Treatments were given to participants as assigned. Upon request, or if an emergency situation arose, a patient was unblinded. Based on a patient’s response to prior caudal epi- dural injections and improvement in physical and functional status, repeat caudal epidural injections were performed when increased levels of pain were reported with deteriorating relief below 50%. However, nonresponsive participants were treated with conservative management and were followed without further epidural injections with medical manage- ment, without unblinding. Conservative management with appropriate drug therapy and a therapeutic exercise program were continued as needed, along with work. There were no other interventions. The objective of this study was to inves- tigate the effectiveness of caudal epidural injections with or without steroids in patients with chronic axial low back pain not caused by disc herniation, radiculitis, or facet joint pain.
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The study was designed to evaluate objectively the effective- ness of cervical epidural injections with or without steroids for managing chronic neck and upper extremity pain second- ary to discogenic pain without disc herniation, radiculitis, or facet joint pain. Outcomes measured included NRS, NDI, work status, and opioid intake in terms of morphine equiva- lents, assessed at baseline and at 3, 6, and 12 months follow- ing treatment. The primary outcome was defined as at least 50% pain relief associated with 50% improvement in NDI. The NRS and NDI have been shown to be valid and reliable in patients with mechanical neck pain. 51–55 Opioid intake was
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Cervical and Thoracic Epidural Injections.—The patient is placed prone and the skin is marked 1 to 2 cm from the midline, slightly caudal to the interlaminar gap. The C-arm fluoroscopic axis is angled 10 8 to 15 8 off midline and caudal for this align- ment. After sterile preparation and draping, 1 to 3 mL of 1% to 2% lidocaine is injected subcutaneously for local anesthesia. The skin is then punctured and an epidural needle is advanced to the dorsal midline epidural space (Fig 7). After filming, 2 to 5 mL of steroid is injected. Anesthetic agent is not injected into the cervical epidural space to avoid the risk of respiratory suppres- sion resulting from high cervical anesthesia. We perform virtu- ally all our cervical epidural punctures at the C7 to T1 level. The epidural space above this level is diminutive and associated with higher risk of dural puncture. For lower thoracic injections (T7 to T8 or below), 3 to 5 mL of 1% lidocaine is injected after instillation of the steroid suspension (Fig 8). Postinjection films are then obtained to document dispersal of injectate and to dem- onstrate possible epidural space abnormalities.
Despite multiple publications, there is still significant debate regarding the medical necessity and indications for lumbar epidural injections, either by interlaminar approach, caudal approach, or transforaminal approach. Multiple sys- tematic reviews, guidelines, and other reviews have identified weak indications for epidural injections, namely radicular pain from herniated lumbar intervertebral discs. However, there is a lack of evidence or recommended indications for other conditions. The preliminary report of the current manuscript showed positive results with interlaminar epidu- ral injections. 39 Similarly, the previous results with caudal
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We enrolled and randomized 130 patients. Three patients were excluded from the study population for the final analysis. One patient in the conventional method group was converted to the alternative method group because of difficulty approaching the sacral canal. Two patients from the alternative method group were converted to the conventional method group because the contrast medium was mostly observed at the coccygeal level, and thus had failed to ascend to the cephalad epidural space. Therefore, data from 64 patients in the conventional method group and 63 patients in the alternative method group were analyzed. In 13 patients in the conventional method group and two in the alternative method group, intravascular uptake was observed, and needle repositioning or a second attempt at the epidural injection was subsequently necessary during the procedure. These patients were excluded in the analysis of epidurogram patterns and the clinical outcomes at 1-month follow-up (Figure 1).
The rationale for injecting local anesthetics (LA) is to block sensory signals from the region being injected. Al- though often used for diagnosis—because it should only lead to a temporary blockade—an injection of LA has the potential to decrease sensitization, which is a feature of chronic or persistent pain, thereby possibly prolong- ing the treatment effect of LA beyond its pharmaco- logical duration of action . Historically, many investigators have published on the successful use of epi- dural injections of saline and LA. Cathelin. F, Pasquier and Leri, and Sicard published reports as early as 1901 . Later, Evans (1931) published a successful report using procaine and saline in 22 of 40 patients . Cyriax published multiple manuscripts referring to safe use of epidural injections using only LA and steroids in more than 20,000 cases [17, 18]. In fact, up until the 1950s, the injectate used for epidural injections in sciat- ica consisted of LA and saline. The first recorded use of steroids in epidural space was by Lievre et al. in 1953 . Discovered by Philip Hench in the 1940s , glu- cocorticoids are potent anti-inflammatory agents. Since then, steroids have been injected for nearly every chronic pain indication . In clinical practice, steroids are typ- ically combined with LA, with or without saline . This practice stems from the hope that the addition of steroid can lengthen the treatment effect . For most CNCP conditions (except for evidently inflammatory conditions such as rheumatoid arthritis), there is no evi- dence that CSI are disease-modifying agents . Whether steroids have any direct effect on pain gener- ation or transmission is not clear. There is some experi- mental evidence demonstrating suppression of ectopic discharge in neuromas . Pre-clinical experiments suggest that steroids may reduce neuropathic pain; how- ever, a paradoxical effect of increased pain in some pa- tients has also been shown . Surprisingly, there are few clinical studies that have attempted to elicit the mechanism behind steroid ’ s effect on chronic pain other than as an anti-inflammatory . Thus, the use of ster- oid for interventions in CNCP lacks clear rationale.
