1
|
Lee DY, Park Y, Song JH, Ahn J, Cho KH, Kim S. Combined Ultrasound and Fluoroscopy versus Ultrasound versus Fluoroscopy-Guided Caudal Epidural Steroid Injection for the Treatment of Unilateral Lower Lumbar Radicular Pain: A Retrospective Comparative Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:809. [PMID: 38792992 PMCID: PMC11123251 DOI: 10.3390/medicina60050809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/07/2024] [Accepted: 05/11/2024] [Indexed: 05/26/2024]
Abstract
Background and Objectives: This study aimed to evaluate the mid-term effectiveness and safety of a combined ultrasound (US) and fluoroscopy (FL)-guided approach in comparison to US-guided and FL-guided caudal epidural steroid injections (CESI) for treating unilateral lower lumbar radicular pain. Materials and Methods: A total of 154 patients who underwent CESI between 2018 and 2022 were included. Patients were categorized into three groups based on the guidance method: combined US and FL (n = 51), US-guided (n = 51), and FL-guided (n = 52). The study design was retrospective case-controlled, utilizing patient charts and standardized forms to assess clinical outcomes, adverse events, complications during the procedures. Results: In all groups, Oswestry Disability Index and Verbal Numeric Scale scores improved at 1, 3, and 6 months after the last injection, with no significant differences between groups (p < 0.05). The treatment success rate at all time points was also similar among the groups. Logistic regression analysis showed that injection method, cause, sex, age, number of injections, and pain duration did not independently predict treatment success. Blood was aspirated before injection in 2% (n = 1), 13.5% (n = 7), and 4% (n = 2) of patients in the combined US and FL groups, FL-guided groups, and US-guided groups, respectively. Intravascular contrast spread was detected in one patient in the combined method groups and seven in the FL-guided groups. Conclusions: When comparing pain reduction and functional improvement, there was no significant difference between the three methods. The combined method took less time compared to using FL alone. The combined approach also showed a lower occurrence of intravascular injection compared to using FL alone. Moreover, blood vessels at the injection site can be identified with an ultrasound using the combined method. Given these advantages, it might be advisable to prioritize the combined US- and FL-guided therapy when administering CESI for patients with unilateral lumbar radicular pain.
Collapse
Affiliation(s)
| | - Yongbum Park
- Department of Rehabilitation Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul 01757, Republic of Korea; (D.y.L.); (J.A.); (K.H.C.); (S.K.)
| | - Jun Hyeong Song
- Department of Rehabilitation Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul 01757, Republic of Korea; (D.y.L.); (J.A.); (K.H.C.); (S.K.)
| | | | | | | |
Collapse
|
2
|
Sivakumar RK, Karmakar MK. Spinal sonography and central neuraxial blocks. Best Pract Res Clin Anaesthesiol 2023; 37:209-242. [PMID: 37321768 DOI: 10.1016/j.bpa.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/18/2023] [Accepted: 04/20/2023] [Indexed: 06/17/2023]
Abstract
Central neuraxial blocks (CNBs), which include spinal, epidural, and combined spinal epidural injections, are indispensable techniques in the anesthesiologist's armamentarium. Indeed, in scenarios such as when dealing with the obstetric population, patients with obesity, or patients having respiratory compromise (e.g., lung disease or scoliosis), CNBs are the mainstay for anesthesia and/or analgesia. Traditionally, CNBs are performed using anatomical landmarks, which are simple, easy to master, and exceptionally successful in most cases. Nevertheless, there are notable limitations with this approach, especially in scenarios where CNBs are considered mandatory and vital. Any limitation of an anatomic landmark-based approach is an opportunity for an ultrasound-guided (USG) technique. This has become particularly true for CNBs, where recent advances in ultrasound technology and research data have addressed many of the shortcomings of the traditional anatomic landmark-based approaches. This article reviews the ultrasound imaging of the lumbosacral spine and its application for CNBs.
Collapse
Affiliation(s)
- Ranjith Kumar Sivakumar
- Department of Anaesthesia and Intensive Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, China.
| | - Manoj Kumar Karmakar
- Department of Anaesthesia and Intensive Care, Faculty of Medicine, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, SAR, China.
| |
Collapse
|
3
|
Zhang P, Chang H, Yang T, Fu Y, He X, Li J, Yang M, Wang R, Li X. Study on MEV90 of 0.5% ropivacaine for US-guided caudal epidural block in anorectal surgery. Front Med (Lausanne) 2023; 9:1077478. [PMID: 36743672 PMCID: PMC9892538 DOI: 10.3389/fmed.2022.1077478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 12/27/2022] [Indexed: 01/20/2023] Open
Abstract
Background Choosing the appropriate concentration and volume of anesthetics is critical for a successful nerve block. The current study aimed to determine the minimum effective volume (MEV) of 0.5% ropivacaine for US-guided CEB in 90% of patients (MEV90) undergoing anorectal surgery. The aims were to reduce the occurrence of complications associated with a sacral blockade in anorectal surgery, broaden the indications for surgical procedures and treatment, and improve patient satisfaction. This study presents the groundwork for the development of individualized anesthetic programs. We believe that the study would serve as a reference for the use of caudal epidural block (CEB) in lower abdominal surgery for intraoperative and postoperative analgesia. Methods This study used a biased coin design (BCD) up-and-down method (UDM). We divided the participants into two groups based on gender, and each group independently performed the biased coin design up-and-down method. We used 0.5% ropivacaine for the first patient in each group; however, the volume was 10 ml for men and 8 ml for women. Therefore, the dose of anesthetics given to each patient was determined by the response of the previous patient. If the block of the previous patient failed, the volume was increased by 2 ml in the following patient. Otherwise, the next subject had an 11% chance of receiving a volume of 2 ml less or an 89% chance of receiving no volume change. We defined a successful block as painless surgery with anal sphincter relaxation 15 min after the drug injection. Enrollment was completed after 45 successful caudal blocks for each group. Results Caudal epidural block was successfully performed on 50 men and 49 women. The MEV90 of ropivacaine for CEB was calculated to be 12.88 ml (95% CI: 10.8-14 ml) for men and 10.73 ml (95% CI: 9.67-12 ml) for women. Men had a MEV99 of 13.88 ml (95% CI: 12.97-14 ml), and women had a MEV99 of 11.87 ml (95% CI: 11.72-12 ml). Conclusion With operability and general applicability, it is possible to increase the success rate of CEB for anorectal surgery to 99% as well as decrease the incidence of anesthesia-related complications. CEB can meet the needs of patients for rapid postoperative rehabilitation, improve patient satisfaction, and lay a solid foundation for postoperative analgesia.
