Platelet-Rich Plasma for the Treatment of Degenerative Lumbosacral Stenosis: A Study with Retired Working Dogs

Traditionally, canine degenerative lumbosacral stenosis (DLS) has been defined as a multifactorial syndrome characterized by lumbosacral pain triggered by the compression of the nerve rootlets of the cauda equina. There is still no consensus on the treatment of this condition, probably because there are a plethora of possible causes. In addition to compression, inflammation is a very important factor in the physiopathology of the disorder. Platelet-rich plasma (PRP) consists of an increased concentration of autologous platelets suspended in a small amount of plasma. Platelets are a source of several growth factors. Growth factors were shown to help in wound healing and biological processes, such as chemotaxis, neovascularization and synthesis of extracellular matrix, and growth factors were used to improve soft tissue healing and bone regeneration. PRP also facilitates the restoration of the structural integrity of the affected anatomy. Fourteen dogs diagnosed with DLS were treated with three epidural injections of PRP on days 0, 15 and 45. All dogs showed clinical improvement 3 months after the initial treatment. Gait was also objectively assessed by means of the use of force platform analysis before and after treatment, showing significant improvement. The results show that PRP may provide a good alternative to other nonsurgical treatments, such as prednisolone epidural injection.

A Comparative Systematic Review and Meta-Analysis of 3 Routes of Administration of Epidural Injections in Lumbar Disc Herniation

BACKGROUND: The Best Practices in Pain Management from the U.S. Department of Health and Human Services (HHS) describes interventional techniques as part of a continuum. Epidural injections are commonly utilized modalities in managing low back and lower extremity pain. Epidural injections were initially administered in 1901 where the first descriptions of caudal epidural with local anesthetic for low back pain appeared. Since then, multiple developments have occurred. Currently, epidural injections are provided by caudal, interlaminar, and transforaminal approaches. The comparative effectiveness of each modality has been studied. However, comparative assessment has been sparse. OBJECTIVES: To assess the efficacy of 3 routes of administration of epidural injections for lumbar disc herniation. STUDY DESIGN: A systematic review and meta-analysis of randomized controlled trials (RCTs) of transforaminal, interlaminar and caudal epidural injections in managing chronic low back and lower extremity pain due to lumbar disc herniation. METHODS: RCTs with a placebo control or an active control design, performed under fluoroscopic guidance, with at least 6 months of follow-up are included. The outcome measures were pain relief and functional status improvement. Significant improvement was defined as 50% or greater pain relief and functional status improvement. Data extraction and methodological quality assessment were performed. Evidence was summarized utilizing principles of best evidence synthesis. RESULTS: A total of 21 trials were included. Of these, 7 studied caudal epidural injections, whereas transforaminal epidural injections were studied in 12 trials, and lumbar interlaminar epidural injections were studied in 10 trials, which all met inclusion criteria. Based on qualitative and quantitative analysis, which included conventional dual-arm and single-arm analysis for interlaminar epidural injections, and single-arm analysis for caudal and transforaminal epidural injections, and the approach to the epidural space, there is Level I evidence for local anesthetic and steroids, Level II for local anesthetic alone for transforaminal and interlaminar approaches, and Level II for the caudal approach with steroids or local anesthetic alone for short- and long-term relief. LIMITATIONS: There is a paucity of literature with intermediate or long-term relief of at least 6 months with appropriate outcome parameters. Conventional dual-arm meta-analysis was feasible only for interlaminar epidural injections. CONCLUSION: Epidural injections with local anesthetic and steroids showed Level I evidence for transforaminal and interlaminar approaches, whereas with local anesthetic alone Level II evidence was demonstrated. In contrast, caudal epidural injections showed Level II evidence with local anesthetic with steroids or local anesthetic alone. KEY WORDS: Chronic low back pain, lumbar radiculopathy, lumbar disc herniation, sciatica, epidural injections, local anesthetic, steroids, caudal epidural injections, interlaminar epidural injections, transforaminal epidural injections

Ultrasound Assisted Neuraxial Blockade in Obstetric Anesthesia

Central Neuraxial Blocks (CNBs) relevant to the practice of obstetric anesthesia and analgesia are spinal, epidural and combined spinal-epidural injections. These techniques are routinely used for cesarean deliveries and labor pain relief. Traditionally, CNBs are performed using surface anatomical landmarks. In the first instance the highest point of each iliac crest is identifies. The imaginary line connecting these points allegedly passes through the L4 vertebral body in non-pregnant women, and L3 vertebral body in pregnant women [1]. Based on this, the operator palpates and counts the spinous processes and decides on the needle entry point. Although this technique is widely accepted as relatively reliable, the correlation is inconsistent even in non-complicated cases. Obesity, tissue edema, pelvic rotation, limited ability to bend forward, hyperlordosis, labor pain, underlying spinal deformity or previous back surgery and instrumentation pose additional difficulty for anesthesiologists to correctly locate the intervertebral levels.