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The study was completed at a tertiary referral center in the upper Midwest after institutional review board approval. A retrospective electronic chart and radiology review was completed for patients who received cervical transforaminal epidural injections between 2006 and 2010. All patients receiving epidural injections completed a pre- procedure study form, which included patient demographics, RMDI, and a VNPS: 0, no pain; ⫺ 10, worst pain of life. Pain scores were defined immediately postprocedure in person and at 2 weeks and 2 months postprocedure by a telephone interview. RMDI was defined at 2 weeks and 2 months postprocedure by telephone interview. Pa- tients with unilateral radicular pain who underwent CT-guided epi-
sponse to ESI and spinal stenosis on MR imaging; however, they reported that the disc location and nerve root compression grades were associated with outcomes. Second, we did not localize a likely spinal level to account for each patient’s symptoms in all cases, which would have enabled us to correlate potential imaging findings at a symptomatic level; nevertheless, epidural injections were performed within 1 lumbar spinal level of the worst stenosis in ⬎ 90% of patients, and transforaminal injections were targeted to the most symptomatic level. Third, the statistical power to de- tect interaction effects may be low, despite large sample sizes, due to multiple potential sources of heterogeneity, including pain and disability levels, treatment approaches, and type and dose of cor- ticosteroids. However, small interaction effects are unlikely to
Patients were admitted to the hospital one day before the ESI and were discharged the day after. Each patient underwent multiple trans- foraminal epidural injections for corresponding spinal stenosis lesions. Next, they received caudal epidural injections through the sacral hiatus using the epidural catheter (Abel epidur- al catheter system, GS Medical, South Korea), under C-arm radiographic guidance.
Background: Lumbar spinal stenosis is one of the most common causes of low back pain among older adults and can cause significant disability. Despite its prevalence, treatment of spinal stenosis symptoms remains controversial. Epidural steroid injections are used with increasing frequency as a less invasive, potentially safer, and more cost- effective treatment than surgery. However, there is a lack of data to judge the effectiveness and safety of epidural steroid injections for spinal stenosis. We describe our prospective, double-blind, randomized controlled trial that tests the hypothesis that epidural injections with steroids plus local anesthetic are more effective than epidural injections of local anesthetic alone in improving pain and function among older adults with lumbar spinal stenosis. Methods: We will recruit up to 400 patients with lumbar central canal spinal stenosis from at least 9 clinical sites over 2 years. Patients with spinal instability who require surgical fusion, a history of prior lumbar surgery, or prior epidural steroid injection within the past 6 months are excluded. Participants are randomly assigned to receive either ESI with local anesthetic or the control intervention (epidural injections with local anesthetic alone). Subjects receive up to 2 injections prior to the primary endpoint at 6 weeks, at which time they may choose to crossover to the other intervention.
Despite the successful identification of cases in which vessels were directly visualized at the same time as epidural contrast in our study, we recognize that the cross-sectional nature of CT may impose some limitations as well. For example, purely intravascu- lar injections into vessels that run in the craniocaudal direction (and therefore outside the axial scan plane) would typically be recognized with CTF by the absence of epidural contrast after injection, even if the vessel is not directly seen. However, when simultaneous epidural and intravascular injection occurs involv- ing a vessel oriented in the craniocaudal direction, it is relatively more difficult to recognize, and these injections could potentially be missed in some cases. Nevertheless, our data suggest that the overall rate for detecting intravascular injections, including those that occur concurrently with epidural injections, is not degraded to a major extent by this potential scenario.
Transforaminal epidural injections (TEI) therapy might be the answer as it is postulated to have an anal- gesic and anti-inflammatory effect which can last several days to weeks. Analgesics and/or corticosteroids are de- posited through a transforaminal approach in close proximity of the affected nerve root. Theoretically, this treatment would enable the patient to remain physically active while awaiting spontaneous recovery. Although its use is widespread, some patients experience a beneficial effect while others report no effect at all or only initial pain relief followed by recurrence of pain after several hours, days or weeks [11, 12]. In the Netherlands some hospitals offer TEI as standard care for sciatica but usually only after 14–16 weeks of conservative therapy.
A total of 116 procedures from 110 patients were identified (6 patients each had 2 procedures during the study period). The average age of the patients was 55 years (range, 30 – 88 years). There were 41 men and 69 women. There were no immediate or delayed minor or major complications. Fifty-two percent of in- jections targeted C5– 6 (n ⫽ 60), and 28% targeted C6 –7 (n ⫽ 32), with the remaining 20% spread across C2–3 (n ⫽ 1), C3– 4 (n ⫽ 6), C4 –5 (n ⫽ 15), and C7–T1 (n ⫽ 2). A 2.5-cm, 25-ga needle was used in 105 cases. A 25-ga, 7.5-cm spinal needle was needed for 11 patients: 1 injection to C3– 4, 4 injections to C5– 6, and 6 injec- tions to C6 –7. Forty procedures required ⬎ 3 CT series to place the needle.