Collapse
Affiliation(s)
- Pei Zhang
- Department of Anesthesiology, Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Hong Chang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China,West China School of Nursing, Sichuan University, Chengdu, China,Chengdu Shang Jin Nan Fu Hospital, Chengdu, China
| | - Taoran Yang
- Department of Anesthesiology, Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yalong Fu
- Department of Anus Intestine, Karamay People's Hospital, Xinjiang, China
| | - Xuemei He
- Department of Anesthesiology, Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Jun Li
- Department of Anesthesiology, Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Mingan Yang
- Division of Biostatistics and Epidemiology, School of Public Health, San Diego State University, San Diego, CA, United States
| | - Rurong Wang
- Department of Anesthesiology, Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China,Chengdu Shang Jin Nan Fu Hospital, Chengdu, China,Rurong Wang ✉
| | - Xuehan Li
- Department of Anesthesiology, Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China,*Correspondence: Xuehan Li ✉
| |
Collapse
|
4
|
Xu L, Zhang P, Long W, Wang R, Li X. Comparison of Patient-Controlled Caudal Epidural Analgesia and Patient-Controlled Intravenous Analgesia After Perianal Surgery: A Randomized Controlled Trial. Pain Ther 2022; 11:1025-1035. [PMID: 35794433 PMCID: PMC9314497 DOI: 10.1007/s40122-022-00411-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/16/2022] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION This study aimed to compare the efficacy between patient-controlled caudal epidural analgesia (PCCA) and patient-controlled intravenous analgesia (PCIA) after perianal surgery, to provide a feasible solution to postoperative pain. METHODS This was a prospective, randomized controlled trial comprising 100 patients who underwent caudal epidural block on perianal surgery at Chengdu Shang Jin Nan Fu Hospital of West China Hospital at Sichuan University between April and August 2020. Patients were randomly divided into the PCCA and PCIA groups. Visual analog scale (VAS) scores were recorded at 2, 4, 6, 24, 48, and 72 h after surgery, and at the first dressing change and first defecation. The lower limb mobility in the post-anesthetic recovery room (PACU) was determined. The analgesic effect, usage amount of patient-controlled analgesia (PCA), usage amount and frequency of remedial analgesic measures, number of individuals who must be catheterized, and incidence of adverse reactions were recorded. Satisfaction of postoperative analgesic effect and convenience of PCA were also assessed. RESULTS The patients in the PCCA group had significantly lower VAS scores at 4, 6, 24, 48, 72 h, the first dressing change, and the first defecation compared with the PCIA group. There were more patients receiving postoperative remedial analgesics in the PCIA group than in the PCCA group. The outcome of the number of PCA and catheterization rates did not differ significantly between the groups. There were two cases of sensory numbness below the S3 plane. The major postoperative complications in the PCIA group were pruritus (3/47, 6.4%), nausea, and vomiting (6/47, 12.8%) (one case combined with pruritus). Patients in the PCCA group were more satisfied with the analgesic effect, while those in the PCIA group were more satisfied with the convenience. CONCLUSION In the postoperative analgesia program of perianal surgery, PCCA may provide a better analgesic effect without increasing the incidence of complications. TRIAL REGISTRATION Chinese Clinical Trial Registry identifier, ChiCTR2000038425, September 2020, retrospectively registered.
Collapse
Affiliation(s)
- Le Xu
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Pei Zhang
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Wei Long
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Rurong Wang
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Xuehan Li
- Department of Anesthesiology, Laboratory of Anesthesia and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
| |
Collapse
|
5
|
Chen S, Wei A, Min J, Li L, Zhang Y. Comparison of Ultrasound-Guided Caudal Epidural Blocks and Spinal Anesthesia for Anorectal Surgery: A Randomized Controlled Trial. Pain Ther 2022; 11:713-721. [PMID: 35501468 PMCID: PMC9098778 DOI: 10.1007/s40122-022-00389-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/08/2022] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION The aim of this study is to observe the effect of spinal anesthesia (SA) and ultrasound-guided caudal epidural blocks (CEB) on perioperative satisfaction in patients undergoing anorectal surgery. METHODS A group of 106 patients were randomly allocated to receive either SA (the SA group) or CEB (the CEB group), and 11 patients were excluded. Finally, 95 patients were left, with 48 in the SA group and 47 in the CEB group for data analysis. The primary endpoint was patient satisfaction with the quality of their anesthetic technique. The secondary outcome measures included postoperative pain at 2, 4, 8, 16, 24, and 48 h after surgery at rest, time to first analgesic request, analgesia requirements, incidence of phantom limb syndrome (PLS), time until return of bowel function, time to ambulation, incidence of postoperative nausea and vomiting (PONV), intraoperative mean arterial pressure (MAP) reduction > 20% from baseline, and surgeon satisfaction. RESULTS A significantly lower proportion of patients in the SA group was highly satisfied with the quality of their anesthetic technique compared with the CEB group (20.8% versus 68.1%). NRS scores at rest were significantly lower at 4, 8, 16, and 24 h after surgery in the CEB group compared with the SA group. The time to first analgesic request was significantly earlier for patients in the SA group compared with patients in the CEB group. Analgesia requirements, the incidence of PLS, the incidence of PONV, and intraoperative MAP reduction > 20% from baseline were significantly decreased in the CEB group. There were no significant differences between the groups in time until return of bowel function, surgeon satisfaction, or time to ambulation. CONCLUSIONS Ultrasound-guided caudal epidural blocks have higher patient satisfaction compared with spinal anesthesia. TRIAL REGISTRATION This study was registered in the Chinese Clinical Trial Registry (ChiCTR 2000041026) on 06/12/2020.
Collapse
Affiliation(s)
- Shibiao Chen
- Department of Anesthesiology, First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, China
| | - Aiping Wei
- Department of Anesthesiology, First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, China
| | - Jia Min
- Department of Anesthesiology, First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, China
| | - Lei Li
- Department of Anesthesiology, First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, China
| | - Yang Zhang
- Department of Anesthesiology, First Affiliated Hospital of Nanchang University, 17 Yong Wai Zheng Street, Nanchang, 330006, Jiangxi, China.
| |
Collapse
|
6
|
Klunklin K, Sangsin A, Leerapun T. Efficacy and safety of ultrasound-guided caudal epidural steroid injection in patients with low back pain and sciatica. J Back Musculoskelet Rehabil 2022; 35:317-322. [PMID: 34366319 DOI: 10.3233/bmr-200224] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND 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 (p< 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 (p< 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.
