scholarly journals Effect of Fluoroscopically Guided Caudal Epidural Steroid or Local Anesthetic Injections in the Treatment of Lumbar Disc Herniation and Radiculitis: A Randomized, Controlled, Double Blind Trial with a Two-Year Follow-Up

2012 ◽  
Vol 4;15 (4;8) ◽  
pp. 273-286 ◽  
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Lower Extremity ◽  
Outcome Measures ◽  
Disc Herniation ◽  
Local Anesthetic ◽  
Low Back ◽  
Epidural Injections ◽  
Lower Extremity Pain ◽  
Group I ◽  
Group Ii ◽  
Caudal Epidural

Background: Lumbar disc herniation and radiculitis are common elements of low back and lower extremity pain. Among minimally invasive treatments, epidural injections are one of the most commonly performed interventions. However, the literature is mixed about their effectiveness in managing low back and lower extremity pain. In general, individual studies and systematic reviews of epidural steroid injections have been hampered by their study design, baseline differences between treatment groups, inadequate sample sizes, highly controlled settings, lack of validated outcome measures, and the inability to confirm the injectate location because fluoroscopy was not used. Study Design: A randomized, controlled, double blind, active control trial. Setting: A private, interventional pain management practice, specialty referral center in the United States. Objectives: To assess the effectiveness of fluoroscopically directed caudal epidural injections with local anesthetic with or without steroids in managing chronic low back and lower extremity pain in patients with disc herniation and radiculitis. Methods: One hundred twenty patients were randomized to two groups: Group I received 10 mL caudal epidural injections of local anesthetic, lidocaine 0.5%; Group II patients received caudal epidural injections of 0.5% lidocaine, 9 mL, mixed with 1 mL of steroid. Outcome Assessment: Multiple outcome measures were utilized. The primary outcome measures were Numeric Rating Scale (NRS) and the Oswestry Disability Index 2.0 (ODI). Secondary outcome measures were employment status and opioid intake. Significant pain relief improvement was defined as 50% or more improvement in NRS and ODI scores. Results: In the successful category, 77% of Group I had significant pain relief of ≥ 50% and functional status improvement of ≥ 50% reduction in ODI scores; in Group II it was 76%, whereas overall it was 60% and 65% in Groups I and II. Over the two years, Group I had an average number of procedures of 5.5 ± 2.8; Group II was 5.3 ± 2.4. Even though there was no significant difference in overall relief between the two groups, the average relief for each procedure was superior for steroids. Limitations: Presumed limitations of this evaluation include lack of a placebo group. Conclusion: Caudal epidural injections of local anesthetic with or without steroids might be an effective therapy for patients with disc herniation or radiculitis. The present evidence illustrates the potential superiority of steroids compared with local anesthetic at two year follow up based on average relief per procedure. Key words: Chronic low back pain, caudal epidural injections, disc herniation, radiculitis, lower extremity pain, local anesthetic, steroids

scholarly journals Preliminary Results of a Randomized, Equivalence Trial of Fluoroscopic Caudal Epidural Injections in Managing Chronic Low Back Pain: Part 2 — Disc Herniation and Radiculitis

2008 ◽  
Vol 6;11 (12;6) ◽  
pp. 801-815 ◽  
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Pain Relief ◽  
Lower Extremity ◽  
Disc Herniation ◽  
Local Anesthetic ◽  
Low Back ◽  
Epidural Injections ◽  
Significant Pain ◽  
Group I ◽  
Group Ii ◽  
Caudal Epidural

