Vertical Small-Needle Caudal Epidural Injection Technique

Comparison of the Particulate Steroids, Betamethasone and Methylprednisolone, in Caudal Steroid Injection Under Ultrasound Guidance

BACKGROUND

Pain relief in lumbar disc hernias is a challenging condition. This study retrospectively compared particulate steroids, methylprednisolone acetate (mid-term effective), against betamethasone acetate (long-term effective) on ultrasound-guided caudal epidural injection for lumbar disc herniation.

METHODS

A total of 40 patients with L4-5 and/or L5-S1 disc herniation were treated with ultrasound-guided caudal epidural injection between September 2021 and June 2022. Nineteen patients who were given methylprednisolone acetate (group A) as a steroid and a total of 21 patients who were used betamethasone acetate (Group B) were retrospectively collected, and their pain levels and functional improvement were compared retrospectively before, immediately after, and 3 weeks after the injection in terms of the visual analog scale (VAS) and Oswestry Disability Index (ODI) as the efficacy value.

RESULTS

There was no statistically significant difference between the groups regarding age, gender, and body mass index (P > 0.05). In group A, preop VAS was 8.84 ± 0.76, immediate postop period 3.10 ± 1.37, and postop third week was 4.73 ± 2.32. In group B, the preop VAS was 8.76 ± 0.76, the postop early period was 3.14 ± 1.27, and the postop third week was 3.12 ± 1.30. In group A preop ODI was 49.84 ± 9.11 and postop third week was 22.84 ± 6.44. In group B, the preop ODI was 46.71 ± 16.15 and postop third week was 30.80 ± 17.65. Significant changes were observed in the reduction of VAS values after the procedure in both groups during the early postoperative period and the third week (P value < 0.05). However, a significant difference was not found between the changes in VAS values between the groups (P value > 0.005). Similarly, significant changes were observed in the decrease of ODI values after the procedure in both groups during the early postoperative period and the third week (P value < 0.05). However, no significant difference was observed in the ODI scores between the two groups.

CONCLUSIONS

No significant difference was observed between betamethasone and methylprednisolone. Both steroid groups showed a substantial improvement in the preoperative pain scores of the patients.

Caudal epidural steroid injection for chronic low back pain: A prospective analysis of 107 patients

BACKGROUND

Low back pain affects 80% of people worldwide at least once in a lifetime and reduces the quality of life and causes absence from work.

OBJECTIVE

To evaluate the pain and functional status of patients with lumbar disc disease who received blind caudal epidural injections (CEI) for pain relief.

METHODS

The records of 107 patients who had been given CEI between September 2017 and January 2018 were retrospectively analyzed. The inclusion criteria were age > 18 years, > 3-month history of low back pain, and diagnosis of lumbar disc disease by magnetic resonance imaging. The epidural injection solution consisted of 2 mL of betamethasone sodium and 8 mL saline. Follow-up examinations were conducted 3 and 6 months post-injection and the patients were evaluated using a visual analog scale (VAS) and the Oswestry Disability Index (ODI).

RESULTS

The most common disc pathology was at the L4-L5 level. The VAS and ODI scores indicated significantly reduced pain at 3 and 6 months compared with the pre-injection baseline. Two patients experienced total anesthesia and paresis of the lower limbs, but recovered fully after 2 weeks. Blood was aspirated during the injection in two patients, but second-attempt injections were successful in both cases. No other complications were observed.

CONCLUSION

Our results suggest that the blind method is safe for administering CEI to patients with chronic low back pain in the absence of radiological screening and results in significant pain relief with improved functional capacity.

Transverse plane ultrasound-guided caudal epidural injections: sonographic anatomy and stepwise technique

PURPOSE

The present study aims to provide a step-by-step procedural and anatomical familiarization guide for transverse plane ultrasound (US)-guided caudal epidural (CE) injection.

METHODS

The study cohort consisted of 23 chronic low back pain patients (23-67 years old) previously unresponsive to conservative management. A transverse plane US-guided CE injection was performed, with each procedure step documenting and emphasizing sonographic anatomy. Several Thiel's method fixed cadaveric specimen dissections were also performed to demonstrate relevant CE injection-related anatomy.

RESULTS

The sacral hiatus location can be estimated by visually forming an equilateral triangle between the posterior superior iliac spines and the sacral apex (trigonum sacrale). Follow-up palpation locates the sacral cornua, guiding transducer placement visualizing over the paired cornua 'bull frog's eye's appearance, with the epidural space visualized as a hypoechoic line, between the eyes. Then, 2-3 ml of 1% lidocaine is injected subcutaneously at the mid-point between the sacral cornua and superficial to the posterior sacrococcygeal ligament (SCL). Although keeping the cornua, superficial posterior SCL and epidural space in view, the needle is slowly advanced to the epidural space at around a 20 degree cephalad angle till the tip becomes visible. Expansion of the epidural space is monitored under the transverse sacral ligament as the injectant is slowly introduced.

CONCLUSION

The present study demonstrated the anatomical landmarks necessary for the transverse ultrasound caudal epidural technique and that the cornua, superficial posterior SCL, CE space, and other relevant sacral hiatal anatomy are well visualized with this technique.

