Adverse effects of fluoroscopically guided interlaminar thoracic epidural steroid injections

OBJECTIVES: To assess the prevalence of adverse effects or complications from fluoroscopically guided thoracic interlaminar epidural steroid injections. DESIGN: A retrospective study with independent observer review. Patients presenting with thoracic radicular pain, caused by either herniated nucleus pulposus or thoracic spondylosis as confirmed by magnetic resonance imaging, received an interlaminar thoracic epidural steroid injection as part of a conservative-care treatment plan. The study was performed in a multidisciplinary spine care center. All injections were performed over a 5-yr period. An independent observer reviewed medical charts, which included a 24-hr postprocedure standardized questionnaire completed by telephone by an ambulatory surgical center nurse. Ambulatory surgical center operative reports and physician follow up office notes up to 3 mos after the procedures, along with epidurograms, were also reviewed. RESULTS: A total of 21 patients who received 39 injections were reviewed. Adverse effects or complications per injection observed included three with increased pain at injection site (7.7%), two with facial flushing (5.1%), one transient nonpositional headache (2.6%), one episode of insomnia the night of the injection (2.6%), and one episode of fever the night of the procedure (2.6%). Statistical analysis revealed no significant difference based on diagnosis (herniated nucleus pulposus vs. spondylosis, P = 0.9156), and age was not linked to higher prevalence of adverse/effects complications (P = 0.3137). CONCLUSIONS: No major complication arose. Adverse effects did occur with a rate of 20.5%. All adverse effects resolved without morbidity. No statistical difference was observed in the rate of adverse effects in patients with herniated nucleus pulposus or spondylosis.     

The basis for recommending repeating epidural steroid injections for radicular low back pain: a literature review

Novak S, Nemeth WC. The basis for recommending repeating epidural steroid injections for radicular low back pain: a literature review.

Objectives

To determine the current evidence to support guidelines for frequency and timing of epidural steroid injections (ESIs), to help determine what sort of response should occur to repeat an injection, and to outline specific research needs in these areas.

Data Sources

A PubMed, Medline (EBSCO), and Cochrane library search (January 1971-December 2005), as well as additional references found from the initial search.

Study Selection

There were no studies that specifically addressed the objectives outlined. Eleven randomized controlled trials, 1 prospective controlled trial, and 2 prospective cohort studies were identified that included a protocol involving repeat epidural injections for radicular pain secondary to herniated nucleus pulposus or spinal stenosis. One qualitative survey was also identified. Five review articles were also included that discussed this topic.

Data Extraction

Data were extracted from clinical trials if they included the following: (1) protocols in clinical trials on ESIs that included repeat injections and the response required to trigger these injections, (2) any evidence given for establishing these protocols, and (3) similar studies that included only 1 injection. Specific mention of repeat ESIs and partial response that was mentioned in review articles was also included.

Data Synthesis

There is limited evidence to suggest guidelines for frequency and timing of ESIs or to help to define what constitutes the appropriate partial response to trigger a repeat injection. No study has specifically evaluated these objectives. Methodologically limited research suggests that repeat injections may improve outcomes, but the evidence is insufficient to make any conclusions.

Conclusions

There does not appear to be any evidence to support the current common practice of a series of injections. Recommendations for further research are made, including a possible study design.     

Complications of fluoroscopically guided transforaminal lumbar epidural injections

OBJECTIVES: To assess the incidence of complications of fluoroscopically guided lumbar transforaminal epidural injections. DESIGN: A retrospective cohort design study. Patients presenting with radiculopathy, caused by either lumbar spinal stenosis or herniated nucleus pulposus confirmed by magnetic resonance imaging or computed tomography scanning, received transforaminal epidural steroid injections as part of a conservative care treatment plan. SETTING: A multidisciplinary spine care center. INTERVENTION: All injections were performed consecutively over a 4-month period by five physiatrists. An independent observer reviewed medical charts, which included a 24-hour postprocedure telephone call by an ambulatory surgery center nurse who had asked a standardized questionnaire about complications following the injections. Physician follow-up office notes 1 to 3 weeks after the injection, along with epiduragrams, were also reviewed. RESULTS: Two hundred seven patients who received 322 injections were reviewed. Complications per injection seen included 10 transient nonpositional headaches that resolved within 24 hours (3.1%), 8 increased back pain (2.4%), 2 increased leg pain (0.6%), 4 facial flushing (1.2%), 1 vasovagal reaction (0.3%), 1 increased blood sugar (258 mg/dL) in an insulin-dependent diabetic (0.3%), and 1 intraoperative hypertension (0.3%). No dural punctures occurred. CONCLUSIONS: There were no major complications. The incidence of minor complications was 9.6% per injection. All reactions resolved without morbidity, and no patient required hospitalization.     