Background: The pathophysiology of lumbar radicular pain is a subject of ongoing research. The prevalence of sciatica or radiculitis ranges from 1.2% to 43%. Epidural injections are one of the most commonly performed interventions in the United States in managing chronic low back and lower extremity pain secondary to disc herniation and radiculitis. There is a paucity of evidence with contemporary methodology used in performing epidural injections under fluoroscopy and based on pain relief and functional status improvement. Study Design: A randomized, double-blind, equivalence trial. Setting: An interventional pain management practice, a specialty referral center, a private practice setting in the United States. Objective: To evaluate the effectiveness of caudal epidural injections with or without steroids in managing chronic low back and lower extremity pain secondary to disc herniation or radiculitis in providing effective and long-lasting pain relief and evaluate the differences between local anesthetic with or without steroids. Methods: Patients were assigned to one of 2 groups; Group I patients received caudal epidural injections with an injection of local anesthetic (lidocaine 0.5%), whereas, Group II patients received caudal epidural injections with 0.5% lidocaine 9 mL mixed with 1 mL of steroid. Randomization was performed by computer-generated random allocations sequence by simple randomization. Outcomes Assessment: Multiple outcome measures were utilized which included the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake with assessment at 3 months, 6 months, and 12 months post-treatment. Significant pain relief was defined as 50% or more, whereas significant improvement in disability score was defined as a reduction of 40% or more. Results: The percentage of patients with significant pain relief of 50% or greater at 12 months was 79% in Group I and 81% in Group II. Reduction of Oswestry scores of at least 40% was seen in 83% of the patients in Group I and 91% in Group II. The overall average procedures per year were 3.9 ± 1.26 in Group I and 3.6 ± 1.08 in Group II with an average total relief per year of 35.2 ± 17.18 weeks in Group I and 35.9 ± 15.34 weeks in Group II over a period of 52 weeks. Limitations: The results of this study are limited by lack of a placebo group and a preliminary report of 42 patients in each group. Conclusion: Caudal epidural injections with or without steroids may be effective in patients with disc herniation or radiculitis with between 79% to 91% of patients showing significant pain relief and improvement in functional status. Key words: Chronic low back pain, disc herniation, radiculitis, lower extremity pain, caudal epidural injections, epidural steroids, local anesthetic

scholarly journals Evaluation of the Effectiveness of Lumbar Interlaminar Epidural Injections in Managing Chronic Pain of Lumbar Disc Herniation or Radiculitis: A Randomized, Double-Blind, Controlled Trial

2010 ◽  
Vol 4;13 (4;7) ◽  
pp. 343-355
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Pain Relief ◽  
Lower Extremity ◽  
Disc Herniation ◽  
Local Anesthetic ◽  
The United States ◽  
Low Back ◽  
Epidural Injections ◽  
Lower Extremity Pain ◽  
Group I ◽  
Group Ii

Background: The pathophysiology of lumbar radicular pain is the subject of ongoing research, with a reported prevalence of sciatica or radiculitis ranging from 1.2% to 43%. Among the numerous nonsurgical interventions available, epidural injections are the most commonly performed interventions in the United States in managing chronic low back and lower extremity pain. 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. Objective: To evaluate the effectiveness of lumbar interlaminar epidural injections with local anesthetic, with or without steroids, in managing chronic low back and lower extremity pain secondary to disc herniation or radiculitis in providing effective and long-lasting pain relief. Methods: Patients were assigned to one of 2 groups with local anesthetic only or with local anesthetic mixed with non-particulate betamethasone. Randomization was performed by computer-generated random allocations sequence by simple randomization. Seventy patients were included in this analysis. Outcomes Assessment: Patient outcomes were measured at baseline, 3, 6, and 12 months post-treatment with the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake. Decrease of ≥ 50% of NRS scores and Oswestry scores were considered significant. Results: Significant pain relief (≥ 50%) was seen at 12 months in 74% of patients in Group I and 86% in Group II, and 69% and 83% in ODI scores respectively. Significant differences were noted in pain relief characteristics at 6 months between Group I and Group II (P = 0.001) and functional status improvement was significantly better in Group II at 6 months and 12 months (P = 0.019 and 0.045). The overall average procedures per year were 4.3 in Group I and 4.2 in Group II with an average total relief per year of 42.2 ± 10.5 weeks in Group I and 41.4 ± 11.0 weeks in Group II over a period of 52 weeks in the successful group. Limitations: The study limitations include the lack of a placebo group and the fact that this is a preliminary report of 35 patients in each group. Conclusion: Overall, 74% of patients in Group I without steroids and 86% in Group II with steroids with lumbar disc herniation or radiculitis might benefit from lumbar interlaminar epidural injections. Key words: Chronic low back pain, lower extremity pain, disc herniation, radiculitis, lumbar interlaminar epidural injections, epidural steroids, local anesthetic

scholarly journals One-Year Results of a Randomized, Double-Blind, Active Controlled Trial of Fluoroscopic Caudal Epidural Injections With or Without Steroids in Managing Chronic Discogenic Low Back Pain Without Disc Herniation or Radiculitis