Collapse
|
7
|
Li X, Li J, Zhang P, Deng H, Yang M, He H, Wang R. The minimum effective concentration (MEC90) of ropivacaine for ultrasound-guided caudal block in anorectal surgery. A dose finding study. PLoS One 2021; 16:e0257283. [PMID: 34534232 PMCID: PMC8448308 DOI: 10.1371/journal.pone.0257283] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 07/13/2021] [Indexed: 02/05/2023] Open
Abstract
Background Caudal epidural block (CEB) provides reliable anesthesia for adults undergoing anorectal surgery. Despite the widely utilization, the minimum effective concentration for 90% patients (MEC90) of ropivacaine for CEB remains unknown. Objective To estimate MEC of ropivacaine for CEB in anorectal surgery. Design A prospective dose-finding study using biased coin design up-and-down sequential method. Setting Operating room and postoperative recovery area of Chengdu Shangjin Nanfu Hospital, from October 2019 to January 2020. Patients 50 males and 51 females scheduled for anorectal surgery. Interventions We conducted two independent biased coin design up-and down trials by genders. The concentration of ropivacaine administered to the first patient of male and female were 0.25% with fixed volume of 14ml for male and 12ml for female patients based on our previous study. In case of failure, the concentration was increased by 0.05% in the next subject. Otherwise, the next subject was randomized to a concentration 0.05% less with a probability of 0.11, or the same concentration with a probability of 0.89. Success was defined as complete sensory blockade of perineal area 15 min after the block evidenced by the presence of a lax anal sphincter and pain-free surgery. Main outcome measures The MEC of ropivacaine to achieve a successful CEB in 90%(MEC90) of the patients. Results The MEC90 of ropivacaine for CEB were estimated to be 0.35% (95% CI 0.29 to 0.4%) for male and 0.353% (95%CI 0.22 to 0.4%) for female. By extrapolation to MEC in 99% of subjects (MEC99) and pooled adjacent violators algorithm (PAVA) adjusted responses, it would be optimal to choose 0.4% ropivacaine with a volume of 14ml for male and 12ml for female. Conclusions A concentration of 0.35% ropivacaine with a volume of 14ml provided a successful CEB in 90% of the male patients, while 0.353% ropivacaine with a volume of 12ml provided a successful CEB in 90% of the female patients. A concentration of 0.4% and a volume of 14ml for male and 12 ml for female would be successful in 99% of the patients. Trial registration Chictr.org.cn identifier: No. ChiCTR 1900024315.
Collapse
Affiliation(s)
- Xuehan Li
- Department of Anesthesiology, and Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Jun Li
- Department of Anesthesiology, and Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Pei Zhang
- Department of Anesthesiology, and Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Huifei Deng
- Department of Anesthesiology, and Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Mingan Yang
- Division of Biostatistics & Epidemiology, School of Public Health, San Diego State University, San Diego, CA, United States of America
| | - Hongbo He
- Benign Coloproctological Diseases Center, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Rurong Wang
- Department of Anesthesiology, and Laboratory of Anesthesia and Intensive Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, China
- * E-mail:
| |
Collapse
|
8
|
Jain A, Barasker SK, Jain S, Waindeskar V. Correlation of correct needle placement in caudal epidural space and anatomical structures of sacral canal in paediatric patients: An observational study. Indian J Anaesth 2021; 65:S74-S79. [PMID: 34188259 PMCID: PMC8191192 DOI: 10.4103/ija.ija_1599_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/15/2021] [Accepted: 03/18/2021] [Indexed: 12/23/2022] Open
Abstract
Background and Aims: Caudal epidural block (CEB) is commonly performed using surface landmark-based technique in the paediatric patients, with a good success rate. Failure to perform CEB is usually attributable to anatomic variations. The aim of this study was to perform measurements of the anatomical landmarks that are generally used to perform CEB and find a relation between these measurements and successful needle placement. Methods: This was an observational study that included 114 patients, aged up to 15 years. Ultrasonography (USG) scan of the sacrococcygeal region with measurement of cornu height, skin to cornu distance, inter-cornu distance (ICD), vertical and oblique size of hiatus were done. Needle placement for CEB was done using the usual palpatory hiatal approach. Needle position was checked by using ultrasound. Spearman correlation coefficient and multi-variate logistic regression were used for measuring the correlation and predictors of correct needle placement, respectively. Results: Correct placement of needle was found in 84% patients. Statistically significant correlation was found between all the anatomical parameters. Regression analysis revealed that only ICD had a statistically significant contribution (OR1.67, 95% CI 1.024–2.7; P = 0.04) in predicting an incorrect needle placement. If ICD was less than 12.5 mm, it predicted a difficult needle placement; all the children were less than 1.5 years in age; AUC was 77%, P = 0.001, sensitivity 83% and specificity 76.5%. Conclusion: ICD can be used as predictor of difficult needle placement for CEB. USG guidance may be of help while performing CEB in children less than 1.5 years.
Collapse
Affiliation(s)
- Anuj Jain
- Department of Anaesthesiology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Swapnil K Barasker
- Department of Anaesthesiology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Suruchi Jain
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Vaishali Waindeskar
- Department of Anaesthesiology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| |
Collapse
|
9
|
Bessar AAA, Arnaout MM, Basha MAA, Shaker SE, Elsayed AE, Bessar MA. Computed tomography versus fluoroscopic guided-sacroiliac joint injection: a prospective comparative study. Insights Imaging 2021; 12:38. [PMID: 33738560 PMCID: PMC7973316 DOI: 10.1186/s13244-021-00982-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/03/2021] [Indexed: 12/28/2022] Open
Abstract
Background There are limited data discussing long-term pain relief and comparability of different image-guided sacroiliac joint (SIJ) injection. This study compared CT and fluoroscopic-guided SIJ injections regarding statistically and clinically significant differences in numeric pain reduction, radiation doses, and patient’s satisfaction. Methods A prospective study conducted on 52 patients who met specific inclusion criteria of SIJ pain. A mixture of 1 ml of 40 mg methylprednisolone acetate diluted in 2 ml of lidocaine 2% was injected under either CT or fluoroscopic guidance. Numeric rating score (NRS) and Oswestry disability index (ODI) were assessed and recorded for each patient before procedure and one-week, and one-, three-, six-, and 12-months after procedure. The results were compared between both groups. Results Analysis of NRS one-month post-procedure showed a significant decrease from baseline in both groups: 12.5% in CT group (p = 0.002) and 9.5% in fluoroscopic group (p = 0.006). No significant difference in NRS between two groups at one- and three-months post-procedure (p = 0.11 and 0.1, respectively). There was a significant difference in NRS between two groups at six- and 12-months post-procedure (p = 0.001 and < 0.0001, respectively). Comparison of ODI at six-month post-procedure revealed that both groups had a statistically significant improvement (p < 0.0001). There was a significant difference in ODI between two groups at six-months post-procedure (p = 0.01). Conclusions CT-guided SIJ injection compares favorably with fluoroscopic guidance and offers statistically and clinically significant long-term pain relief. The use of dose reduction protocol in CT is important for decreasing the radiation dose.
