Caudal epidural steroid injection: a randomized controlled trial

 

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Abstract

Study design: Prospective study.

Study rationale: A recurrent phenomenon, the lifetime prevalence of low back pain has been reported as 54%–80%, while annual prevalence ranges from 15%–45% [1]. It is also associated with enormous economic, societal, and health impact [2]. India, being a developing country, has its problem compounded by the occupational compulsions in parts of the rural areas [3].

For some interventional therapies, like epidural steroid injections, utilization rates have increased dramatically [4], [5], [6], [7], [8], [9]. They have become one of the most commonly performed interventions in the United States for low back pain with radiculopathy [10].

Clinical question: Multiple systematic reviews [11], a meta-analysis [12], several guidelines [13], health technology assessments by insurers, and local medical review policies and coverage decisions have been published. However, controversy continues regarding the effectiveness of epidural steroid injections. In addition three types of epidurals, namely interlaminar, transforaminal, and caudal, with variable results complicate the picture for practice of interventional pain management. The underlying mechanism of action of epidurally administered steroid and local anesthetic injections is still not well understood and compounds the problem [14].

Objective: To evaluate and update the effects of caudal epidural injection in the management of chronic low back pain and sciatica.

The definiton of the different classes of evidence is available here.

• REFERENCES

• 1 Lawrence RC, Helmick CG, Arnett FC et al. 1998; Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum 41 (5) 778-799
  CrossrefPubMedGoogle Scholar
• 2 Saastamoinen P, Leino-Arjas P, Laaksonen M et al. 2005; Socio-economic differences in the prevalence of acute, chronic and disabling chronic pain among ageing employees. Pain 114 (3) 364-371
  CrossrefPubMedGoogle Scholar
• 3 Sharma SC, Singh R, Sharma AK et al. 2003; Incidence of low back pain in workage adults in rural North India. Indian J Med Sci 57 (4) 145-147
  PubMedGoogle Scholar
• 4 Desmoulin GT, Yasin NI, Chen DW. 2007; Initial results using Khan Kinetic Treatment™ as a low back pain treatment option. J Musculoskel Pain 15 (3) 91-102
  PubMedGoogle Scholar
• 5 Peng B, Wu W, Li Z et al. 2007; Chemical radiculitis. Pain 1-2 (127) 11-16
  PubMedGoogle Scholar
• 6 Mulleman D, Mammou S, Griffoul I et al. 2006; Pathophysiology of disc-related sciatica. I–Evidence supporting a chemical component. Joint Bone Spine 73: 151-158
  CrossrefPubMedGoogle Scholar
• 7 Macario A, Pergolizzi JV. 2003; Systematic literature review of spinal decompression via motorized traction for chronic discogenic low back pain. Spine 6 (3) 171-178
  PubMedGoogle Scholar
• 8 Slipman CW, Shin CH, Patel RK et al. 2002; Etiologies of failed back surgery syndrome. Pain Med 3 (3) 200-217
  CrossrefPubMedGoogle Scholar
• 9 Friedly J, Chan L, Deyo R. 2007; Increases in lumbosacral injections in the Medicare population: 1994 to 2001. Spine 32 (16) 1754-1760
  CrossrefPubMedGoogle Scholar
• 10 Manchikanti L. 2006; Medicare in interventional pain management: A critical analysis. Pain Physician 9 (3) 171-197
  PubMedGoogle Scholar
• 11 Abdi S, Datta S, Lucas LF. 2005; Role of epidural steroids in the management of chronic spinal pain: a systematic review of effectiveness and complications. Pain Physician 1 (8) 127-143
  PubMedGoogle Scholar
• 12 Watts RW, Silagy CA. 1995; A meta-analysis on the efficacy of epidural corticosteroids in the treatment of sciatica. Anaesth Intensive Care 23 (5) 564-569
  PubMedGoogle Scholar
• 13 Boswell MV, Shah RV, Everett CR et al. 2005; Interventional techniques in the management of chronic spinal pain: evidence-based practice guidelines. Pain Physician 8 (1) 1-47
  PubMedGoogle Scholar
• 14 Byröd G, Otani K, Brisby H et al. 2000; Methylprednisolone reduces the early vascular permeability increase in spinal nerve roots induced by epidural nucleus pulposus application. J Orthop Res 6 (18) 983-987
  PubMedGoogle Scholar
• 15 Ackerman III WE, Ahmad M. 2007; The efficacy of lumbar epidural steroid injections in patients with lumbar disc herniations. Anesthesia Analog 104 (5) 1217-1222
  PubMedGoogle Scholar
• 16 Abdi S, Datta S, Trescot AM et al. 2007; Epidural steroids in the management of chronic spinal pain: a systematic review. Pain Physician 10 (1) 185-212
  PubMedGoogle Scholar
• 17 Boswell MV, Hansen HC, Trescot AM et al. 2003; Epidural steroids in the management of chronic spinal pain and radiculopathy. Pain Physician 6 (3) 319-334
  PubMedGoogle Scholar
• 18 Cuckler JM, Bernini PA, Wiesel SW et al. 1985; The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study. J Bone Joint Surg Am 67 (1) 63-66
  CrossrefPubMedGoogle Scholar
• 19 Singh V, Manchikanti L. 2002; Role of caudal epidural injections in the management of chronic low back pain. Pain Physician 2 (5) 133-148
  PubMedGoogle Scholar
• 20 Dashfield AK, Taylor MB, Cleaver JS et al. 2005; Comparison of caudal steroid epidural with targeted steroid placement during spinal endoscopy for chronic sciatica: a prospective, randomized, double-blind trial. Br J Anaesth 94 (4) 514-519
  CrossrefPubMedGoogle Scholar
• 21 Ogoke BA. 2000; Caudal epidural steroid injections. Pain Physician 3 (3) 305-312
  PubMedGoogle Scholar
• 22 Bush K, Hillier S. 1991; A controlled study of caudal epidural injections of triamcinelone plus procaine for the management of intractable sciatica. Spine 5 (16) 572-575
  PubMedGoogle Scholar
• 23 Boscainos PJ, Sapkas G, Stilianessi E et al. 2003; Greek versions of the Oswestry and Roland-Morris Disability Questionnaires. Clin Orthop Relat Res 411: 40-53
  CrossrefPubMedGoogle Scholar
• 24 Quintero N, Laffont I, Bouhmidi L et al. 2006; [Transforaminal epidural steroid injection and paraplegia: case report and bibliographic review]. Ann Readapt Med Phys 49 (5) 242-247
  CrossrefPubMedGoogle Scholar
• 25 Tsui BC, Tarkkila P, Gupta S et al. 1999; Confirmation of caudal needle placement using nerve stimulation. Anesthesiology 91 (2) 374-378
  CrossrefPubMedGoogle Scholar
• 26 Stitz MY, Sommer HM. 1999; Accuracy of blind versus fluoroscopically guided caudal epidural injection. Spine 24 (13) 1371-1376
  CrossrefPubMedGoogle Scholar
• 27 Eastwood D, Williams C, Buchan I. 1998; Caudal epidurals: the whoosh test. Anaesthesia 53 (3) 305-307
  CrossrefPubMedGoogle Scholar
• 1 Weinstein JN, Tosteson TD, Lurie JD et al. 2006; Surgical vs nonoperative treatment for lumbar disc herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA 296: 2441-2450
  CrossrefPubMedGoogle Scholar