Fluoroscopy-guided caudal epidural steroid injection (EDSI) is an option for conservative treatment of low back pain and sciatica; however, repeated exposure to radiation is a concern. With the blind technique, the needle misplacement rate is 30%; hence, ultrasound-guided caudal EDSI is a favored option.
OBJECTIVE:
To determine the efficacy of ultrasound-guided EDSI for low back pain and sciatica.
METHODS:
One hundred and ten patients with low back pain and sciatica who were unresponsive to conservative treatment, were prospectively recruited. Ultrasound-guided caudal EDSI was administered at 0, 3, and 6 weeks. Visual Analog Scale (VAS) score was recorded at 0, 2, 4, 12, and 24 weeks. Patients completed the Roland-Morris Disability Questionnaire (RMDQ) at pre-injection and 24 weeks post-injection.
RESULTS:
VAS was significantly reduced at 2, 4, 12, and 24 weeks ( 0.01). At 2, 4, 12, and 24 weeks after injection, 20%, 26%, 74%, and 83% of patients displayed 50% VAS reduction, respectively. The mean pre-injection RMDQ score was 15 and that post-injection at 24 weeks was 7 ( 0.01). The majority of patients had 50% reduction in the RMDQ score.
CONCLUSIONS:
Ultrasound-guided EDSI was safe and efficacious for low back pain and sciatica treatment at the intermediate follow-up.
Van TulderMWKoesBWBouterLMMetsemakersJF. Management of chronic nonspecific low back pain in primary care: a descriptive study. Spine (Phila Pa 1976).1997; 22: 76-82.
2.
KalffREwaldCWaschkeAGobischLHopfC. Degenerative lumbar spinal stenosis in older people: current treatment options. Dtsch Arztebl Int.2013; 110: 613-624.
3.
MullemanDMammouSGriffoulIWatierHGoupilleP. Pathophysiology of disk-related low back pain and sciatica. II. Evidence supporting treatment with TNF-alpha antagonists. Joint Bone Spine.2006; 73: 270-7.
4.
TakahashiNYabukiSAokiYKikuchiS. Pathomechanisms of nerve root injury caused by disc herniation: an experimental study of mechanical compression and chemical irritation. Spine (Phila Pa 1976).2003; 28: 435-41.
5.
AlvarezJAHardyRH Jr. Lumbar spine stenosis: a common cause of back and leg pain. Am Fam Physician.1998; 57: 1825-34.
6.
RobecchiACapraR. Hydrocortisone (compound F); first clinical experiments in the field of rheumatology. Minerva Med.1952; 98: 1259-63.
7.
LievreJABloch-MechelHPeanG. L’hydrocortisone en injection locale. Rev Rhum.1953; 20: 310-11.
8.
BarreLLutzGESouthernDCooperG. Fluoroscopically guided caudal epidural steroid injections for lumbar spinal stenosis: a restrospective evaluation of long term efficacy. Pain Physician.2004; 7: 187-93.
9.
ChenCPWongAMHsuCCTsaiWCChangCNLinSC, et al. Ultrasound as a screening tool for proceeding with caudal epidural injections. Arch Phys Med Rehabil.2010; 91: 358-63.
10.
ParkKDKimTKLeeWYAhnJKohSHParkY. Ultrasound-guided versus fluoroscopy-guided caudal epidural steroid injection for the treatment of unilateral lower lumbar radicular pain: case-controlled, retrospective, comparative study. Medicine (Baltimore).2015; 94: e2261.
11.
BlanchaisALLe GoffBGuillotP, et al. Feasibility and safety of ultrasound-guided caudal epidural glucocorticoid injections. Joint Bone Spine.2010; 77: 440-44.
12.
FardonDFMilettePC. Combined task forces of the north american spine society, american society of spine radiology, and american society of neuroradiology. Nomenclature and classification of lumbar disc pathology. Recommendations of the combined task forces of the north american spine society, american society of spine radiology, and american society of neuroradiology. Spine (Phila Pa 1976).2001; 26: 93-113.
13.
MamischNBrumannMHodlerJHeldUBrunnerFSteurerJ. Lumbar spinal stenosis outcome study working group zurich. Radiologic criteria for the diagnosis of spinal stenosis: results of a Delphi survey. Radiology.2012; 264: 174-9.
14.
BydonMAlviMAGoyalA. Degenerative lumbar spondylolisthesis: definition, natural history, conservative management, and surgical treatment. Neurosurg Clin N Am.2019; 30: 299-304.
15.
PorterRW. Spinal stenosis and neurogenic claudication. Spine (Phila Pa 1976).1996; 21: 2046-52.
16.
MarshallLLTrethewieERCurtainCC. Chemical radiculitis, a clinical physiological and immunological study. Clin Orthop.1977; 129: 61-67.
17.
OlmarkerKBlomquistJStrombergJ, et al. Inflammatogenic properties of nucleus pulposus. Spine.1995; 20: 665-69.
18.
ByrodGOtaniKBrisbyHRydevikBOlmarkerK. Methylprednisolone reduces the early vascular permeability increase in spinal nerve roots induced by epidural nucleus pulposus application. J Orthop Res.2000; 18: 983-7.
19.
LeeJHAnJHLeeSH. Comparison of the effectiveness of interlaminar and bilateral transforaminal epidural steroid injections in treatment of patients with lumbosacral disc herniation and spinal stenosis. Clin J Pain.2009; 25: 206-10.
20.
HelsaPEBreivikH. Epidural analgesia and epidural steroid injection for treatment of chronic low back pain and sciatica. Tidsskr Nor Laegeforen.1979; 99: 936-39.
21.
AbdiSDattaSTrescotAMSchultzDMAdlakaRAtluriSL, et al. Epidural steroids in the management of chronic spinal pain: a systematic review. Pain Physician.2007; 10: 185-212.
22.
PriceCMRogersPDProsserASArdenNK. Comparison of the caudal and lumbar approaches to the epidural space. Ann Rheum Dis.2000; 59: 879-82.
23.
StitzMYHillelSM. Accuracy of blind versus fluoroscopically guided caudal epidural injection. Spine.1999; 24: 1371-76.
LiuJZhouHLuL, et al. The effectiveness of transforaminal versus caudal routes for epidural steroid injections in managing lumbosacral radicular pain: a systematic review and meta-analysis. Medicine (Baltimore).2016; 95: e3373.
26.
ManchikantiLSinghVCashKAPampatiVDamronKSBoswellKV. 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. Pain Physician.2012; 15: 273-86.
27.
WaldmanSD. The caudal epidural administration of steroids in combination with local anesthetics in the palliation of pain secondary to radiographically documented lumbar herniated disc: a prospective outcome study with 6-months follow-up. Pain Clinic.1998; 11: 43-49.
28.
IbrahimMEAwadallaMAOmarASAl-ShatouriM. Ultrasound-guided caudal epidural steroid injection in chronic radicular low back pain: short-term electrophysiologic benefits. BJR Open.2020; 2: e20190006.