2011 ◽  
Vol 1;14 (1;1) ◽  
pp. 25-36 ◽  
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Disc Herniation ◽  
Local Anesthetic ◽  
Chronic Low Back Pain ◽  
Low Back ◽  
Epidural Injections ◽  
Group I ◽  
Group Ii ◽  
Caudal Epidural

Background: Lumbar radicular pain pathophysiology continues to be the subject of research and debate as discogenic pain is increasingly seen as a cause of non-specific low back pain. Among non-surgical methods used to manage chronic low back pain with or without disc herniation, epidural injections are one of the most common modalities. However, there is little evidence utilizing contemporary methodology for using epidural injections in patients with discogenic pain. Study Design: A randomized, double-blind, active-controlled trial. Setting: An interventional pain management practice, a specialty referral center, a private practice setting in the United States. Objectives: To evaluate the effectiveness of caudal epidural injections with local anesthetic, with or without steroids, in managing chronic low back pain without disc herniation or radiculitis. Methods: A total of 120 patients were assigned to one of 2 groups. Group I patients received caudal epidural injections with local anesthetic (lidocaine 0.5% 10 mL); Group II patients received caudal epidural injections with 9 mL of 0.5% lidocaine mixed with 1 mL of steroid (either brand name or non-particulate betamethasone [6 mg] or methylprednisolone [40 mg]. Computer-generated randomization and random allocation sequence by simple randomization were the randomization techniques utilized. Outcomes Assessment: Multiple outcome measures were utilized which included the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, functional status, and opioid intake at 3, 6, and 12 months post treatment. Significant pain relief and functional status improvement were described as a 50% or more reduction in scores from baseline. Results: Significant pain relief and functional status improvement were observed in 55% of the patients in Group I and 68% of the patients in Group II. In contrast, 84% of patients in Group I and 85% in Group II saw significant pain relief and functional status improvement in the successful group (62% in Group I and 68% in Group II). The average procedures per year were 3.8 ± 0.9 for Group I and 4.3 ± 0.9 for Group II. Average pain scores decreased from 8.0 ± 0.9 to 4.3 ± 1.79 for Group I and from 7.9 ± 1.0 to 3.8 ± 1.59 for Group II. There were no differences among the patients receiving one of the 3 steroids. Limitations: The results of this study are limited by lack of a placebo group. Conclusion: Caudal epidural injections with local anesthetic with or without steroids are effective in patients with chronic low back pain of discogenic origin without facet joint pain, disc herniation, and/or radiculitis. Clinical Trial: NCT00370799 Key words: Chronic low back pain, lower extremity pain, discogenic pain, facet joint pain, disc herniation, radiculitis, lumbar interlaminar epidural injections, epidural steroids, local anesthetic

scholarly journals Lumbar Interlaminar Epidural Injections in Central Spinal Stenosis: Preliminary Results of a Randomized, Double-Blind, Active Control Trial

2012 ◽  
Vol 1;15 (1;1) ◽  
pp. 51-63 ◽  
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Pain Relief ◽  
Lower Extremity ◽  
Spinal Stenosis ◽  
Local Anesthetic ◽  
Low Back ◽  
Epidural Injections ◽  
Lower Extremity Pain ◽  
Group I ◽  
Successful Group ◽  
Group Ii