Collapse
Affiliation(s)
- Ahmed A A Bessar
- Department of Radiodiagnosis, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt.
| | - Mohamed M Arnaout
- Department of Neurosurgery, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | | | - Shady E Shaker
- Department of Internal Medicine, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Ashraf E Elsayed
- Department of Anesthesia, Surgical Intensive Care and Pain Medicine, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Manar Awad Bessar
- Department of Radiodiagnosis, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| |
Collapse
|
10
|
Park SJ, Yoon KB, Shin DA, Kim K, Kim TL, Kim SH. Influence of needle-insertion depth on epidural spread and clinical outcomes in caudal epidural injections: a randomized clinical trial. J Pain Res 2018; 11:2961-2967. [PMID: 30538535 PMCID: PMC6255053 DOI: 10.2147/jpr.s182227] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background A caudal epidural steroid injection (CESI) is a commonly used method to improve symptoms of lumbosacral pain. We compared the achievement of successful epidurograms and patient-reported clinical outcomes following different needle-insertion depths during CESI. Methods For the conventional method group, the needle was advanced into the sacral canal. For the alternative method group, the needle was positioned immediately after penetration of the sacrococcygeal ligament. Epidural filling patterns and vascular uptake during fluoroscopy were determined to verify successful epidural injection. Procedural pain scores were investigated immediately after the procedure. Pain scores and patient global impression of symptom change were evaluated at 1-month follow-up. Results Assessments were completed by 127 patients (conventional method, n=64; alternative method, n=63). The incidence of intravascular injection was significantly lower in the alternative method group than in the conventional method group (3.2% vs 20.3%, P=0.005). Procedural pain during needle insertion was significantly lower in the alternative method group (3.7±1.3 vs 5.3±1.2, P<0.001). Epidural contrast filling patterns were similar in both groups. One-month follow-up pain scores and patient global impression of symptom change were comparable in both groups. Conclusion Compared with the conventional method, the alternative method for CESI could achieve similar epidural spread and symptom improvement. The alternative technique exhibited clinical benefits of a lower rate of intravascular injection and less procedural pain.
Collapse
Affiliation(s)
- Sang Jun Park
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea, .,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea,
| | - Kyung Bong Yoon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea, .,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea,
| | - Dong Ah Shin
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kiwook Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea,
| | - Tae Lim Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea,
| | - Shin Hyung Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea, .,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea,
| |
Collapse
|
11
|
Oh S, Chung K, Bang S, Kim SY, Kwon W. Alternative way to find sacral hiatus for blind caudal block - Based on 3D pelvis CT anthropometry: A retrospective study. Med Hypotheses 2018; 121:70-73. [PMID: 30396497 DOI: 10.1016/j.mehy.2018.09.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 09/07/2018] [Accepted: 09/12/2018] [Indexed: 12/27/2022]
Abstract
The aim of this study is to develop an alternative way to locate the sacral hiatus for blind caudal block from the anthropometrical data measured on 3D pelvic CT. The intersection of the line connecting two sacral cornua and the midline is considered the ideal point (IP) for caudal block. The mean length from the coccyx tip to the IP was measured using 3D pelvic CT images in 30 men and 30 women and was 6.5 cm and 6.0 cm, respectively. For the conventional method group, we used the conventional equilateral triangle method to find the sacral hiatus, which was named conventional method group needling point (CNP). For the experimental method group, the point 6.5 cm or 6.0 cm (mean length from the coccyx tip to the IP) away from the coccyx tip was called the experimental method group needling point (ENP). Drawing the three points of the IP, CNP, and ENP on the same patient's 3D pelvic CT, we compared the distance from the IP to the CNP with the distance from the IP to the ENP. We propose that the experimental method is comparable to the conventional method in locating the sacral hiatus, which is crucial for a successful caudal block procedure. Anthropometric measurements and virtual comparative test between two methods were done on the 3D pelvis CT. In men, the distance from the CNP to the IP was 0.8 ± 0.5 cm in the conventional method group, while the distance from the ENP to the IP was 0.5 ± 0.4 cm in the experimental method group (p < 0.05). In women, the same distances were 1.5 ± 0.8 cm and 0.7 ± 0.3 cm, respectively (p < 0.05). In conclusion, finding a point of 6.5 cm from the coccyx tip in men and 6.0 cm in women could be an alternative way to find the sacral hiatus for blind caudal block.
Collapse
Affiliation(s)
- Saechol Oh
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyudon Chung
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seunguk Bang
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seo Yeong Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Woojin Kwon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| |
Collapse
|
12
|
Koo BS, Kang WB, Park JW, Lee SJ, Lee MS, Cho AN, Chung YH, Lee JH, Kim YI, Chae WS. Analysis of caudal epidurogram in single center: A preliminary study of lumbar radiculopathy management. Medicine (Baltimore) 2018; 97:e12810. [PMID: 30313112 PMCID: PMC6203536 DOI: 10.1097/md.0000000000012810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
A caudal epidural block involves placing a needle through the sacral hiatus and delivering medication into the epidural space. The procedure is safe and simple, but failure rates can be as high as 25%. The purpose of this study was to investigate the success rate of caudal epidural block by analyzing needle placement and dye flow pattern.We retrospectively analyzed the medical records of patients who underwent caudal epidural block under spinal stenosis. A case was defined as a failure if it met at least one of the following four criteria: the epidural needle was not placed correctly inside the caudal canal; blood regurgitation or aspiration in the needle was observed; the contrast dye was injected into a blood vessel; or a large amount of the dye leaked into the sacral foramen or did not reach the L5-S1 level.At least 1 failure criterion was observed in 14 cases (17.7%), while none of the failure criteria were satisfied in 65 successful cases (82.3%).No matter how experienced the anesthesiologist may be, delivery of adequate therapeutic agent is not achieved in approximately 20% of cases. Therefore, we recommend fluoroscopy-guided needle placement and confirmation by radio-contrast epidurograpy as the best choice.