Physiotherapy. L. Blum. Treatment of sciatic nerve inflammation with epidural injections. Uber die Behandlung der Ischias mit epiduralen Injectionen.—Münch. med. Wochensch. 1910

The epidural injection technique was proposed almost simultaneously by Sicard and Chatelin. The author used epidural injections in the treatment of chronic ischias using first 1% cocaine solution or 4% stovaina, and subsequently with physiological sodium chloride solution.

Epidural Injections for Lumbar Radiculopathy or Sciatica: A Comparative Systematic Review and Meta-Analysis of Cochrane Review

BACKGROUND: Epidural injections are one of the commonly performed procedures in managing low back and lower extremity pain. In the past, Pinto et al and Chou et al performed systematic reviews and meta-analyses with a recent update from Oliveira et al showing lack of effectiveness of epidural steroid injections in managing lumbar radiculopathy. In contrast, multiple other systematic reviews and meta-analyses have supported the efficacy and use of epidural injections utilizing fluoroscopic guidance. STUDY DESIGN: A systematic review and meta-analysis of randomized controlled trials (RCTs) of epidural injections in managing chronic low back and lower extremity pain with sciatica or lumbar radiculopathy. OBJECTIVES: To assess the efficacy of 3 categories of epidural injections for lumbar radiculopathy or sciatica performed utilizing saline with steroids, local anesthetic alone, or steroids with local anesthetic. METHODS: In this systematic review and meta-analysis, RCTs with a placebo control or an active control design, performed under fluoroscopic guidance, with at least 6 months of followed-up were included. The outcome measures were pain relief and functional status improvement. Significant improvement was defined as 50% or greater pain relief and functional status improvement. Literature search was performed through January 2021. Methodological quality assessments were performed. Evidence was summarized utilizing principles of best evidence synthesis. RESULTS: In this analysis, a total of 21 RCTs were utilized with at least 6 months of follow-up and performed under fluoroscopic guidance. However, only 6 of 25 trials from Cochrane review met inclusion criteria for this review. Based on qualitative analysis, of the 21 trials included in the present analysis, there was only one placebo-controlled trial found to be negative. With conventional meta-analysis, there was no significant difference among the studies because all of the studies were active control with local anesthetic or local anesthetic and steroids. Further, with single-arm analysis, of the 5 trials included in that portion of the study, significant improvement was seen with local anesthetic alone compared to local anesthetic and steroids. There was a tendency for better improvement with steroids in terms of both pain relief and functional status. The level of evidence is Level I or strong for local anesthetic with steroids and Level I to II or moderate to strong for local anesthetic as a single agent based on multiple relevant high quality RCTs. LIMITATIONS: Despite multiple trials available, there is a paucity of true RCTs performed under fluoroscopic guidance with any of the approaches. CONCLUSION: Epidural injections with or without steroids for radiculopathy showed significant effectiveness with Level I or strong evidence for local anesthetic with steroids and Level II to I or moderate to strong evidence with local anesthetic alone. KEY WORDS: Chronic low back pain, lumbar radiculopathy, sciatica, epidural injections, local anesthetic, steroids, caudal epidural injections, interlaminar epidural injections, transforaminal epidural injections

Role of paraspinal mapping before transforaminal epidural injections for lumbar radiculopathy

Objectives: This study aims to investigate whether electromyography (EMG) including paraspinal mapping (PM) and specific clinical findings before the injection have a predictive role on the results in patients undergoing unilateral transforaminal epidural steroid injection (TFESI). Patients and methods: In this prospective study, a total of 46 patients (19 males, 17 females; mean age: 44.0±10.8 years; range, 23 to 60 years) with unilateral L5 root compression confirmed by physical examination, EMG and lumbar MRI between March 2013 and January 2014 were included. The patients underwent L5 TFESI. After the injection, they were examined at 1 h, three weeks, and three months. Results: The clinical findings and presence of acute involvement on EMG were not predictive for TFESI results; however, the patients with lower scores for the L5 segment in PM benefited more from the injection, compared to patients with higher scores for the L5 segment in PM. Conclusion: In patients with very clearly defined L5 radiculopathy, PM EMG can give us an idea about the effectiveness of L5 TFESI.