Laser-assisted disc decompression: a clinical trial of the holmium:YAG laser with side-firing fiber

In order to evaluate the efficacy of laser-assisted disc decompression (LADD) as an alternative treatment modality for nonsequestered herniated nucleus pulposus of the lumbar spine, we used the Holmium:YAG laser with Sidefire laser fiber on 223 consecutive patients who met inclusion criteria. Patients were evaluated by an independent interviewer postoperatively, and at 1 week, 3 months, 6 months, and 1 year. Ratings were based upon the modified Macnab criteria. All patients presented with leg pain with or without back pain that had failed a minimum of 6 weeks conservative treatment (e.g., rest, NSAIDs, physical therapy, epidural steroid injections). Patients were not considered for LADD if the primary source of neurologic findings was a result of scar tissue from a previous discectomy, lateral recess or central stenosis, or sequestered discs. At 1 year postoperative follow-up, the surgical success rate was 84%. For patients requiring an additional LADD procedure, results at 6 month follow-up yielded surgical success rates of 92.3% and 90% for additional level and index level LADD, respectively. LADD appears to be a viable treatment modality for nonsequestered herniated nucleus pulposus recalcitrant to conservative treatment. LADD may represent a more cost-effective and safer treatment alternative to traditional invasive surgical procedures and other percutaneous methods.     

腰椎间盘突出症非手术治疗效果系统评价综述

腰椎间盘突出症是临床上引起腰腿痛的最常见原因之一。腰椎间盘突出症的非手术治疗方法众多,在临床实践中广泛使用。为获得最佳治疗方案,笔者全面检索了近年发表的非手术治疗腰椎间盘突出症的系统评价,最终共获得13篇相关系统评价,其中1篇关于保守治疗,8篇涉及中医治疗,4篇关于化学酶髓核溶解和封闭疗法。其结果显示:保守治疗涉及注射、牵引、理疗、卧床、手法、药物和针灸,但未发现哪种保守治疗方法明确优于包括不治疗的其他保守方法。有系统评价结果显示:中医治疗安全性较高。中医综合治疗效果较单一治疗效果相对较好;电针与常规治疗(卧床休息、腰围保护、骨盆牵引、手法或理疗)和口服药物相比,是一种安全有效的治疗方法,能更有效地改善患者的疼痛和整体功能;中药熏蒸联合牵引治疗较单纯牵引有效。胶原酶髓核溶解经皮治疗的Meta分析结果显示其短期疗效不错。硬膜外类固醇经皮注射治疗也有一定疗效。综上所述,中医治疗、化学酶髓核溶解和封闭疗法治疗腰椎间盘突出症可能有一定疗效。但因为当前证据质量不高,甚至出现结论冲突,尚需开展更多高质量的临床研究加以验证。     

Disk entry: a complication of transforaminal epidural injection--a case report

Correctly identifying the etiology of low back pain can be challenging. The importance of making an expedient, accurate diagnosis of lumbar radicular pain cannot be overemphasized, as proper treatment is based on the outcome. The application of fluoroscopically guided, contrast enhancement during spinal injections is commonly performed, but is not without complications. Intradiskal placement of contrast dye during lumbar transforaminal epidural injection is important to identify, as serious potential complications, such as diskitis, may occur. Additionally, postprocedure assessment may not be accurate if contrast placement is not correctly identified. This case report reviews the literature on complications of transforaminal steroid injection and presents the first documentation of intradiskal placement of contrast dye in the United States. A 72-year-old man presenting with a right L4 radiculopathy underwent a fluoroscopically guided, contrast-enhanced lumbar transforaminal epidural steroid injection and experienced intradiskal placement of contrast as a complication of this procedure. Although the patient was treated prophylactically and achieved good results, the need for fluoroscopy and contrast enhancement during performance of spinal injections is reemphasized.     

