and ID.

RESULTS

Overall incidence of ID was 3.7%. There was a significant difference in incidence of LESI (27.1% vs 35.0%, P < .001) between our control and ID groups. An adjusted odds ratio (OR) showed that prior LESI within 3 to 6 months (OR 1.47, 95% CI 1.20-1.81, P < .001) and within less than 3 months (OR 1.46, 95% CI 1.24-1.72, P < .001) of surgery were significantly associated with ID.

CONCLUSION

LESI increases the risk of ID in patients who undergo a subsequent lumbar discectomy within 6 months of injection.

The Incidence of Various Types of Systemic Reactions Related to Epidural Steroid Injections: A Prospective Observational Study

Objective

To evaluate the incidence, types and association of systemic reactions after an epidural steroid injection (ESI) with patient demographics, ESI factors and repeated occurrence of an ESI.

Materials and Methods

This prospective observational study was approved by the Institutional Review Board of our hospital, and written informed consent was obtained from all the participants. From October to December 2011, systemic reactions at 2 weeks after 960 ESIs among 885 patients were measured. Patients were evaluated by phone interviews to obtain the patients' demographics, history of previous ESI, ESI factors, and ESI reoccurrence. Statistical analyses were performed using the chi-square tests, Fisher's exact tests and a binary logistic regression analysis.

Results

Overall, 557 types of systemic reactions occurred after 292 injections (30.4%) of a total of 960 ESIs in which facial flushing was most common (131/557, 23.5%) and 144 ESIs were followed by a mixed form of systemic reactions (49.3%). Age of 62 years or younger (odds ratio [OR], 2.361), female sex (OR, 1.674), and history of diabetes mellitus (OR, 1.681) were significant risk factors in the occurrence of systemic reactions after an ESI. In 73 patients with repeated ESI, 14 patients re-experienced systemic reactions (19.2%), of which twelve re-experienced the same systemic reaction as the previous one.

Conclusion

Systemic reactions followed about 30% of ESIs, and more commonly occurred in patients 62 years of age or younger, women, and diabetic patients. Half of the patients experienced a mixed form of systemic reactions. Patients with recurring systemic reactions tend to re-experience the same systemic reaction as the prior one after an ESI.

Tachon Syndrome: Rare Side Effect of Articular Injections of Corticosteroids. A Report of Two Cases

Epidural or intra-articular injections of corticosteroids are an option for the treatment of several pain conditions but are not without adverse effects. Here, we discuss a rare systemic side effect of this therapy: Tachon syndrome. We report two cases, a 64-year-old woman and a 43-year-old man, who presented with Tachon syndrome after receiving, respectively, a shoulder and a lumbar injection of cortivazol 3.75 mg/1.5 ml suspension for injection in pre-filled syringes. The indication for this therapy was, respectively, tendinopathy of the supraspinatus and a mechanical L5 lumbosciatica. A few minutes after receiving the injection, patients experienced acute low back pain, chest tightness, facial erythema and profuse sweating. All vital and biologic parameters were normal. In the first case, improvement was spontaneous and all symptoms resolved in 20 min. The second patient remained under observation and received an intravenous ‘physiological’ infusion. Both patients recovered fully and returned home. A causal relationship between the corticosteroid injections and the patients’ symptoms was very likely because of the acute clinical presentation and the rapid improvement in the patients’ conditions and that no further signs indicating other serious complications developed.

Filum Terminale Needle Placement During Caudal Epidural Steroid Injection

Objective

Caudal epidural steroid injections (ESIs) are commonly used to treat lumbar radicular pain. Touhy needles are placed under live fluoroscopic guidance to ensure epidural administration of medication. 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.

Design

Single case report.

Setting

Beth Israel Deaconess Medical Center.

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.

Interventions

Caudal epidural steroid injection.

Outcome Measures

Patient safety.

Results

The needle and catheter placement were confirmed via intrathecal contrast spread to be in the filum terminale, which prompted abortion of the procedure.

Conclusions

Although caudal ESI is 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, it serves also to reveal unexpected and unwanted spread. We present the first report of a needle being inserted directly into the filum terminale during a caudal ESI.