Collapse
|
13
|
Snider KT, Redman CL, Edwards CR, Bhatia S, Kondrashova T. Ultrasonographic Evaluation of the Effect of Osteopathic Manipulative Treatment on Sacral Base Asymmetry. J Osteopath Med 2018; 118:159-169. [DOI: 10.7556/jaoa.2018.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Abstract
Context
Patients with low back pain (LBP) may receive osteopathic manipulative treatment (OMT) to resolve or manage their pain. The indication for OMT for patients with LBP is the presence of somatic dysfunction, diagnosed using palpatory examination. Because palpatory findings commonly have poor interexaminer reliability, the current study used ultrasonography (US) to establish pre-OMT and post-OMT musculoskeletal measurements of relative asymmetry between pelvic and sacral bony landmarks.
Objective
To document objective musculoskeletal changes that occur in response to OMT using US and to compare palpatory assessment of landmark asymmetry with US assessment.
Methods
Sixty men and women aged 20 to 55 years with at least 1 episode of LBP in the past 2 weeks were assigned to a seated control, walking control, or OMT group (20 participants per group). Participants received an initial, bilateral US measurement of the skin to posterior superior iliac spine (SPSIS), skin to sacral base position (SBP), and sacral sulcus depth (SSD). Participants in seated control and OMT groups received a palpatory assessment of SBP and SSD prior to initial US assessment. After assessment, the seated control group sat in a waiting room for 30 minutes, the walking control group walked for 5 minutes, and the OMT group received OMT to address sacral base asymmetry using predominantly direct techniques for a maximum of 20 minutes. Participants then received a second US assessment of the same structures.
Results
Body mass index (BMI) was correlated with SPSIS (r=0.5, P=.001) and SBP (r=0.6, P<.001). More participants in seated control (75%) and OMT (65%) groups had an increase in asymmetry from first to second US assessment for SPSIS compared with participants in the walking control group (35%, P=.05). No significant differences were found between groups for absolute asymmetry or total change in asymmetry (all P>.10). The κ was −0.1 (95% CI, −0.2 to 0.03) for SBP and −0.01 (95% CI, −0.1 to 0.1) for SSD.
Conclusion
Musculoskeletal changes in SPSIS and SBP measurements related to OMT could not be readily identified using US. The SPSIS and SBP measurements were dependent on BMI, which may have affected the accuracy of US to detect small changes in asymmetry. Qualitative palpatory assessments did not correlate with US measurements. Further study is needed to identify US measurements that demonstrate change with OMT. (ClinicalTrials.gov number NCT02820701)
Collapse
|
14
|
Caudal Epidural Block: An Updated Review of Anatomy and Techniques. BIOMED RESEARCH INTERNATIONAL 2017; 2017:9217145. [PMID: 28337460 PMCID: PMC5346404 DOI: 10.1155/2017/9217145] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 12/17/2016] [Accepted: 02/07/2017] [Indexed: 12/26/2022]
Abstract
Caudal epidural block is a commonly used technique for surgical anesthesia in children and chronic pain management in adults. It is performed by inserting a needle through the sacral hiatus to gain entrance into the sacral epidural space. Using conventional blind technique, the failure rate of caudal epidural block in adults is high even in experienced hands. This high failure rate could be attributed to anatomic variations that make locating sacral hiatus difficult. With the advent of fluoroscopy and ultrasound in guiding needle placement, the success rate of caudal epidural block has been markedly improved. Although fluoroscopy is still considered the gold standard when performing caudal epidural injection, ultrasonography has been demonstrated to be highly effective in accurately guiding the needle entering the caudal epidural space and produce comparative treatment outcome as fluoroscopy. Except intravascular and intrathecal injection, ultrasonography could be as effective as fluoroscopy in preventing complications during caudal epidural injection. The relevant anatomy and techniques in performing the caudal epidural block will be briefly reviewed in this article.
Collapse
|
15
|
Ultrasonographic Evaluation of Anatomic Variations in the Sacral Hiatus: Implications for Caudal Epidural Injections. Spine (Phila Pa 1976) 2016; 41:E759-E763. [PMID: 27340767 DOI: 10.1097/brs.0000000000001448] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective study OBJECTIVE.: The aim of this study was to evaluate variations in the sacral hiatus based on ultrasonographic images. SUMMARY OF BACKGROUND DATA Caudal epidural injection is commonly used for the treatment of lower back pain, but blind injections commonly lead to mistakes made at the injection site due to anatomic variations in the sacral hiatus. METHODS A total of 339 patients with low back pain or sciatica were studied using a linear-array ultrasound transducer. The transducer was placed at the sacral cornua and the distance between the bilateral cornua and the width of the sacrococcygeal ligament between the bilateral cornua were measured in the transverse view. The transducer was also placed between the two cornua and the distance between the skin and posterior sacral bony surface was measured, including the depth of the subcutaneous fat, in the longitudinal view. The surface distance was then measured from the natal cleft to the apex of the sacral hiatus. RESULTS The mean distance between the bilateral cornua was 18.1 ± 3.2 mm and mean width of the sacrococcygeal ligament was 10.5 ± 2.6 mm. The mean diameter of the sacral canal was 6.8 ± 2.5 mm but 6 of 339 patients (1.8%) found less than 2 mm. The mean surface distance from the natal cleft to the apex of the sacral hiatus was 29.3 ± 12.3 mm. The distance between the sacral hiatus and the natal cleft ranged from -2.0 to 75.0 mm. CONCLUSION We believe that the variations found in the surface distance from the natal cleft to the sacral hiatus are significant for caudal epidural injection. However, the other measurements may also have clinical importance in this area. LEVEL OF EVIDENCE 3.
Collapse
|
16
|
Maniquis Smigel L, Dean Reeves K, Jeffrey Rosen H, Patrick Rabago D. Vertical Small-Needle Caudal Epidural Injection Technique. Anesth Pain Med 2016; 6:e35340. [PMID: 27826539 PMCID: PMC5097855 DOI: 10.5812/aapm.35340] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/13/2016] [Accepted: 03/02/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Anecdotal evidence suggests that a vertical small-needle injection method enters the caudal epidural space with comparable efficacy to cephalad-directed methods, with less intravascular injection. OBJECTIVES Assess the success rate of vertical caudal epidural injection using epidurography and the frequency of intravascular injection using a vertical small-needle approach. PATIENTS AND METHODS Participants had chronic generalized non-surgical low back pain and either gluteal and/or leg pain and were enrolled in a simultaneous clinical trial assessing the analgesic effect of 5% dextrose epidural injection. A 25 gauge 3.7 cm hypodermic needle was placed at the sacral hiatus using a fingertip-guided vertical technique without imaging assistance, followed by fluoroscopic epidurography. Minimal needle redirection was allowed up to 10 degrees from the vertical plane if the initial epidurogram showed an extradural pattern, followed by repeat epidurography. RESULTS First needle placement without imaging resulted in blood return in 1/199 participants and positive epidurography in 179/199 (90%). Minimal needle repositioning resulted in a positive epidurogram in the remaining 19 attempts. No intravascular injection patterns were observed. CONCLUSIONS This compares favorably to published success rates of fluoroscopically-guided technique and was well tolerated. Vertical caudal epidural injection may be suitable for combination with ultrasound-guided methods with Doppler flow monitoring.