The current status of epidural steroids

Caudal, lumbar, and cervical epidural steroid injections (ESI) have been used for a number of years. A suspension of methylprednisolone acetate or triamcinolone diacetate is injected with a diluent of normal saline or local anesthetic. Steroids are used to decrease nerve root inflammation and suppress neuronal discharge. Response to lumbar ESI has been correlated with herniated disk, nerve root irrigation, and recent onset of symptoms. Failure to respond has been associated with prolonged duration of pain, unemployment due to pain, nonradicular diagnosis, and smoking. The few well-performed studies of ESI have yielded conflicting results. For cervical ESI, radicular pain predicts a better response; a radiologic diagnosis of herniated disk or a normal scan predicts a poorer outcome. ESI-related complications occur infrequently and are generally benign. However, adrenal suppression occurs for 1 month after injection. Preventive efforts are indicated for the rare but serious sequelae of epidural hematoma or abscess formation.     

Complications of fluoroscopically guided interlaminar cervical epidural injections

OBJECTIVES: To assess the incidence of complications of fluoroscopically guided interlaminar cervical epidural injections. DESIGN: A retrospective cohort design study. SETTING: A multidisciplinary spine care center. PARTICIPANTS: One hundred fifty-seven consecutive patients with cervical radicular pain caused by cervical spondylosis or herniated nucleus pulposus confirmed by magnetic resonance imaging or computed tomography scanning. INTERVENTIONS: Fluoroscopically guided interlaminar cervical epidural injections were performed at the C7-T1 or C6-7 level using an 18-gauge, 9-mm Tuohy needle with 2mL of 1% lidocaine (Xylocaine) and 80-mg of triamcinolone acetonide (Kenalog). All injections were performed consecutively over a 12-month period by 1 of 5 physicians. MAIN OUTCOME MEASURES: An independent observer reviewed medical charts, which included a 24-hour postprocedure telephone call by an ambulatory surgery center nurse who asked a standardized questionnaire about complications after the injections. Also reviewed were physician notes regarding office follow-up consultations 3 weeks or less after the injections and epidurograms. RESULTS: The charts of 157 patients, who received 345 injections, were reviewed. Complications per injection included 23 increased neck pain (6.7%), 16 transient nonpositional headaches that resolved within 24 hours (4.6%), 6 episodes of insomnia the night of the injection (1.7%), 6 vasovagal reactions (1.7%), 5 facial flushing (1.5%), 1 fever the night of the procedure (0.3%), and 1 dural puncture (0.3%). The incidence of all complications per injection was 16.8%. CONCLUSIONS: Because all complications resolved without morbidity and no patient required hospitalization, fluoroscopically guided interlaminar cervical epidural injections may be a safe procedure for use in patients with cervical radicular pain.     

Epidural abscess and meningitis after epidural corticosteroid injection

Epidural abscess with and without associated meningitis after epidural corticosteroid injections for radicular back pain is a rarely reported complication. We report the occurrence of an epidural abscess and meningitis in a 70-year-old man after 2 epidural corticosteroid injections for treatment of acute radicular lumbar back pain. At the time of diagnosis, cerebrospinal fluid cultures grew Staphylococcus aureus, and the patient was treated with intravenous antibiotics. Possible predisposing factors for the development of an epidural abscess and meningitis in this patient include a 2-year history of neutropenia and an accidental dural puncture that occurred during performance of the first epidural injection. A literature search identified 11 reported cases of epidural abscess, 2 of epidural abscess and meningitis, and 1 of meningitis attributed to epidural corticosteroid injections. Eight of the 14 reported patients were immunocompromised, and 8 (67%) of the 12 in whom cultures of blood, cerebrospinal fluid, or epidural pus were performed had results positive for S. aureus. Antibiotic prophylaxis for S. aureus should be considered for immunocompromised patients undergoing epidural corticosteroid injections.     