A search of the literature revealed one previous case study with a possible association between a single steroid injection and SEL . However, when this previous case study was examined further it became difficult to determine the significance of the increased epidural fat. Tok et al.  found an increase in epidural fat after a single LESI; how- ever, they did not use the measuring classification devel- oped by Borre et al. . The authors did measure the epidural fat in the space ventral to the dural sac and found a 2.3 mm anterior posterior increase . When the im- agines in the Tok et al.  article are measured using the Borre et al.  method the patient in the case study was found to have a grade II SEL and a slightly worse, but still grade II SEL post injection. Since the SEL grade did not change it is difficult to determine if this result demonstrates a clinically significant change. If a significant change was determined to have taken place it would be difficult to rule out a natural progression of the patient ’ s already present grade II SEL.
BACKGROUND AND PURPOSE: Cervical transforaminal epidural steroid injections are commonly performed for temporary pain relief or diagnostic presurgical planning in patients with cervical radiculopathy. Intravascular injection of steroids during the procedure can potentially result in cord infarct, stroke, and even death. CT-ﬂuoroscopy allows excellent anatomic resolution and precise needle positioning. This study sought to determine the safest needle tip position during CT-guided cervical transforaminal epidural steroid injection as determined by the incidence of intravascular injection.
study evaluated the clinical effectiveness of epidural injection in radicular pain; Rados et al. compared the efficacy of deposit- ing the steroid into the lumbar epidural space through transfor- aminal and interlaminar routes. The two studies revealed that long-term (greater than six weeks) pain relief and clinically rel- evant improvement in functional status of significant proportion of the patients followed transforaminal steroid injections. Fur- thermore, reductions in pain scores and enhanced performance of daily activities obtained in the present study are similar to the results of some previous studies. 15–18 Pain relief achieved by
CTFESI was performed by an experienced physician (XZ) in the Pain Management Center of Shanghai Jiao Tong Uni- versity Affiliated Sixth People’s Hospital and took place in the procedure suite under ultrasound and C-arm fluoroscopic guidance. Briefly, patients were placed in the lateral decu- bitus position. The physician stood in front of the patient’s face. After preparation of the skin with antiseptic solution, a linear high-frequency ultrasound probe (6 MHz, S-Nerve; SonoSite, Bothell, WA, USA) was placed transversely on the lateral side of the neck to obtain a transverse axial view. The cervical spinal nerve can be identified between the pos- terior and anterior tubercle in this view (Figure 2A). Then, the probe was rotated vertically to gain a longitudinal view of the spinal nerve: this nerve running through the cervical foramina can be obtained in this image. Further, deep inside the foramina, the epidural membrane was visible as a hyper- echoic line (Figure 2B). Further, with the cervical foramina as the clockwise axis, the probe was rotated until it was parallel to the sternocleidomastoid muscle. Here, the spinal nerve is seen only as a curvature above the cervical foramina (Figure 2C). The puncture needle can then be advanced easily toward the cervical foramina from the anterior to posterior direction using the ultrasound-guided in-plane approach. The needle tip was advanced until it hit the foraminal edge (Figure 2D). After careful aspiration, 1 mL 0.9% NaCl was injected to confirm that the needle tip was in the proper position. After confirmation, 2 mL contrast medium was injected under real-time fluoroscopic guidance. No intravascular injections were observed in any of the procedures. Fluoroscopic images were captured 2 minutes after contrast-medium injection, showing the medium outlining the cervical spinal nerve-end root and spreading into the epidural space without any other
Epidural steroid injection (ESI) with the transforaminal and interlaminar administration of steroids and local anes- thetics is among the more common treatments for patients with refractory PHN. However, its effectiveness is contro- versial. To our knowledge, the only study investigating factors associated with improved ef ﬁ cacy of transforam- inal ESI for PHN reported a symptom duration of <3 months as the only signi ﬁ cant predictor of bene ﬁ t. 18 The speci ﬁ c aims of the present study were to seek other factors associated with the ef ﬁ cacy of ESI in our patient population with PHN and to report our experience for therapeutic success with ESI.
steroid is the well-accepted mechanism; therefore, epidurals performed in spinal locations with dense local arterial flow are most vulnerable to these devastating outcomes. Available case series reports support this theory, as the incidence of severe neurological deficits are disproportionally more com- mon with cervical transforaminal epidural spinal injections than with epidurals performed in areas with less prominent arterial structures. 15 This theory of intra-arterial particulate
Interestingly, our first patient received transforaminal LESI with only limited spread of the injected drugs in the epidural space, developed relatively localized arachnoidi- tis, whereas the second patient, who received interlaminar injection with more diffuse epidural spread and developed arachnoiditis along the entire lumbar spine. This seems to support the possibility that the injected substances served as a causative factor. Lastly, the possibility that arachnoiditis can result from degenerative spine disease (thus, unrelated to the