Is the outcome of caudal epidural injections affected by patient positioning?

Spine (Phila Pa 1976). 2010 Jul 1;35(15):E687-90

Authors: Makki D, Nawabi DH, Francis R, Hamed AR, Hussein AA

A prospective, randomized controlled trial.

PMID: 20535042 [PubMed – indexed for MEDLINE]

An unusual complication following caudal epidural steroid injection: a case report.

Acta Orthop Belg. 2008 Oct;74(5):720-2

Authors: Somanchi BV, Mohammad S, Ross R

The authors present a case in which paraplegia developed following administration of caudal epidural steroid injection (ESI) and discuss the different pathophysiological mechanisms involved. The authors strongly recommend that 0.5% bupivacaine should be used with caution for caudal epidural injection.

PMID: 19058714 [PubMed – indexed for MEDLINE]

Transforaminal ventral epidural adhesiolysis.

Pain Physician. 2001 Jul;4(3):273-9

Authors: Hammer M, Doleys DM, Chung OY

Epidural fibrosis with chronic low back pain, nonresponsive to traditional measures of treatment including surgery, is a common entity in modern medicine. Traditionally, epidural steroid injections have been employed to treat chronic low back pain and radiculopathy associated with failed back surgery. Due to the poor effectiveness of epidural steroid injections in post lumbar laminectomy syndrome, epidural adhesiolysis was introduced in the early 1980s. Caudal epidural adhesiolysis with hypertonic saline neurolysis has been described extensively in the literature and has been proven to be relatively successful and safe. To improve the results and reach the target area with steroid, transforaminal ventral epidural adhesiolysis has been utilized. This retrospective case analysis included 14 patients. Transforaminal ventral epidural adhesiolysis was performed on an outpatient basis in all patients. The results showed 93% improvement initially, which decreased to 71% at 1 month, 57% at 3 months, 43% at 6 months and 21% at 1 year. The results of this case study show that ventral epidural lysis of adhesions with hypertonic saline neurolysis is safe and effective in managing chronic low back and lower extremity pain in patients who failed to respond to other conservative modalities of treatments, including fluoroscopically directed transforaminal epidural steroid injections.

PMID: 16900254 [PubMed]

Treatment of lumbar spinal stenosis with epidural steroid injections: a retrospective outcome study.

Arch Phys Med Rehabil. 2004 Mar;85(3):479-84

Authors: Delport EG, Cucuzzella AR, Marley JK, Pruitt CM, Fisher JR

To determine patient satisfaction, relief of pain, frequency of injections, change of function, and subsequent surgical rate in patients who received epidural steroid injections (ESIs) for the diagnosis of lumbar spinal stenosis (LSS).

PMID: 15031837 [PubMed – indexed for MEDLINE]

Transient paralysis associated with epidural steroid injection.

J Spinal Disord. 1997 Oct;10(5):441-4

Authors: McLain RF, Fry M, Hecht ST

Epidural steroid therapy is a commonly applied “conservative” therapy, but it is not inherently benign. Although arachnoiditis, infection, and meningitis have been reported, acute paraplegia has not been reported as a complication of either caudal or spinal epidural steroid injection. A unique case of transient, profound paralysis after epidural steroid injection is reported here. The procedure was carried out without fluoroscopic control and was complicated by a puncture of the thecal sack. Radiographic studies demonstrated a focal, space-occupying lesion in the spinal canal at the level corresponding to the neurologic deficit, which spontaneously resolved over the next 2-3 h. Surgical decompression was initially considered and then deferred in favor of observation. The patient recovered motor, sensory, and bowel and bladder function over the next 48 h. The period of recovery was consistent with an acute but brief compressive injury and inconsistent with an anesthetic effect. Radiographic studies suggest three possible explanations: (a) inadvertent thecal penetration during injection may have produced an atypical anesthetic block; (b) loculation of the injected fluid may have caused a transient compressive lesion; or (c) intrathecal injection may have produced an iatrogenic arachnoid cyst. Although pathologic confirmation of the cause was not possible, the potential for this alarming complication should be recognized by physicians prescribing epidural steroid therapy. We do not suggest that epidural steroid therapy is the treatment of choice for patients with multiple back operations or that it is efficacious for these patients. Our purpose is to alert surgeons and therapists to a rare but potentially devastating complication and to provide our experience in treating it.

PMID: 9355063 [PubMed – indexed for MEDLINE]

Protocol for evaluation of the comparative effectiveness of percutaneous adhesiolysis and caudal epidural steroid injections in low back and/or lower extremity pain without post surgery syndrome or spinal stenosis.

Pain Physician. 2010 Mar-Apr;13(2):E91-E110

Authors: Manchikanti L, Pampati V, Cash KA

Treatment of chronic low back pain with or without lower extremity pain continues to be a challenge. Epidural steroids are commonly utilized in patients after the failure of conservative treatment. The results of epidural steroid injections have been variable based on the pathophysiology, the route of administration, injected drugs, and utilization of fluoroscopy. In patients resistant to fluoroscopically directed epidural injections, percutaneous epidural adhesiolysis and percutaneous targeted delivery of injections with or without adhesiolysis has been recommended. Percutaneous adhesiolysis has been studied in chronic pain syndromes related to post laminectomy syndrome and spinal stenosis with encouraging results. There is a paucity of literature regarding the effectiveness of the targeted delivery of medications with or without epidural adhesiolysis in patients recalcitrant to epidural steroid injections without a history of surgery and spinal stenosis.