Persistent cauda equina syndrome after caudal epidural injection under severe spinal stenosis: a case report

Caudal epidural injection (CEI) is one of the most common treatments for low-back pain with sciatica. CEI rarely leads to neurologic complications. We report a case of persistent cauda equina syndrome after CEI. A 44-year-old male patient with severe L4 and L5 spinal ste-nosis underwent CEI for low-back pain and sciatica. The CEI solution consisted of bupivacaine, hyaluronidase, triamcinolone acetonide, and normal saline. He experienced motor weakness and sensory loss in both lower extremities and neurogenic bladder for more than 1 year after the procedure. His ankle dorsiflexors, big-toe extensors, and ankle plantar flexors on both sides were checked and categorized as motor-power Medical Research Council grade 0. His bilateral ankle-jerk reflection was absent. An electrophysiological study showed lumbosacral polyradiculopathy affecting both sides of the L5 and S1 nerve roots. A urodynamic study revealed hypoactive neurogenic bladder affecting both sacral roots.

Discordant lumbar epidural hematoma after caudal steroid injection: A case report (CARE-compliant)

RATIONALE

Caudal epidural injection is one of the conventional treatments of chronic back pain. Even though spinal epidural hematoma after caudal epidural injection is rare but it can cause serious neurologic complication.

PATIENT CONCERNS

An 83-year-old woman taking cilostazol received caudal epidural steroid injection because of her chronic back pain. Six hours later, she experienced an acute hip pain which worsened with time.

DIAGNOSIS

Magnetic resonance image showed acute cord compression due to a spinal epidural hematoma at L2-S1 level with concomitant central canal compromise at L2/3, L3/4 level.

INTERVENTIONS

Emergency decompressive laminectomy and evacuation of the lumbar epidural hematoma were performed.

OUTCOMES

All of her symptoms were resolved over the 72 hours following surgery.

LESSONS

Continuous vigilance after caudal epidural injection is important to prevent catastrophic neurologic deterioration with early detection and early treatment.

Effect of Drugs Associated With Bleeding Tendency on the Complications and Outcomes of Transforaminal Epidural Steroid Injection

STUDY DESIGN

This is a retrospective case-control study.

OBJECTIVE

To evaluate the influence of medication-related bleeding tendency on the clinical outcomes and complications of transforaminal epidural steroid injection (TFESI).

SUMMARY OF BACKGROUND DATA

TFESI may result in serious complications such as epidural hematoma or adhesions in patients with medication-related bleeding tendency. However, little is known about the true relationship between medication-related bleeding tendency and postprocedural complications.

METHODS

Retrospective review of the medical records of patients who had TFESI from 2010 to 2014 was done. Commonly used medications such as warfarin, heparin, aspirin, clopidogrel, and Opalmon (limaprost alfadex) were included as medications associated with bleeding tendency. Patients were divided into 3 groups and the treatment outcomes for each group were compared: The first group used medications associated with bleeding tendency, but discontinued them in due time before the procedure (discontinued group). The second group used medications associated with bleeding tendency and continued receiving medication (continuing group). The third group did not use any medications associated with a bleeding tendency (nonmedicated group).

RESULTS

Among 2,469 patients, 1,234 were in the discontinued group, 408 patients in the continuing group, and 827 patients in the nonmedicated group. There were no statistically significant differences between groups for the treatment outcomes such as the degree of pain relief, duration of improvement, and complication rates including symptomatic epidural hematoma. Moreover, for the discontinued group and continuing group, the treatment outcomes were compared among patients with same medication, and revealed no differences.

CONCLUSIONS

This study demonstrated that continued use of medications associated with bleeding tendency does not increase epidural hematoma or symptomatic exacerbation, and thus should not be considered as a contraindication for TFESI.

LEVEL OF EVIDENCE

Level 3.

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

INTRODUCTION

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.

AIM

To assess the efficacy of caudal epidural steroid injection in patients of lumbosacral sciatica in comparison to placebo.

MATERIALS AND METHODS

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 4^th 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 4^th week were also considered as failure.

RESULTS

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).

CONCLUSION

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.

Intracranial Chronic Subdural Hematoma Presenting with Intractable Headache after Cervical Epidural Steroid Injection

Postdural punctural headache (PDPH) following spinal anesthesia is due to intracranial hypotension caused by cerebrospinal fluid (CSF) leakage, and it is occasionally accompanied by an intracranial hematoma. To the best of our knowledge, an intracranial chronic subdural hematoma (CSDH) presenting with an intractable headache after a cervical epidural steroid injection (ESI) has not been reported. A 39-year-old woman without any history of trauma underwent a cervical ESI for a herniated nucleus pulposus at the C5-6 level. One month later, she presented with a severe headache that was not relieved by analgesic medication, which changed in character from being positional to non-positional during the preceding month. Brain magnetic resonance imaging revealed a CSDH along the left convexity. Emergency burr-hole drainage was performed and the headache abated. This report indicates that an intracranial CSDH should be considered a possible complication after ESI. In addition, the event of an intractable and changing PDPH after ESI suggests further evaluation for diagnosis of an intracranial hematoma.