Fluoroscopically guided lumbar transformational epidural steroid injections in degenerative lumbar stenosis: an outcome study

OBJECTIVE: To identify the short- and long-term therapeutic benefit of fluoroscopically guided lumbar transforaminal epidural steroid injections in patients with radicular leg pain from degenerative lumbar stenosis. DESIGN: This prospective cohort study performed at a multidisciplinary spine center. There were a total of 34 patients who met our inclusion criteria for the treatment of unilateral radicular pain from degenerative lumbar spinal stenosis who underwent fluoroscopically guided lumbar transforaminal epidural injections. Patients with radiculopathy, who did not respond to physical therapy, antiinflammatories, or analgesics, caused by degenerative lumbar stenosis and confirmed by magnetic resonance imagining received fluoroscopically guided lumbar transforaminal epidural steroid injections at the presumed symptomatic nerve root. The injectant consisted of 12 mg of betamethasone acetate and 2 ml of 1% preservative-free lidocaine HCL. Patients were evaluated by an independent observer and received questionnaires before the initial injection, at 2 mo, and at 12 mo after the injections. Questionnaires included a visual analog scale, Roland 5-point pain scale, standing/walking tolerance, and patient satisfaction scale. RESULTS: A total of 34 patients met our inclusion criteria and were followed for 1 yr. Seventy-five percent of patients had successful long-term outcome, reporting at least a >50% reduction between preinjection and postinjection pain scores, with an average of 1.9 injections per patient. Sixty-four percent of patients had improved walking tolerance, and 57% had improved standing tolerance at 12 mo. CONCLUSION: Fluoroscopically guided transforaminal epidural steroid injections may help reduce unilateral radicular pain and improve standing and walking tolerance in patients with degenerative lumbar spinal stenosis.     

Ropivacaine (naropin), local anesthetic of choice for epidural blockade]

The purpose of this study, carried out in 132 patients with intense acute radicular pain, was search for an optimal local anesthetic to be used in combination with a steroid for therapeutic epidural blockade. Comparative analysis of analgesia attained by epidural injections of 5 ml 2% lidocaine, 4 ml 0.5% bupivacaine, and 4 ml 1% ropivacaine showed the advantages of the latter drug in stable arrest of radicular pain immediately after injection. The duration of analgesia after blockade was 1.4 +/- 0.5, 3.1 +/- 0.3, and 9.5 +/- 1.2 h, respectively. Use of ropivacaine eliminated the main shortcoming of epidural blockade in the treatment of patients with radicular pain, consisting in temporary pain relapse after discontinuation of the local anesthetic effect before development of antiinflammatory effect of the steroid.     

Spontaneous regression of a large sequestered lumbar disc herniation: a case report and literature review

Lumbar disc herniation is a common disorder in adults that is accompanied by lower back and radicular pain. A 32-year-old man visited our clinic with 1-week history of persistent lower back pain and weakness in his right big toe. Magnetic resonance imaging (MRI) of his lumbar spine revealed herniated discs at L3/L4, L5/S1 and L4/L5, where a right-sided intraspinal mass lesion deep to the L4 vertebral body was causing compression of the nerve root. The patient underwent conservative treatment and reported no symptoms referrable to his back or leg 4 months later. Follow-up MRI showed no herniation of the nucleus pulposus at the L4/L5 level or lesion deep to the vertebral body of L4, whereas no changes had occurred to the status of the herniated L3/L4 and L5/S1 discs. The present case and a literature review show that a sequestered lumbar disc herniation can regress within a relatively short timeframe without surgery. The authors emphasise the utility of conservative therapy for patients who do not have a definitive surgical indication.     

软骨终板形态与椎间盘退变的相关性

背景:以往研究证明多种内环境因素共同作用引发椎间盘退变,最重要的机制为椎间盘软骨终板的退变。目的:分析椎间盘退变与终板形态的关系。方法:回顾性分析62例因椎间盘源性慢性下腰痛和79例因髓核脱出致神经根性症状患者的腰椎MRI正中矢状位图像资料。根据腰椎MRI正中矢状位T1W1图像确定终板形态,T2W1图像确定椎间盘退变程度分级。结果与结论:平坦型和不规则型终板最常见于椎间盘退变人群下腰椎,L5/S1平坦型最多见。髓核脱出组与椎间盘源性慢性下腰痛组中凹陷型终板椎间盘退变程度均较平坦型、不规则型低,平坦型终板椎间盘退变程度较不规则型低(P<0.01)。两组间凹陷型与不规则型终板椎间盘退变程度差异无显著性意义,髓核脱出组平坦型椎间盘退变程度较椎间盘源性慢性下腰痛组高(P<0.05)。提示随着椎间盘退变程度的加重,软骨终板形态有由凹陷型向平坦型、不规则型依次转变的趋势。     