PMID: 20309389 [PubMed – indexed for MEDLINE]

Preliminary results of a randomized, equivalence trial of fluoroscopic caudal epidural injections in managing chronic low back pain: Part 4–Spinal stenosis.

Pain Physician. 2008 Nov-Dec;11(6):833-48

Authors: Manchikanti L, Cash KA, McManus CD, Pampati V, Abdi S

Spinal stenosis is one of the 3 most common diagnoses of low back and leg symptoms which also include disc herniation and degenerative spondylolisthesis. Spinal stenosis is a narrowing of the spinal canal with encroachment on the neural structures by surrounding the bone and soft tissue. In the United States, one of the most commonly performed interventions for managing chronic low back pain are epidural injections, including their use for spinal stenosis. However, there have not been any randomized trials and evidence is limited with regards to the effectiveness of epidural injections in managing chronic function-limiting low back and lower extremity pain secondary to lumbar spinal stenosis.

PMID: 19057629 [PubMed – indexed for MEDLINE]

Effectiveness of caudal epidural injections in discogram positive and negative chronic low back pain.

Pain Physician. 2002 Jan;5(1):18-29

Authors: Manchikanti L, Singh V, Rivera JJ, Pampati V, Beyer C, Damron K, Barnhill RC

Epidural steroid injections are the most commonly used procedures to manage chronic low back pain in interventional pain management settings. The overall effectiveness of epidural steroid injections has been highly variable, and in the role has not been evaluated in patients discographically evaluated. One hundred consecutive patients, without evidence of disc herniation or radiculitis, who had failed to respond to conservative management with physical therapy, chiropractic and/or medical therapy, underwent discography utilizing strict criteria of concordant pain, and negative adjacent discs, after being judged to be negative for facet joint and/or sacroiliac joint pain utilizing comparative local anesthetic blocks. Any other type of response was considered negative. This study included 62 patients, who underwent caudal epidural steroid injections with Sarapin. They included Group I, comprised of 45 of 55 patients negative on provocative discography; and Group II, with 17 of 45 patients with positive provocative discography. Results showed that there was significant improvement in patients receiving caudal epidural injections, with a decrease in pain associated with improved physical, functional, and mental status; decreased narcotic intake, and increased return to work. The study showed that at 1 month, 100% of the patients evaluated showed significant improvement in both groups; this declined to 86% at 3 months in Group I, but remained at 100% in Group II, declining to 60% and 64% at 6 months in Group I and Group II, respectfully, with administration of one to three injections. Analysis with one to three injections, which included all (62) patients showed significant relief in 71% and 65% of the patients at 1 month, in 67% and 65% at 3 months, and in 47% and 41% at 6 months, in Group I and Group II, respectively. In conclusion, caudal epidural injections with or without steroids is an effective modality of treatment in managing chronic, persistent low back pain failing to respond to conservative modalities of treatments, in patients negative for facet joint and sacroiliac joint pain, whether positive or negative, on evaluation with provocative discography.

PMID: 16896354 [PubMed]

Sonographically guided caudal epidural steroid injections.

J Ultrasound Med. 2003 Nov;22(11):1229-32

Authors: Klocke R, Jenkinson T, Glew D

Caudal epidural steroid injections are used for the symptomatic treatment of radicular lumbosacral pain syndromes, but incorrect injection placement has been recognized as a common problem with the routinely used unguided technique. We aimed to explore the use of sonography to facilitate this procedure.

PMID: 14620894 [PubMed – indexed for MEDLINE]

A meta-analysis on the efficacy of epidural corticosteroids in the treatment of sciatica.

Anaesth Intensive Care. 1995 Oct;23(5):564-9

Authors: Watts RW, Silagy CA

The efficacy of epidural corticosteroids in the treatment of sciatica was investigated by meta-analysis of all randomized controlled trials. Eleven suitable trials of good quality were identified involving a total of 907 patients. The use of epidural (caudal or lumbar) steroid in the short-term (up to 60 days) increased the odds ratio (OR) of pain relief ( > 75% improvement) to 2.61 (95% CI 1.90-3.77) when compared with placebo. Despite some variations in trial characteristics there was little evidence of significant heterogeneity (P = 0.07). When the trials were analysed for near or total relief of pain in the short-term the OR is 2.79 (95% CI 1.92-4.06), for heterogeneity (P = 0.07). For longterm relief of pain (up to 12 months) the OR is 1.87 (95% CI 1.31-2.68). Efficacy is independent of the route of injection; for caudal epidural steroid the OR is 3.80 (95% CI 1.36-10.6) and for the lumbar epidural steroid 2.43 (95% CI 1.77-3.74). Adverse events included dural tap (2.5%), transient headache (2.3%) and a transient increase in pain (1.9%). There were no reported longterm adverse events. In conclusion we present quantitative evidence from meta-analysis of pooled data from randomized trials that epidural administration of corticosteroids is effective in the management of lumbosacral radicular pain.

PMID: 8787255 [PubMed – indexed for MEDLINE]

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