Interventional Therapies for Chronic Low Back Pain: A Focused Review (Efficacy and Outcomes)

Context:

Lower back pain is considered to be one of the most common complaints that brings a patient to a pain specialist. Several modalities in interventional pain management are known to be helpful to a patient with chronic low back pain. Proper diagnosis is required for appropriate intervention to provide optimal benefits. From simple trigger point injections for muscular pain to a highly complex intervention such as a spinal cord stimulator are very effective if chosen properly. The aim of this article is to provide the reader with a comprehensive reading for treatment of lower back pain using interventional modalities.

Evidence Acquisition:

Extensive search for published literature was carried out online using PubMed, Cochrane database and Embase for the material used in this manuscript. This article describes the most common modalities available to an interventional pain physician along with the most relevant current and past references for the treatment of lower back pain. All the graphics and images were prepared by and belong to the author.

Results:

This review article describes the most common modalities available to an interventional pain physician along with the most relevant current and past references for the treatment of lower back pain. All the graphics and images belong to the author. Although it is beyond the scope of this review article to include a very detailed description of each procedure along with complete references, a sincere attempt has been made to comprehensively cover this very complex and perplexing topic.

Conclusion:

Lower back pain is a major healthcare issue and this review article will help educate the pain practitioners about the current evidence based treatment options.

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.

Vasovagal rates in flouroscopically guided interventional procedures: a study of over 8,000 injections

OBJECTIVE

To determine the rate of vasovagal (vv) complications in fluoroscopically guided interventional procedures.

DESIGN

Retrospective case series analysis of prospectively collected data from March 8, 2004 to January 30, 2009.

SETTING

A single academic medical center.

SUBJECTS

Four thousand one hundred eighty-three subjects undergoing 8,010 consecutive injections.

OUTCOME MEASURES

Pearson's chi-square test was used to determine the relationship between categorical variables.

RESULTS

A total of 8,010 injections, including epidural steroid injections, radiofrequency nerve ablations, medial branch blocks, hip injections, knee injections, and glenohumeral injections were performed. Overall vv reaction rate was 2.6%, with 0.8% of procedures resulting in early terminated due to vv reaction. Peripheral joint injections had a vv rate of 0.2%, all occurring in hip injections. Transforaminal epidural steroid injections had a vv rate of 3.5%. Diagnostic blocks of the medial branches had the highest rate of vv (5.1%). Other predictors of vv reactions were identified including preprocedure pain score visual analog scale <5 (P = 0.004), male gender (P < 0.001), and age less than 65 years old (P < 0.001).

CONCLUSIONS

vv reactions have an overall low occurrence rate (2.6%) in interventional procedures ranging from 0% in peripheral knee and shoulder injections to 5.1% in medial branch blocks. Conservative treatment of vv reaction and willingness to terminate procedures resulted in no serious adverse events related to vv reaction in 8,010 procedures.

Epidural steroid injection resulting in epidural hematoma in a patient despite strict adherence to anticoagulation guidelines

Epidural steroid injections are relatively safe procedures, although the risk of hemorrhagic complications in patients undergoing long-term anticoagulation therapy is higher. The American Society for Regional Anesthesia and Pain Medicine has specific guidelines for treatment of these patients when they undergo neuraxial anesthetic procedures. In this paper, the authors present a case in which the current American Society for Regional Anesthesia and Pain Medicine guidelines were strictly followed with respect to withholding and reintroducing warfarin and enoxaparin after an epidural steroid injection, but the patient nevertheless developed a spinal epidural hematoma requiring emergency surgical evacuation. The authors compare the case with the 8 other published cases of postinjection epidural hematomas in patients with coagulopathy, and the specific risk factors that may have contributed to the hemorrhagic complication in this patient is analyzed.

Efficacy of lumbosacral transforaminal epidural steroid injections: a systematic review

OBJECTIVE

To critically review the best available studies evaluating the efficacy of lumbosacral transforaminal epidural steroid injections (TFESIs) in the treatment of radicular pain.

DATA SOURCES

MEDLINE, EMBASE, and the Cochrane database were searched for the period between 1950 and May 2008. Search terms included epidural steroid injection (ESI), transforaminal ESI, foraminal ESI, selective nerve root block, nerve root injection (NRI), selective NRI, periradicular infiltration, and periradicular injection. Randomized controlled trials (RCTs), published in English, which evaluated the efficacy of fluoroscopically guided TFESIs were reviewed.

STUDY SELECTION

Studies were analyzed with a quality checklist modeled after the 2001 CONSORT Statement: Revised Recommendations for Improving the Quality of Reports of Parallel-Group Randomized Trials. Nine studies were found to include a majority of these items.

