Caudal InjectionWood, Dimitrios Varvarousis, James L. The aim of this study is to evaluate prospectively the efficacy of caudal epidural steroid injection CESI and transforaminal epidural steroid test prop t bol cycle TFESI in lumbar spinal stenosis patients with sciatic pain. Thirty-one patients average age 62 years from two hospitals, with single dermotomal distribution of sciatic pain due to spinal stenosis were included in the study. Patients underwent epidural steroid injections caudal steroid injection results by the same injectionist. Winstrol depot orally outcome measures were the improvement of function of at least 15 points caudal steroid injection results Oswestry Disability Index [ODI] at 6 months and the changes of VAS and ODI and at 2 weeks, at 3 months, and at 6 months postinjection. All patients with TFSI showed improvement of function at 6 months while only three
Epidural Results and Precautions
Wood, Dimitrios Varvarousis, James L. The aim of this study is to evaluate prospectively the efficacy of caudal epidural steroid injection CESI and transforaminal epidural steroid injection TFESI in lumbar spinal stenosis patients with sciatic pain.
Thirty-one patients average age 62 years from two hospitals, with single dermotomal distribution of sciatic pain due to spinal stenosis were included in the study. Patients underwent epidural steroid injections done by the same injectionist. Secondary outcome measures were the improvement of function of at least 15 points of Oswestry Disability Index [ODI] at 6 months and the changes of VAS and ODI and at 2 weeks, at 3 months, and at 6 months postinjection.
All patients with TFSI showed improvement of function at 6 months while only three Out of the total 31 patients, two patients from group A underwent a second CESI at 15 days postinjection and decompressive spine surgery between 3 and 6 months postinjection.
The effectiveness of transforaminal steroid injection for the stenosis patients with sciatica was superior to caudal at 6 months postinjection. A short-term 6 months effectiveness study of epidural steroid injections ESIs in lumbar spinal stenosis patients with sciatic pain is presented. Thirty-one patients were included in two comparative groups according to the route of injection. The transforaminal route was found more effective in terms of pain and disability than the caudal injections at 6 months postinjection in patients with spinal stenosis.
It is also associated with enormous economic, societal, and health impact . ESIs have been increasingly used lately, and they have become one of the most commonly performed interventions for sciatic pain. Although not definitive, the data strongly suggest that ESIs are beneficial for the short-term relief of radicular symptoms, but are less compelling for long-term effects or relief of radicular or back pain .
Considering the significant risks and great expense associated with surgery, and the similar long-term outcomes in pain and disability of lumbar disc herniation and spinal stenosis patients with or without surgery [3,4] , the possibility that ESIs could prevent even a small percentage of surgeries is reasonable arguments in support of ESI before proceeding directly with surgery [2,5].
In addition three types of epidurals, namely transforaminal epidural steroid injection TFESI , interlaminar epidural steroid injection ILESI , and caudal epidural steroid injection CESI , with variable results complicate the picture for practice of interventional pain management .
CESI offers a relatively simple even without fluoroscopy , rapid, and easily performed day-care procedure with improvement noted even 6 months later . Even though the transforaminal route of ESI has been reported as most effective and beneficial route than CESI for the administration of epidural steroids, this has not been proven clearly by level I studies [11,12].
Thirty-one consecutive patients from two adult orthopedic spine centers at an Army-Veterans Hospital and at a University Hospital, respectively between and were prospectively followed for 6 months following an ESI.
Patients were diagnosed with sciatica with or without back pain due to lumbar disc herniation or lumbar spinal stenosis. All patients were proposed surgical treatment in addition to injection but elected to proceed with ESI treatment.
The same injection technique was offered to all patients depending on the hospital they attended. If the injections failed to provide satisfactory relief by 3-month follow-up time, then patients were consulted for surgery at that time. This study was approved by our institution's Scientific Research Board and was conducted in accordance with the ethics in research. Monosegmental dermotomal pain distribution based on symptomatology and magnetic resonance imaging [MRI] findings at L4 medial lower leg , L5 lateral lower leg, dorsum foot, great toe or S1 calf, lateral foot and ankle, 4th—5th toes root levels.
The VAS for leg pain as well as the Oswestry Disability Index ODI questionnaire were obtained before injection for all patients and were followed up at 15 days, at 3 weeks, at 3 months, and at 6 months postinjection for both groups.
Secondary outcome measures included 15 or more degrees of functional improvement at 6 months. For these patients who received surgical treatment, the 6-month follow-up time was the preoperative time point.
The injections were performed in a surgical suite with vital signs monitoring including respiratory rate, pulse rate, electrocardiogram, and blood pressure. An intravenous line was inserted and a dose of first generation cephalosporin was infused before every injection. For the CESI procedure, the patient was placed in a prone position on the operating table. Straight after the procedure, a lateral radiographic view of lumbosacral spine was performed to confirm the presence of epidurogram within the canal.