Background: Chronic, persistent low back and lower extremity pain is often caused by spinal stenosis. Surgery and other interventions, including epidural injections, have been used to relieve this pain. However, there is little in the medical literature to support interlaminar, or transforaminal epidural injections under fluoroscopy for managing lumbar pain of central spinal stenosis, while the caudal epidural approach has been studied. Study Design: A randomized, double-blind, active control trial. Setting: A private, interventional pain management practice, specialty referral center in the United States. Objective: This study sought to determine if low back and lower extremity pain secondary to lumbar central stenosis can be managed and long-lasting pain relief can be achieved with interlaminar epidural injections of local anesthetic, with or without steroids. Methods: The study comprised 2 groups: one that received local anesthetic only and another received local anesthetic combined with nonparticulate betamethasone. A total of 120 patients were randomized by a computer-generated random allocations sequence to one of the 2 groups. The results of 30 patients in each group were assessed. Outcomes Assessment: Sixty patients were included in this analysis. Outcomes measurements were taken at baseline and at 3, 6, and 12 months post-treatment. Measurements taken were Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status and opioid intake. A decrease in both the NRS and ODI of ≥ 50% was considered significant. Results: Significant pain relief and improvement in ODI scores were seen in both groups at 12 months. Group I’s significant pain relief was 70%; Group II’s was 63%. The significant ODI improvement in Group I was 70%; in Group II it was 60%. Group I patients on average received 3.8 procedures a year; Group II patients received 4.0 procedures a year in successful group. Over 52 weeks in the successful group, total relief for Group I was 40.8 ± 11.7 weeks; for Group II it was 37.1 ± 12.6 weeks. Combined pain relief and functional status improvement were seen in 80% of patients in Group I and 72% in Group II in successful group. Limitations: The lack of a placebo group and preliminary results are limitations. Conclusion: Patients might benefit from receiving lumbar interlaminar injections with or without steroids for lumbar central spinal stenosis. Key words: Chronic low back pain, lower extremity pain, lumbar spinal stenosis, central stenosis, lumbar interlaminar epidural injections, epidural steroids, local anesthetic.

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

2012 ◽  
Vol 4;15 (4;8) ◽  
pp. E363-E404
Author(s):  
Ramsin Benyamin
Keyword(s):  
Lower Extremity ◽  
Spinal Stenosis ◽  
Disc Herniation ◽  
Local Anesthetic ◽  
Chronic Low Back Pain ◽  
Randomized Trials ◽  
Low Back ◽  
Discogenic Pain ◽  
Epidural Injections ◽  
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 > 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

scholarly journals 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

2010 ◽  
Vol 4;13 (4;7) ◽  
pp. E279-E292
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Pain Relief ◽  
Disc Herniation ◽  
Local Anesthetic ◽  
Chronic Low Back Pain ◽  
Low Back ◽  
Epidural Injections ◽  
Group I ◽  
Group Ii

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

scholarly journals Preliminary Results of a Randomized, Equivalence Trial of Fluoroscopic Caudal Epidural Injections in Managing Chronic Low Back Pain: Part 1 — Discogenic Pain without Disc Herniation or Radiculitis

2008 ◽  
Vol 6;11 (12;6) ◽  
pp. 785-800 ◽  
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Disc Herniation ◽  
Local Anesthetic ◽  
Chronic Low Back Pain ◽  
Low Back ◽  
Discogenic Pain ◽  
Epidural Injections ◽  
Group I ◽  
Caudal Epidural