Collapse
Affiliation(s)
| | - Kenneth Dean Reeves
- Private Practice PM&R and Pain Management, Roeland Park, Kansas, USA
- Past Clinical Assistant/Associate Professor, Department of Physical Medicine and Rehabilitation, University of Kansas Medical Center, Kansas City, Kansas, USA
- Corresponding author: Kenneth Dean Reeves, Private Practice PM&R and Pain Management, Roeland Park, Kansas, USA. Tel: +1-9133621600, Fax: +1-9133624452, E-mail:
| | - Howard Jeffrey Rosen
- Private Practice Anesthesiology and Pain Management Anaheim and Monterey, California, USA
| | - David Patrick Rabago
- Department of Family Medicine and Community Health, University of Wisconsin, School of Medicine and Public Health, Madison, USA
| |
Collapse
|
17
|
Park KD, Kim TK, Lee WY, Ahn J, Koh SH, Park Y. 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. [PMID: 26683948 PMCID: PMC5058920 DOI: 10.1097/md.0000000000002261] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of the article is to investigate the efficacy of ultrasound (US)-guided Caudal Epidural Steroid Injection (CESI) compared with fluoroscopy (FL)-guided CESI in patients with unilateral lower lumbar radicular pain. This case-controlled, retrospective, comparative study was done at the university hospital. A total of 110 patients treated with US- or FL-guided CESI were administered a mixture of 20 cc (0.5% lidocaine 18.0 mL + dexamethason 10 mg 2 mL). Outcome measurement was assessed by Oswestry Disability Index (ODI), verbal numeric pain scale (VNS) before injections and at 3, 6, and 12 months after the last injections. Successful outcome was defined as measured by >50% improvement in the VNS score and >40% improvement in the ODI. ODI and VNS showed improvement at 3, 6, and 12 months after the last injection in both groups. No statistical differences in ODI, VNS were observed between groups (P < 0.05). No significant differences in the proportion of patients with successful treatment were observed between the groups from the 3-month to 6-month to 12-month outcomes. US-guided CESI is deserving of consideration in conservative management of unilateral lower lumbar radicular pain.
Collapse
Affiliation(s)
- Ki Deok Park
- From the Department of Rehabilitation Medicine, Gachon University, Gil Medical Center, Incheon, Korea (KDP); Department of Rehabilitation Medicine, Hanyang University College of Medicine, Seoul, South Korea (TKK); Department of Anesthesiology, Sanggye Paik Hospital, Inje University College of Medicine (WYL); and Department of Rehabilitation Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea (JA, SHK, YP)
| | | | | | | | | | | |
Collapse
|
18
|
Park GY, Kwon DR, Cho HK. Anatomic Differences in the Sacral Hiatus During Caudal Epidural Injection Using Ultrasound Guidance. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:2143-2148. [PMID: 26491092 DOI: 10.7863/ultra.14.12032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 03/03/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES The aim of this study was to clarify differences in the anatomic structure of the sacral hiatus and angle of needle insertion during caudal epidural steroid injection using ultrasound guidance in patients according to sex and age. METHODS A total of 237 patients with low back pain with or without sciatica were included. Sonograms of the sacral hiatus were obtained, and caudal epidural steroid injection using ultrasound guidance was performed in all patients. The intercornual distance, diameter of the sacral canal, thickness of the sacrococcygeal ligament, optimal angle for needle insertion, and actual angle of needle insertion were measured. RESULTS Between men and women, significant differences were observed for the intercornual distance (17.7 versus 16.5 mm; P< .01) and thickness of the sacrococcygeal ligament (4.3 versus 3.9 mm; P = .02). In all patients, the thickness of the sacrococcygeal ligament (r= 0.28) and diameter of the sacral canal (r= 0.40) were positively correlated with the optimal angle for needle insertion (P < .01). In women, the thickness of the sacrococcygeal ligament (r = -0.24), diameter of the sacral canal (r = -0.27), optimal angle for needle insertion (r = -0.29), and actual angle of needle insertion (r = -0.18) were negatively correlated with age. In men, only the diameter of the sacral canal was negatively correlated with age (r = -0.30). CONCLUSIONS We found that the sacral hiatus has anatomic differences between patients of different sexes and ages. Understanding these differences, especially in women, may improve the safety and reliability of caudal epidural steroid injection.
Collapse
Affiliation(s)
- Gi-young Park
- Department of Rehabilitation Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Dong Rak Kwon
- Department of Rehabilitation Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Hee Kyung Cho
- Department of Rehabilitation Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| |
Collapse
|
19
|
Assessment of factors affecting the difficulty of caudal epidural injections in adults using ultrasound. Pain Res Manag 2014; 19:275-9. [PMID: 25111987 PMCID: PMC4197755 DOI: 10.1155/2014/679128] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Caudal epidural block is used to treat pain in the lower back and lower extremities. The procedure can be difficult to perform, particularly when a blind technique is being used. The authors of this study aimed to identify variables affecting the difficulty of caudal epidural blocks performed using a blind technique by measuring relevant anatomical variables using ultrasonography. BACKGROUND: In unaided caudal epidural block (CEB), incorrect needle insertion has been reported to occur in 15% to 38% of attempts. OBJECTIVE: To statistically analyze the anatomical variables affecting difficult CEB using ultrasonographic measurement. METHODS: Preprocedural ultrasonography was performed and the following measurements were obtained in 146 patients: the distance from the skin to the apex of the sacral hiatus; the depth of the sacral canal at the apex of the sacral hiatus; the length of the sacrococcygeal ligament between the apex of the sacral hiatus and sacral base; the distance from the skin to the apex of the sacral cornu; and the distance between the apexes of bilateral cornua. One clinician, unaware of the ultrasonographic findings, performed the injections using the landmark technique. The procedures were videotaped and were subsequently reviewed by an independent investigator. RESULTS: The means (± SDs) of the abovementioned measurements were 12.1±3.7 mm, 6.1±2.1 mm, 25.9±7.4 mm, 10.0±4.0 mm and 16.4±3.2 mm, respectively. Injections failed in 16 (11%) patients and were defined as difficult in 21 (14.4%) patients. The depth of the sacral canal at the apex of sacral hiatus (P<0.001) and the length of the sacrococcygeal ligament between the apex of the sacral hiatus and sacral base (P=0.001) were significant predictors of difficult CEB. Of all patients, 85.7% and 75.2% were correctly classified as difficult or not difficult, respectively. The cutoff values of the depth of the sacral canal at the apex of the sacral hiatus and the length of the sacrococcygeal ligament between the apex of the sacral hiatus and the sacral base to predict a difficult CEB were 3.7 mm and 17.6 mm, respectively. CONCLUSIONS: Both the depth of the sacral canal at the apex of the sacral hiatus and the length of the sacrococcygeal ligament between the apex of the sacral hiatus and sacral base are significant variables affecting the difficulty of the CEB.