Pulsed Radiofrequency for Radicular Pain Due to a Herniated Intervertebral Disc—An Initial Report

Abstract: Pulsed radiofrequency (PRF) has been used for the treatment of radicular pain, due to a herniated intervertebral disc, but so far the data are anecdotal. This is a retrospective study on 13 consecutive patients with this type of pain, at levels L3 to S1. All patients had a diagnosis confirmed by imaging, all had neurological abnormalities, and all were scheduled for surgical intervention. All 12 patients who had a profession had stopped working. Treatment consisted of application of PRF to the dorsal root ganglion of the affected segmental nerve, or in the case of S1 to the segmental nerve at the level of the S1 foramen. One patient underwent disc surgery, and one other patient underwent a spinal fusion 1 year following PRF treatment. He had no leg pain at the time of operation. The remaining patients did not require surgical intervention. The numeric rating scale (NRS) score fell from 7.83 to 2.25 over the first 2 weeks, followed by a gradual further fall to 0.27 at the final follow‐up, 15.8 (11 to 23) months after the procedure. Compared with the initial NRS score the data were significant (P < 0.01) from 4 weeks after the procedure. Neurological abnormalities resolved except in one patient, who had decreased sensibility in a small area in the L3 dermatome at the last follow‐up. All professionally active patients went back to work after 0.49 months (0.1 to 1). It is concluded that PRF may potentially be a viable alternative for epidural steroid injections in the treatment of acute radicular pain, due to a herniated intervertebral disc, and that further studies, including a control group, should be carried out to establish the value of this method.     

Persistent hiccup associated with thoracic epidural injection

Epidural steroid injections are commonly used to treat lumbosacral radicular and discogenic pain. When used in this manner, these agents can cause minor, transient systemic side effects and rarely result in any serious complications. Because adverse reactions are uncommon and transient, epidural injections are considered a safe therapeutic intervention. We describe the first case of persistent hiccups as a consequence of a thoracic epidural steroid injection in a patient with thoracic discogenic pain.     

Epidural steroid injections for low back pain

Epidural steroid injection (ESI) has been used as a treatment for low back pain for over 50 years. In the last 10 to 15 years, there has been a significant increase in the use of ESIs for the treatment of low back pain and radicular pain without clear improvements in outcomes. Recent literature has focused on the use of ESIs as treatment for radicular pain associated with low back pain, with some studies showing benefit over control groups for limb symptoms. There is a lack of literature, however, to support the use of ESIs for the treatment of axial low back pain. The theoretical basis for their use, technical considerations, and the literature available for different approaches of access to the epidural space as pertaining to the treatment for low back pain without radiculopathy are reviewed.     

Interventional Pain Management for Failed Back Surgery Syndrome

Patients who suffer from the condition known as failed back surgery syndrome (FBSS) present to the offices of physicians, surgeons, and pain specialists alike in overwhelming numbers. This condition has been defined as persistent back and/or leg pain despite having completed spinal surgery. As lumbar surgery continues to grow in prevalence, so will the number patients suffering from FBSS. It is important for physicians treating this population to expand their knowledge of FBSS etiologies and appropriate diagnostic imaging modalities, combined with confirmatory diagnostic injections, and proper technique for interventional pain procedures. In doing so, the physician may adequately be prepared to manage these complex cases in the future, ideally with the support of stronger evidence. Management begins with a systematic evaluation of common FBSS etiologies such as new‐onset stenosis, recurrent herniated nucleus pulposus (HNP), epidural fibrosis, pseudarthrosis, and others. History and physical may be supplemented by imaging including X‐ray, magnetic resonance imaging, or computed tomography myelography. Certain diagnoses may be confirmed with diagnostic procedures such as intra‐articular injections, medial branch blocks, or transforaminal nerve root blocks. Once an etiology is determined, a multidisciplinary approach to treatment is most effective. This includes exercise or physical therapy, psychological counseling, medication, and interventional procedures. The most invasive treatment option, short of revision surgery, is spinal cord stimulation. This intervention has a number of studies demonstrating its efficacy and cost‐effectiveness in this population. Finally, revision surgery may be used when indicated such as with progressive neurological impairment or with issues regarding previous surgical instrumentation.     