After the usual sterile prep, drape, and local anesthesia, a gauge 3. Both anterior—posterior and lateral fluoroscopic projections confirmed proper needle placement. On the lateral view, the needle was positioned just below and slightly lateral to the pedicle in the ventral aspect of the intervertebral foramen.
On the anterior—posterior view, the needle was placed just beneath the midportion of the corresponding pedicle. If there was no dye flow marking the corresponding nerve root, the needle was repositioned.
Once adequate flow of contrast to the target area was documented, 1. Following the injections and during the follow-time, patients could take analgesics or use modalities for pain control as symptomatic treatment.
Comparisons between groups in regard of age, ODI, and VAS measurements were tested using nonparametric tests, as data were not considered to be normally distributed. Statistical comparisons regarding gender, diagnosis, root involvement, need for second injection, and ultimate surgical decision were done with chi-square test. Within groups, nonparametric related sample Friedman's two-way analysis of variance test was used for significant changes in ODI and VAS at different times of follow-up.
All statistical tests were conducted at a 0. In the Table , the preinjection demographic data age, gender , data regarding diagnosis stenosis or herniated disc, dermotomal distribution at L4 or L5 or S1 root and clinical outcomes VAS, ODI are presented. All patients included had neurology of L4, L5, or S1 roots suggesting radiculitis with predominantly pain symptomatology. Of the 31 stenosis patients, central and subarticular stenoses were seen in all patients, and foraminal was found in 11 patients.
The degree of stenosis was mild to moderate in all patients. Diagram showing mean visual analog scale VAS of patients at different follow-up time points. All caudal epidural injections were considered successful as an epidurogram was seen in postinjection lateral lumbosacral radiograph. For the transforaminal epidurals, the injection of steroid solution was performed only if adequate epidurogram was seen. No major complications were seen following the injections.
Minor complications included vagal reactions in four patients two in each group before the start of procedure, which necessitated rescheduling to another day. Of the total 31 patients, only two Clinical outcomes in terms of disability and pain as means ODI and VAS have shown improvement at 2 weeks, 3 months, and 6 months postinjection compared with preinjection for stenosis patients receiving injection by both techniques.
Only two patients both from CESI group out of the 31 total required a second injection at 15 days postinjection and, finally, these two patients underwent surgery within 6 months postinjection. The most beneficial and effective route of administration for epidural steroids remain controversial. Caudal epidural injections are deemed as the safest and easiest epidural injections, with minimal risk of inadvertent dural puncture or other side effects.
They have also been shown to be significantly effective compared with interlaminar epidural injections [7,13]. Three years later, the same group of injectionists who reported on the epiduropgraphy patterns of interlaminar injections, reported fluoroscopically guided caudal ESIs may help reduce bilateral radicular pain and improve standing and walking tolerance in patients with degenerative lumbar spinal stenosis .
In the present study, one group of patients was treated by caudal epidural injections and postinjection radiograph to check for epidurograms. According to postinjection epidurograms and clinical outcomes, CESI injections were precise and successful in all of these patients. However, different injectate volumes did not affect the final outcome irrespective of administration route . In the randomized evaluator-blinded study for subjects with S1 radiculopathy secondary to L5-S1 herniated nucleus pulposus treated with TFESIs, ILESIs, or CESIs, the transforaminal route of epidural steroid placement was more effective regarding pain and function than the caudal at 12 and 24 weeks; and the patients with ventral epidural spread, more common in TFESI group, had better outcomes .
In the study presented by our group, stenosis patients who received TFESIs had significantly better outcomes than patients in CESI group at 6 months, even though we elected to use double steroid dosage with high injectate volume in the caudal route.
The duration of pain relief from ESI varies and can reach up to a year [18,20]. Limitations to this study were the small number of patients included even if the original plan was to include at least 50 consecutive patients in each group so that significant differences in clinical outcomes could be identified.
This is attributed to the limited number of patients in the CESI group, one hospital, and the premature closure of the study as the interim analysis necessitated from our Scientific Research Board showed improved results from TFESIs. Initially, we also planned to include in the study patients with the diagnosis of disc herniation, as a separate subgroup.
Due to the small number of disc herniation patients, we included only the stenosis patients in the statistical analysis of group comparison. Another limitation of our study was that the volume of solution and corticosteroid dosage used were not identical between the two groups.
However, because of the large volume of the epidural space in the sacral area and the distance from the inflammation site, an increased injectate volume and steroid concentrate in this anatomic area were chosen to be used for the CESI group. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.
Sign In or Create an Account. Close mobile search navigation Article navigation. Injections , Transforaminal , Caudal , Stenosis. Demographic and clinical data of patients included in the study are presented. Statistically significant values indicated in bold. View large Download slide. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States.
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