Collapse
|
20
|
Nikooseresht M, Hashemi M, Mohajerani SA, Shahandeh F, Agah M. Ultrasound as a screening tool for performing caudal epidural injections. IRANIAN JOURNAL OF RADIOLOGY 2014; 11:e13262. [PMID: 25035698 PMCID: PMC4090639 DOI: 10.5812/iranjradiol.13262] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Revised: 12/13/2013] [Accepted: 02/09/2014] [Indexed: 11/17/2022]
Abstract
Background: The caudal approach to the epidural space has been used for decades to treat low back pain caused by lumbosacral root compression. The use of fluoroscopy during epidural steroid injection is the preferred method for placing the needle more accurately in the sacral hiatus, but it carries the risk of radiation hazard. Objectives: The aim of the study was to assess the anatomical structure of the sacral hiatus and the feasibility of caudal epidural injections under ultrasound guidance. Patients and Methods: Two hundred and forty patients (male = 100, female = 140) with low back pain and sciatica who were candidates for caudal epidural injection were enrolled into this study. Ultrasound images of the sacral hiatus and bilateral cornua were obtained by a real-time linear array ultrasound transducer. The distance between bilateral cornua and the anterior and posterior wall of the sacrum were measured at the base (sacral hiatus). Under the guide of ultrasonography, we defined the injection successful if turbulence of medication fluid was observed in the sacral canal, but correct placement of the needle and injectant was confirmed on fluoroscopic view as the gold standard technique. Results: The epidurogram showed that the injection was successful in 230 of the 240 patients (95.8%). In eight patients, the injection was not in the correct place in the sacral canal. The sacral hiatus could not be identified by ultrasound images in only two patients who had a closed sacral hiatus identified by fluoroscopy. The mean distance of the sacral hiatus was 4.7 ± 1.7 mm and the mean distance between bilateral cornua was 18.0 ± 2.8 mm. The mean duration of the procedure was 10.8 ± 6.8 minutes. No major complication was observed in the next month. Conclusions: In conclusion, ultrasound could be used as a safe, fast and reliable modality to observe the anatomic variation of the sacral hiatus and to perform caudal epidural injections.
Collapse
Affiliation(s)
- Mahshid Nikooseresht
- Department of Anesthesiology, Hamadan University of Medical Sciences, Hamedan, Iran
| | - Masoud Hashemi
- Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Corresponding author: Masoud Hashemi, Department of Anesthesiology, Akhtar Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran, Tel/Fax: +98-2122612252, E-mail:
| | - Seyed Amir Mohajerani
- Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farideh Shahandeh
- Department of Radiology, Akhtar Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahvash Agah
- Department of Anesthesiology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| |
Collapse
|
21
|
Affiliation(s)
- Young Hoon Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea School of Medicine, Seoul, Korea
| |
Collapse
|
22
|
Jee H, Lee JH, Park KD, Ahn J, Park Y. Ultrasound-guided versus fluoroscopy-guided sacroiliac joint intra-articular injections in the noninflammatory sacroiliac joint dysfunction: a prospective, randomized, single-blinded study. Arch Phys Med Rehabil 2013; 95:330-7. [PMID: 24121083 DOI: 10.1016/j.apmr.2013.09.021] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 07/23/2013] [Accepted: 09/17/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To compare the short-term effects and safety of ultrasound (US)-guided sacroiliac joint (SIJ) injections with fluoroscopy (FL)-guided SIJ injections in patients with noninflammatory SIJ dysfunction. DESIGN Prospective, randomized controlled trial. SETTING University hospital. PARTICIPANTS Patients (N=120) with noninflammatory sacroiliac arthritis were enrolled. INTERVENTION All procedures were performed using an FL or US apparatus. Subjects were randomly assigned to either the FL or US group. Immediately after the SIJ injections, fluoroscopy was applied to verify the correct placement of the injected medication and intravascular injections. MAIN OUTCOME MEASURES Treatment effects and functional improvement were compared at 2 and 12 weeks after the procedures. RESULTS The verbal numeric pain scale and Oswestry Disability Index improved at 2 and 12 weeks after the injections without statistical significances between groups. Of 55 US-guided injections, 48 (87.3%) were successful and 7 (12.7%) were missed. The FL-guided SIJ approach exhibited a greater accuracy (98.2%) than the US-guided approach. Vascularization around the SIJ was seen in 34 of 55 patients. Among the 34 patients, 7 had vascularization inside the joint, 23 had vascularization around the joint, and 4 had vascularization both inside and around the joint. Three cases of intravascular injections occurred in the FL group. CONCLUSIONS The US-guided approach may facilitate the identification and avoidance of the critical vessels around or within the SIJ. Function and pain relief significantly improved in both groups without significant differences between groups. The US-guided approach was shown to be as effective as the FL-guided approach in treatment effects. However, diagnostic application in the SIJ may be limited because of the significantly lower accuracy rate (87.3%).