Background: Intervertebral discs, facet joints, ligaments, fascia, muscles, and nerve root dura have been described as tissues capable of transmitting pain in the low back. The pathophysiology of spinal radicular pain is the subject of ongoing research and controversy with discogenic pain assuming a major role as a cause of non-specific low back pain. Even though epidural injections are frequently administered in managing axial low back pain, the evidence is lacking. Study Design: A randomized, double-blind, equivalence trial. Setting: An interventional pain management practice, a specialty referral center, a private practice setting in the United States. Objectives: To evaluate the effectiveness of caudal epidural injections with or without steroids in managing chronic low back pain without disc herniation or radiculitis in providing effective and longlasting pain relief and to evaluate the differences between local anesthetic with or without steroids. Methods: Patients were randomly assigned to one of 2 groups, Group I patients received caudal epidural injections with local anesthetic (lidocaine 0.5%), whereas Group II patients received caudal epidural injections with 0.5% lidocaine 9 mL mixed with 1 mL of steroid. Randomization was performed by computer-generated random allocation sequence by simple randomization. Outcomes Assessment: Multiple outcome measures were utilized which included the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake with assessment at 3 months, 6 months, and 12 months post-treatment. Significant pain relief was defined as 50% or more, whereas significant improvement in disability score was defined as reduction of 40% or more. Results: Significant pain relief (≥ 50%) was demonstrated in 72% to 81% of patients and functional status improvement was demonstrated by a reduction of 40% in the ODI scores in 81% of the patients. The overall average procedures per year were 3.6 ± 1.05 in Group I and 3.9 ± 1.33 in Group II with an average total relief per year of 32.3 ± 16.93 weeks in Group I and 30.7 ± 17.94 weeks in Group II over a period of 52 weeks. Limitations: The results of this study are limited by lack of a placebo group and a preliminary report of 36 patients in each group. Conclusion: Caudal epidural injections with or without steroids may be effective in patients with chronic function-limiting low back pain without facet joint pain, disc herniation, and/or radiculitis in over 70% of the patients. Key words: Chronic low back pain, caudal epidural injections, discogenic pain, disc herniation, radiculitis, local anesthetic, steroids, controlled comparative local anesthetic blocks, provocation discography

scholarly journals Lumbar Interlaminar Epidural Injections in Managing Chronic Low Back and Lower Extremity Pain: A Systematic Review

2009 ◽  
Vol 1;12 (1;1) ◽  
pp. 163-188 ◽  
Author(s):  
Allan T. Parr
Keyword(s):  
Systematic Review ◽  
Lower Extremity ◽  
Spinal Stenosis ◽  
Disc Herniation ◽  
Low Back ◽  
Short Term ◽  
Discogenic Pain ◽  
Epidural Injections ◽  
Lower Extremity Pain

Background: Low back pain with or without lower extremity pain is the most common problem among chronic pain disorders with significant economic, societal, and health 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, transforaminal – and for various conditions, namely – intervertebral disc herniation, spinal stenosis, and discogenic pain without disc herniation or radiculitis. 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: Review of the literature and methodologic quality assessment were performed according to the Cochrane Musculoskeletal Review Group Criteria as utilized for interventional techniques for randomized trials and the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies. The level of evidence was classified as Level I, II, or III based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF) for therapeutic interventions. Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE from 1966 to November 2008, and manual searches of bibliographies of known primary and review articles. Results of analysis were performed for multiple conditions separately. Outcome Measures: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. Results: The available literature included only blind epidural injections without fluoroscopy. The indicated evidence is positive (Level II-2) for short-term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis. The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections. Limitations: The limitations of this study include paucity of literature, lack of quality evidence, lack of fluoroscopic procedures, and lack of applicable evidence in contemporary interventional pain management practices. Conclusion: The evidence based on this systematic review is limited for blind interlaminar epidurals in managing all types of pain except for short-term relief of pain secondary to disc herniation and radiculitis. This evidence does not represent contemporary interventional pain management practices and also the evidence may not be extrapolated to fluoroscopically directed lumbar interlaminar epidural injections. Key words: Chronic low back pain, lower extremity pain, disc herniation, radiculitis, spinal stenosis, discogenic pain, lumbar interlaminar epidural injections, caudal epidural injections, transforaminal epidural injections, epidural steroids, local anesthetic

scholarly journals Management of Pain of Post Lumbar Surgery Syndrome: One-Year Results of a Randomized, Double-Blind, Active Controlled Trial of Fluoroscopic Caudal Epidural Injections

2010 ◽  
Vol 6;13 (6;12) ◽  
pp. 519-521
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Pain Relief ◽  
Local Anesthetic ◽  
Low Back ◽  
Lumbar Surgery ◽  
Epidural Injections ◽  
Group I ◽  
One Year ◽  
Caudal Epidural