The efficacy of lumbar epidural steroid injections: transforaminal, interlaminar, and caudal approaches

Conservative management of low back pain includes the use of lumbar epidural steroid injections, which have become increasingly more popular in the last 20 years. The body of literature regarding the efficacy of these injections is vast, conflicting, and difficult to summarize. This article reviews the updated evidence for efficacy and the indications for these injections.     

Relevanz von Nervenblockaden bei der Diagnose und Therapie von Rückenschmerzen

Diagnostic nerve blocks: The popularity of neural blockade as a diagnostic tool in painful conditions, especially in the spine, is due to features like the unspecific character of spinal pain, the irrelevance of radiological findings and the purely subjective character of pain. It is said that apart from specific causes of pain and clear radicular involvement with obvious neurological deficits and corresponding findings of a prolapsed disc in MRI or CT pictures, a diagnosis of the anatomical cause of the pain can only be established if invasive tests are used [5]. These include zygapophyseal joint blocks, sacroiliacal joint blocks, disc stimulation and nerve root blocks. Under controlled conditions, it has been shown that among patients with chronic nonradicular low back pain, some 10-15% have zygapophyseal joint pain [58], some 15-20% have sacroiliacal joint pain [36, 59] and 40% have pain from internal disc disruption [60]. The diagnostic use of neural blockade rests on three premises. First, pathology causing pain is located in an exact peripheral location, and impulses from this site travel via a unique and consistent neural root. Second, injection of local aneasthetic totally abolishes sensory function of intended nerves and does not affect other nerves. Third, relief of pain after local anaesthetic block is attributable solely to block of the target afferent neural pathway. The validity of these assumptions is limited by complexities of anatomy, physiology, and psychology of pain perception and the effect of local anaesthetics on impulse conduction [28]. Facet joints: The prevalence of zygapophyseal joint pain among patients with low back pain seems to be between 15% and 40% [62], but apparently only 7% of patients have pure facet pain [8, 29]. Facet blockade is achieved either by injection of local anaesthetic into the joint space or around the medial branches of the posterior medial rami of the spinal nerves that innervate the joint. There are several problems with intraarticular facet injections, mainly failure to enter the joint capsule and rupture of the capsule during the injection [11]. There is no physiological means to test the adaequacy of medial nerve block, because the lower branches have no cutaneous innervation. Medial ramus blocks (for one joint two nerves have to be infiltrated) are as effective as intraarticular joint blocks [37]. Reproducibility of the test is not high, the specifity is only 65% [61]. For diagnosis of facet pain fluoroscopic control is always necessary as in the other diagnostic blocks. Sacroiliacal joint: Definitely the sacroiliacal joint can be the source of low back pain. Stimulation of the joint by injection in subjects without pain produces pain in the buttock, in the posterior thigh and the knee. There are many clinical tests which confirm the diagnosis, but the interrater reliability is moderate [53]. Intraarticular injection can be achieved in the lower part of the joint with fluoroscopic guidance only, but an accurate intraarticular injection, which is confirmed by contrast medium, even at this place is often difficult. It is not clear whether intraarticular spread is necessary to achieve efficacy. Discography: Two primary syndromes concerning the ventral compartment have been described: anular fissures of the disc and instability of the motion segment. In the syndrome of anular tear, leakage of nucleus pulposus material into the anulus fibrosus is considered to be the source of pain. The studies of Vaharanta [71] and Moneta [41] show a clear and significant correlation between disc pain and grade 3 fissures of the anulus fibrosus. intervertebral discs are difficult to anaesthetize. Intradiskal injections of local anaesthetics may succeed in relieving the patient's pain, but such injections are liable to yield false negative results if the injected agent fails to adequately infiltrate the nerve endings in the outer anulus fibrosus that mediate the patient's pain. In the majority of cases MRI provide adaequate information, but discography may be superior in early stages of anular tear and in clarifying the relation between imaging data and pain [71]. Selective spinal nerve injection: In patients with complicated radiculopathy, the contribution of root inflammation to pain may not be certain, or the level of pathology may be unclear. Diagnostic root blocks are indicated in the following situations: atypical topography of radicular pain, disc prolapses or central spinal stenosis at more than