Collapse
Affiliation(s)
- Haemi Jee
- Department of Health & Fitness Management, Namseoul University, Cheonan-Si, Republic of Korea
| | - Ji-Hae Lee
- Department of Radiology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Ki Deok Park
- Department of Rehabilitation Medicine, Gachon University of Medicine and Science, Gil Medical Center, Incheon, Republic of Korea
| | - Jaeki Ahn
- Department of Physical Medicine & Rehabilitation, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea
| | - Yongbum Park
- Department of Physical Medicine & Rehabilitation, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
23
|
Ultrasound Guided Spine Injections: Advancement Over Fluoroscopic Guidance? CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2013. [DOI: 10.1007/s40141-013-0016-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
24
|
Chen CP, Hsu CC, Yeh WL, Lin HC, Hsieh SY, Lin SC, Chen TT, Chen MJ, Tang SF. Optimizing human synovial fluid preparation for two-dimensional gel electrophoresis. Proteome Sci 2011; 9:65. [PMID: 21988904 PMCID: PMC3206423 DOI: 10.1186/1477-5956-9-65] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Accepted: 10/11/2011] [Indexed: 12/20/2022] Open
Abstract
Background Proteome analysis is frequently applied in identifying the proteins or biomarkers in knee synovial fluids (SF) that are associated with osteoarthritis and other arthritic disorders. The 2-dimensional gel electrophoresis (2-DE) is the technique of choice in these studies. Disease biomarkers usually appear in low concentrations and may be masked by high abundant proteins. Therefore, the main aim of this study was to find the most suitable sample preparation method that can optimize the expression of proteins on 2-DE gels that can be used to develop a reference proteome picture for non-osteoarthritic knee synovial fluid samples. Proteome pictures obtained from osteoarthritic knee synovial fluids can then be compared with the reference proteome pictures obtained in this study to assist us in identifying the disease biomarkers more correctly. Results The proteomic tool of 2-DE with immobilized pH gradients was applied in this study. A total of 12 2-DE gel images were constructed from SF samples that were free of osteoarthritis. In these samples, 3 were not treated with any sample preparation methods, 3 were treated with acetone, 3 were treated with 2-DE Clean-Up Kit, and 3 were treated with the combination of acetone and 2-D Clean-Up Kit prior to 2-DE analysis. Gel images were analyzed using the PDQuest Basic 8.0.1 Analytical software. Protein spots that were of interest were excised from the gels and sent for identification by mass spectrometry. Total SF total protein concentration was calculated to be 21.98 ± 0.86 mg/mL. The untreated SF samples were detected to have 456 ± 33 protein spots on 2-DE gel images. Acetone treated SF samples were detected to have 320 ± 28 protein spots, 2-D Clean-Up Kit treated SF samples were detected to have 413 ± 31 protein spots, and the combined treatment method of acetone and 2-D Clean-Up Kit was detected to have 278 ± 26 protein spots 2-DE gel images. SF samples treated with 2-D Clean-Up Kit revealed clearer presentation of the isoforms and increased intensities of the less abundant proteins of haptoglobin, apolipoprotein A-IV, prostaglandin-D synthase, alpha-1B-glycoprotein, and alpha-2-HS-glycoprotein on 2-DE gel images as compared with untreated SF samples and SF samples treated with acetone. Conclusions The acetone precipitation method and the combined treatment effect of acetone and 2-DE Clean-Up Kit are not preferred in preparing SF samples for 2-DE analysis as both protein intensities and numbers decrease significantly. On the other hand, 2-D Clean-Up Kit treated SF samples revealed clearer isoforms and higher intensities for the less abundant proteins of haptoglobin, apolipoprotein A-IV, prostaglandin-D synthase, alpha-1B-glycoprotein, and alpha-2-HS-glycoprotein on 2-DE gels. As a result, it is recommended that SF samples should be treated with protein clean up products such as 2-D Clean-Up Kit first before conducting proteomic research in searching for the relevant biomarkers associated with knee osteoarthritis.
Collapse
Affiliation(s)
- Carl Pc Chen
- Department of Physical Medicine & Rehabilitation Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine, Tao-Yuan County, Taiwan.
| | | | | | | | | | | | | | | | | |
Collapse
|
25
|
|
26
|
Iversen T, Solberg TK, Romner B, Wilsgaard T, Twisk J, Anke A, Nygaard O, Hasvold T, Ingebrigtsen T. Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial. BMJ 2011; 343:d5278. [PMID: 21914755 PMCID: PMC3172149 DOI: 10.1136/bmj.d5278] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To assess the efficacy of caudal epidural steroid or saline injection in chronic lumbar radiculopathy in the short (6 weeks), intermediate (12 weeks), and long term (52 weeks). DESIGN Multicentre, blinded, randomised controlled trial. SETTING Outpatient multidisciplinary back clinics of five Norwegian hospitals. PARTICIPANTS Between October 2005 and February 2009, 461 patients assessed for inclusion (presenting with lumbar radiculopathy >12 weeks). 328 patients excluded for cauda equina syndrome, severe paresis, severe pain, previous spinal injection or surgery, deformity, pregnancy, ongoing breast feeding, warfarin therapy, ongoing treatment with non-steroidal anti-inflammatory drugs, body mass index >30, poorly controlled psychiatric conditions with possible secondary gain, and severe comorbidity. INTERVENTIONS Subcutaneous sham injections of 2 mL 0.9% saline, caudal epidural injections of 30 mL 0.9% saline, and caudal epidural injections of 40 mg triamcinolone acetonide in 29 mL 0.9% saline. Participants received two injections with a two week interval. MAIN OUTCOME MEASURES Primary: Oswestry disability index scores. Secondary: European quality of life measure, visual analogue scale scores for low back pain and for leg pain. RESULTS Power calculations required the inclusion of 41 patients per group. We did not allocate 17 of 133 eligible patients because their symptoms improved before randomisation. All groups improved after the interventions, but we found no statistical or clinical differences between the groups over time. For the sham group (n = 40), estimated change in the Oswestry disability index from the adjusted baseline value was -4.7 (95% confidence intervals -0.6 to -8.8) at 6 weeks, -11.4 (-6.3 to -14.5) at 12 weeks, and -14.3 (-10.0 to -18.7) at 52 weeks. For the epidural saline intervention group (n = 39) compared with the sham group, differences in primary outcome were -0.5 (-6.3 to 5.4) at 6 weeks, 1.4 (-4.5 to 7.2) at 12 weeks, and -1.9 (-8.0 to 4.3) at 52 weeks; for the epidural steroid group (n=37), corresponding differences were -2.9 (-8.7 to 3.0), 4.0 (-1.9 to 9.9), and 1.9 (-4.2 to 8.0). Analysis adjusted for duration of leg pain, back pain, and sick leave did not change this trend. CONCLUSIONS Caudal epidural steroid or saline injections are not recommended for chronic lumbar radiculopathy. Trial registration Current Controlled Trials ISRCTN No 12574253.
Collapse
Affiliation(s)
- Trond Iversen
- Department of Rehabilitation, University Hospital of North Norway, 9038 Tromsø, Norway
| | | | | | | | | | | | | | | | | |
Collapse
|