Background: Post lumbar surgery syndrome represents a cluster of nomenclature and syndromes following spine surgery wherein the expectations of the patient and spine surgeon are not met, with persistent pain following lumbar surgery. Multiple causes have been speculated to cause pain after lumbar surgery. Epidural steroid injections are most commonly used in managing post surgical pain in the lumbar spine. However, there is a paucity of evidence of epidural injections in managing chronic low back pain with or without lower extremity pain in post surgery syndrome. Study Design: A randomized, double-blind, active controlled trial. Setting: An interventional pain management practice, a specialty referral center, a private practice setting in the United States. Objectives: To evaluate the effectiveness of caudal epidural injections in patients with chronic low back and lower extremity pain after surgical intervention with post lumbar surgery syndrome. Methods: One-hundred forty patients were randomly assigned to one of 2 groups; Group I patients received caudal epidural injections with local anesthetic (lidocaine 0.5%), whereas Group II patients received caudal epidural injections with 0.5% lidocaine 9 mL mixed with 1 mL of 6 mg non-particulate Celestone. Randomization was performed by computer-generated random allocation sequence by simple randomization. Outcomes Assessment: Multiple outcome measures were utilized which included the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake with assessment at 3 months, 6 months, and 12 months post-treatment. Significant pain relief and disability reduction were described as 50% or more reduction in scores from baseline. Results: Combined pain relief (≥50%) and disability reduction was recorded in 53% of the patients in the local anesthetic group, and 59% of patients in the local anesthetic and steroid group with no significant differences noted with or without steroid over a period of one-year. However, the data from the successful group showed improvement in 70% of patients in Group I and 75% of patients in Group II. The average procedures per year were 4 with an average total relief per year of 38.1 ± 14.5 weeks in Group I and 38.4 ± 13.2 weeks in Group II over a period of 52 weeks in the successful group. Limitations: The results of this study are limited by the lack of a placebo group and one-year outcomes. Conclusion: Caudal epidural injections in chronic function-limiting low back pain in post surgery syndrome without facet joint pain may be effective in a significant proportion of patients with improvement in functional status and significant pain relief. Key words: Post lumbar surgery syndrome, post lumbar laminectomy syndrome, chronic low back pain, epidural adhesions, epidural steroid injections, epidural fibrosis, recurrent disc herniation, spinal stenosis

scholarly journals Efficacy of epidural injection of steroid in treatment of lumber disc prolapse: article review

2021 ◽  
Vol 8 (1) ◽  
pp. 10-19
Author(s):  
Musaed hekmat AL-Dahhan
Keyword(s):  
Lower Extremity ◽  
Disc Herniation ◽  
Epidural Injection ◽  
Low Back ◽  
Steroid Injections ◽  
Epidural Steroid Injections ◽  
Lower Extremity Pain ◽  
Epidural Steroid ◽  
Caudal Epidural ◽  
Corticosteroid Injections

"Chronic low back and lower extremity pain is mainly caused by lumbar disc herniation (LDH) and radiculitis. Various surgery and nonsurgical modalities, including epidural injections, have been used to treat LDH or radiculitis. Caudal epidural injection of local anesthetics with or without steroids is one of the most commonly used interventions in managing chronic low back and lower extremity pain. To describe the indications, rationale, techniques, alternatives, contraindications, complications, and efficacy of lumbar and caudal epidural corticosteroid injections. Interventions: Three reviewers with formal training and certification in evidence-based medicine searched the literature on non–image guided lumbar interlaminar epidural steroid injections. A larger team of seven reviewers independently assessed the methodology of studies found and appraised the quality of the evidence presented. A systematic literature search was performed, in the Medline Case reports and retrospective and prospective studies were extensively reviewed to provide detailed descriptions of the clinical features of lumbar and caudal epidural corticosteroid injections. Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE , and manual searches of bibliographies of known primary and review articles. Epidural corticosteroid injections are commonly requested treatments for patients with various low-back or lower-extremity pain syndromes (or both). Most of the reports on the use of this type of treatment are retrospective and noncontrolled. These studies indicate benefit; however, the prospective controlled studies provide varied results about the efficacy of lumbar and caudal epidural corticosteroid injections. In conclusions: In patients with lumbar radicular pain secondary to disc herniation or neurogenic claudication due to spinal stenosis, interlaminar epidural steroid injections appear to have clinical effectiveness limited to short-term pain relief. Therefore, in a contemporary medical practice, these procedures should be restricted to the rare settings where fluoroscopy is not available."

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