DATA EXTRACTION

Data included study design, inclusion criteria, symptom duration, randomization protocol, blinding protocol, intervention, control, outcomes, follow-up, dropout, statistical analysis, and conclusions.

DATA SYNTHESIS

Each article was assigned a level of evidence: I (high-quality RCT) or II (RCT with <80% follow-up, no blinding or improper randomization). Studies were divided according to control, and overall evidence was graded as A (good), B (fair), C (conflicting/poor quality), or I (insufficient).

CONCLUSIONS

There is fair evidence supporting TFESIs as superior to placebo for treating radicular symptoms. There is good evidence that TFESIs should be used as a surgery-sparing intervention, and that TFESIs are superior to interlaminar ESIs (ILESIs) and caudal ESIs for radicular pain. In patients with subacute or chronic radicular symptoms, there is good evidence that a single TFESI has similar efficacy as a single transforaminal injection of bupivacaine or saline. Future studies should address the ideal number of injections. While more placebo-controlled trials are needed to conclusively define the role of TFESIs, current studies support their use in the treatment of lumbosacral radicular pain.

Evidence-informed management of chronic low back pain with epidural steroid injections

The management of chronic low back pain (CLBP) has proven very challenging in North America, as evidenced by its mounting socioeconomic burden. Choosing amongst available nonsurgical therapies can be overwhelming for many stakeholders, including patients, health providers, policy makers, and third-party payers. Although all parties share a common goal and wish to use limited health-care resources to support interventions most likely to result in clinically meaningful improvements, there is often uncertainty about the most appropriate intervention for a particular patient. To help understand and evaluate the various commonly used nonsurgical approaches to chronic low back pain, the North American Spine Society has sponsored this special focus issue of The Spine Journal, titled Evidence-Informed Management of Chronic Low Back Pain Without Surgery. Articles in this special focus issue were contributed by leading spine practitioners and researchers, who were invited to summarize the best available evidence for a particular intervention and encouraged to make this information accessible to nonexperts. Each of the articles contains five sections (description, theory, evidence of efficacy, harms, and summary) with common subheadings to facilitate comparison across the 24 different interventions profiled in this special focus issue, blending narrative and systematic review methodology as deemed appropriate by the authors. It is hoped that articles in this special focus issue will be informative and aid in decision making for the many stakeholders evaluating nonsurgical interventions for CLBP.

Adverse Effects of Fluoroscopically Guided Interlaminar Thoracic Epidural Steroid Injections

OBJECTIVES

To assess the prevalence of adverse effects or complications from fluoroscopically guided thoracic interlaminar epidural steroid injections.

DESIGN

A retrospective study with independent observer review. Patients presenting with thoracic radicular pain, caused by either herniated nucleus pulposus or thoracic spondylosis as confirmed by magnetic resonance imaging, received an interlaminar thoracic epidural steroid injection as part of a conservative-care treatment plan. The study was performed in a multidisciplinary spine care center. All injections were performed over a 5-yr period. An independent observer reviewed medical charts, which included a 24-hr postprocedure standardized questionnaire completed by telephone by an ambulatory surgical center nurse. Ambulatory surgical center operative reports and physician follow up office notes up to 3 mos after the procedures, along with epidurograms, were also reviewed.

RESULTS

A total of 21 patients who received 39 injections were reviewed. Adverse effects or complications per injection observed included three with increased pain at injection site (7.7%), two with facial flushing (5.1%), one transient nonpositional headache (2.6%), one episode of insomnia the night of the injection (2.6%), and one episode of fever the night of the procedure (2.6%). Statistical analysis revealed no significant difference based on diagnosis (herniated nucleus pulposus vs. spondylosis, P = 0.9156), and age was not linked to higher prevalence of adverse/effects complications (P = 0.3137).

CONCLUSIONS

No major complication arose. Adverse effects did occur with a rate of 20.5%. All adverse effects resolved without morbidity. No statistical difference was observed in the rate of adverse effects in patients with herniated nucleus pulposus or spondylosis.