Fluoroscopic evaluation of the influence of needle gauge on epidural spread in caudal block

Caudal block has limited injectate distribution to the desired lumbar level due to the relatively long distance from the injection site and reduction in the volume of injectate due to leakage into the sacral foramen. The objective of this study was to investigate the influence of needle gauge on fluoroscopic epidural spread and to assess the correlation between the spread level and analgesic efficacy in patients undergoing caudal block. We retrospectively analyzed data from 80 patients who received caudal block for lower back and radicular pain. We categorized patients based on the epidural needle gauge used into group A (23 gauge), group B (20 gauge), and group C (17 gauge). Fluoroscopic image of the final level of contrast injected through the caudal needle and pain scores before the block and 30 minutes after the block recorded using a numerical rating scale, were evaluated. Of the 80 patients assessed for eligibility, 7 were excluded. Thus, a total of 73 patients were finally analyzed. Age, sex, body mass index, diagnosis, lesion level, lesion severity, and duration of pain did not differ among the 3 groups. All patients showed cephalic spread of contrast. Contrast spread beyond L5 was seen in 26.9% of patients in group A, 41.7% in group B, 39.1% in group C, and 35.6% overall; there was no significant difference among the groups (P = .517). Analgesic efficacy was not significantly different among the groups (P = .336). The needle gauge did not influence the level of epidural spread or analgesic efficacy in caudal block.

Analgesic Effect and Potential Cumulative Benefit from Caudal Epidural D5W in Consecutive Participants with Chronic Low-Back and Buttock/Leg Pain

Objectives: Chronic low-back pain (CLBP) participants in a prior controlled study reported short-term pain relief after caudal epidural injection of 5% dextrose (D5W). This study assessed whether repeated caudal epidural injections of D5W results in serial short-term diminution of CLBP and progressive long-term decrease in pain and disability.

Design: Prospective uncontrolled study.

Settings/Location: Outpatient pain clinic.

Subjects: Adults with CLBP with radiation to gluteal or leg areas.

Interventions: Caudal epidural injection of 10 mL of D5W (without anesthetic) every 2 weeks for four treatments and then as needed for 1 year.

Outcome measures: Numerical Rating Scale (NRS, pain, 0–10 points), Oswestry Disability Index (ODI, disability, %), and fraction of participants with ≥50% reduction in NRS score. Analysis by intention to treat.

Results: Participants (n = 32, 55 ± 9.8 years old, nine female) had moderate-to-severe CLBP (6.5 ± 1.2 NRS points) for 11.1 ± 10.8 years. They received 5.5 ± 2.9 caudal D5W injections through 12 months of follow-up. The data capture rate for analysis was 94% at 12 months for NRS and ODI outcome measures, with 6% carried forward by intention to treat. A consistent pattern of analgesia was demonstrated after D5W injection. Compared with baseline status, NRS and ODI scores improved by 3.4 ± 2.3 (52%) and 18.2 ± 16.4% (42%) points, respectively. The fraction of participants with 50% reduction in NRS-based pain was 21/32 (66%).

Conclusion: Epidural D5W injection, in the absence of anesthetic, resulted in consistent postinjection analgesia and clinically significant improvement in pain and disability through 12 months for most participants. The consistent pattern postinjection analgesia suggests a potential sensorineural effect of dextrose on neurogenic pain.

Short Term Analgesic Effects of 5% Dextrose Epidural Injections for Chronic Low Back Pain: A Randomized Controlled Trial

Background

Hypertonic dextrose injection (prolotherapy) is reported to reduce pain including non-surgical chronic low back pain (CLBP), and subcutaneous injection of 5% dextrose is reported to reduce neurogenic pain, hyperalgesia and allodynia. The mechanism in both cases is unclear, though a direct effect of dextrose on neurogenic pain has been proposed. This study assessed the short-term analgesic effects of epidural 5% dextrose injection compared with saline for non-surgical CLBP.

Methods

Randomized double-blind (injector, participant) controlled trial. Adults with moderate-to-severe non-surgical low back pain with radiation to gluteal or leg areas for at least 6 months received a single epidurogram-confirmed epidural injection of 10 mL of 5% dextrose or 0.9% saline using a published vertical caudal injection technique. The primary outcome was change in a numerical rating scale (NRS, 0 - 10 points) pain score between baseline and 15 minutes; and 2, 4, and 48 hours and 2 weeks post-injection. The secondary outcome was percentage of participants achieving 50% or more pain improvement at 4 hours.

Results and Conclusions

No baseline differences existed between groups; 35 participants (54 ± 10.7 years old; 11 female) with moderate-to-severe CLBP (6.7 ± 1.3 points) for 10.6 ± 10.5 years. Dextrose participants reported greater NRS pain score change at 15 minutes (4.4 ± 1.7 vs 2.4 ± 2.8 points; P = 0.015), 2 hours (4.6 ± 1.9 vs 1.8 ± 2.8 points; P = 0.001), 4 hours (4.6 ± 2.0 vs 1.4 ± 2.3 points; P < 0.001), and 48 hours (3.0 ± 2.3 vs 1.0 ± 2.1 points; P = 0.012), but not at 2 weeks (2.1 ± 2.9 vs 1.2 ± 2.4 points; P = 0.217). Eighty four percent (16/19) of dextrose recipients and 19% (3/16) of saline recipients reported ≥ 50% pain reduction at 4 hours (P < 0.001). These findings suggest a neurogenic effect of 5% dextrose on pain at the dorsal root level; waning pain control at 2 weeks suggests the need to assess the effect of serial dextrose epidural injections in a long-term study with robust outcome assessment.