one level and monoradicular pain, lateral spinal stenosis, postnucleotomysyndrome. Injection of individual spinal nerves by paravertebral approach has to be used to elucidate the mechanism and source of pain in this unclear situations. The premise is that needle contact will identify the nerve that produces the patient's characteristic pain and that local anaesthetic delivered to the pathogenic nerve will be uniquely analgesic. Often, this method is used for surgical planning, such as determining the site of foraminotomy. All diagnostic nerve root blocks have to be done under fluoroscopic guidance. Pain relief with blockade of a spinal nerve cannot distinguish between pathology of the proximal nerve in the intervertebral foramen or pain transmitted from distal sites by that nerve. Besides, the tissue injury in the nerve's distribution and neuropathic pain (for instance as a result of root injury) likewise would be relieved by a proximal block of the nerve. Satisfactory needle placement could not be achieved in 10% of patient's at L4, 15% at L5 and 30% at S1 [28]. The positive predictive value of indicated radiculopathy confirmed by surgery ranged between 87-100% [14, 22]. The negative predictive value is poorly studied, because few patients in the negative test group had surgery. Negative predictive values were 27% and 38% of the small number of patients operated on despite a negative test. Only one prospective study was published, which showed a positive predictive value of 95% and an untested negative predictive value [66]. Some studies repeatedly demonstrated that pain relief by nerve root block does not predict success by neuroablative procedures, neither by dorsal rhyzotomy nor by dorsal gangliectomy [46]. Therapeutic nerve blocks - facet joints: Intraarticular injection of steroids offer no greater benefit than injections of normal saline [8, 15] and long lasting success is lacking. In this case, a denervation of the medial branches can be considered. To date three randomized controlled studies of radiofrequency facet denervation have been published. One study [20] reported only modest outcomes and its results remained inconclusive, another study [72] with a double blind controlled design showed some effects in a small selected group of patients (adjusted odds ratio 4.8) 3, 6 and 12 months after treatment, concerning not only reduction of pain but alleviating functional disability also. The third study (34a) showed no effect 3 months after treatment. Discogenic pain: Intradiscal radiofrequency lesions, intradiscal injections of steroids and phenol have been advocated, but there are no well controlled studies. Just recently, intradiscal lesion and denervation of the anulus has been described with promising results, but a randomized controlled study is lacking up to now [31, 55]. Epidural Steroids: Steroids relieve pain by reducing inflammation and by blocking transmission of nociceptive C-fiber input. Koes et al. [33] reviewed the randomized trials of epidural steroids: To date, 15 trials have been performed to evaluate the efficacy, 11 of which showed method scores of 50 points (from 100) ore more. The trials showed inconsistent results of epidural injections. Of the 15 trials, 8 reported positive results and 7 others reported negative results. Consequently the efficacy of epidural steroid injections has not yet been established. The benefits of epidural steroid injections seem to be of short duration only. Future efficacy studies, which are clearly needed, should take into account the apparent methological shortcomings. Furthermore, it is unclear which patients benefit from these injections. In our hands the injection technique can be much improved by fluoroscopic guidance of the needle, with a prone position of the patient, and lateral injection at the relevant level and with a small volume (1-2 ml) and low dose of corticosteroid (20 mg triamcinolone in the case of a monoradicular pain, for example). In the case of epidural adhesions in postoperative radicular pain [50], the study of Heafner showed that the additional effect of hyaloronidase and hypertonic saline to steroids was minimal. In our hands there was no effect in chronic radicular pain 3 months after the injection.     

Sonographically guided caudal epidural steroid injections.

OBJECTIVE: Caudal epidural steroid injections are used for the symptomatic treatment of radicular lumbosacral pain syndromes, but incorrect injection placement has been recognized as a common problem with the routinely used unguided technique. We aimed to explore the use of sonography to facilitate this procedure. METHODS: In patients with clinically unreliable anatomic landmarks, high-resolution real-time sonography was used to identify those landmarks and to assist in correct needle placement. RESULTS: Sonography enabled localization of the sacral hiatus landmarks. We found this method particularly useful for guiding needle placement in patients with moderate obesity. CONCLUSIONS: Real-time sonography can facilitate caudal epidural steroid injections.