The feasibility of color Doppler ultrasonography for caudal epidural steroid injection

Although it entails a radiation hazard risk, the use of fluoroscopy during caudal epidural steroid injection has increased to help place the medication more accurately and allowed physicians to maximize the procedure's therapeutic success rate. To investigate the feasibility of using real-time high resolution ultrasonography for guiding the epidural needle into the caudal epidural space and to confirm any vascular intake of medication, we performed color Doppler ultrasonography while medication was being injected into the caudal epidural space of 53 patients with low back pain and sciatica. We defined the injection as being successful if unidirectional flow (observed as one dominant color) of the solution was observed with color Doppler ultrasonography through the epidural space beneath the sacrococcygeal ligament, with no flows being observed in other directions (observed as multiple colors). The correct placement of the medication was then confirmed by fluoroscopy. In 52 of the 53 subjects, the medications were successfully injected into the caudal epidural space with ultrasonography assistance. In fluoroscopy, of these 52 patients, 50 revealed correct placement of the medicine into the epidural space. In conclusion, ultrasonography may be a reliable imaging modality for caudal epidural steroid injection, and its several advantages such as its convenience and the lack of a radiation hazard, make it preferable to fluoroscopy.

Preemptive analgesia for postoperative pain relief in lumbosacral spine surgeries: a randomized controlled trial

BACKGROUND CONTEXT

Administration of analgesic medication, before the actual onset of painful stimulus, is more effective than that after the onset of painful stimulus. This is the principle of preemptive analgesia. Although it is often considered superior to other forms of analgesia, its role in postoperative pain relief after lumbosacral spinal surgery has not been fully investigated.

PURPOSE

To analyze the efficacy of preemptive analgesia with a single caudal epidural injection for patients undergoing surgeries on the lumbosacral spine by the posterior approach.

STUDY DESIGN/SETTING

Randomized, double-blinded and controlled clinical trial.

PATIENT SAMPLE

Eighty-two patients who underwent discectomy in the lumbosacral spine by the posterior approach, with or without instrumentation, were randomized to the control group (n=40) and to the study group (n=42).

METHODS

Patients in control group received a single caudal epidural injection of 20 ml of normal saline. Patients in study group received a single caudal epidural injection of 20 ml containing bupivacaine and tramadol as the active agents. The time interval between this injection and the surgical incision was never less than 20 minutes in either of the groups. This facilitated enough time for the drug to get fixed to the nerve roots, leading to effective preemptive analgesia.

OUTCOME MEASURES

Patients were monitored for postoperative pain immediately after surgery when they had completely recovered and regained consciousness from general anesthesia, and subsequently 4, 8, 12 and 24 hours thereafter. Pain was quantified using the visual analog scale (VAS) and the verbal rating scale (VRS). The time at which supplemental analgesic medication was first demanded in the postoperative period by the patient was also noted.

RESULTS

The two groups were comparable for age, sex, body weight and the type of surgery they underwent. Because the data did not have a normal Gaussian distribution, the one-tailed Mann-Whitney test, being a nonparametric test, was adopted for statistical analysis. Accordingly, VAS and VRS values at all time intervals were significantly lower (p<.0001) in the study group as compared with the control group. This indicated significantly better pain relief in the study group. There was also a significant delay (p=.0041) in the first demand for supplemental analgesic medication in the postoperative period in the study group. No complication specific to the procedure was noted except for the development of postoperative urinary retention, which was transient and appropriately managed with urinary catheterization.

CONCLUSIONS

Preemptive analgesia with a single caudal epidural injection of bupivacaine and tramadol is a safe, simple and effective method for postoperative pain relief.

Epidural steroid injections

Epidural steroid injections have a significant role in the treatment of patients with low back, neck, and radicular pain. Although these procedures may not address the causative lesions, they often shorten the clinical course of the disease process, keep patients out of the hospital, and provide symptomatic relief that improves quality of life. These procedures are most accurately performed with fluoroscopic guidance and major complications are rare. Although support for cervical epidural steroid injection is less uniform than that for lumbar and caudal injections, a growing body of experience is beginning to support its efficacy and safety.

Surgical management of spinal stenosis

Proper patient selection is the key to successful surgical management. The presence of the appropriate symptoms, signs and imaging findings--along with the individual psychologic and socioeconomic factors--play a significant role in the selection process. Patient education is important so that the patient's expectations from surgery are aligned with the surgeon's expectations. When the patient has been properly selected, and there has been adherence to the decision-making principles, along with meticulous surgical technique, good outcomes can be expected with surgical management of patients with spinal stenosis.

Lumbar epidural steroid injections in the patient with lumbar spinal stenosis

Epidural steroid injections seem to be a useful component of a comprehensive and functionally oriented rehabilitation program for the patient with LSS. Review of the literature indicates the injections seem to be effective and are safe when performed with proper technique.

Image-guided epidural steroid injections

Epidural steroid injection has been proven to be useful in the treatment of acute lumbosacral radicular pain syndromes. The use of image guidance significantly increases accuracy and decreases complication rates. The technique of performing these injections, including translaminar approach, is described in this article. Necessary precautions and potential risks are also described.