Subject ReviewLumbar and Caudal Epidural Corticosteroid Injections
Section snippets
Indications And Rationale
Caudal and lumbar epidural corticosteroid injections have historically been administered to patients with various symptoms and diagnostic classifications. Some reported indications are sciatica or sciatic pain;4, 5, 6, 7, 8, 9, 10, 11, 12 low-back pain or backache;13, 14, 15, 16, 17, 18, 19, 20, 21 low-back pain and sciatica;22, 23, 24, 25, 26 radicular pain and radiculopathy or lumbar nerve root compression.;3, 19, 27, 28 protruding, prolapsed, or herniated lumbar disks or discogenic pain; 29,
Corticosteroids
Corticosteroids, which are used for epidural injections, decrease edema, fibrin deposition, capillary dilatation, local migration of leukocytes, phagocytic activity, capillary proliferation, fibroblast proliferation, deposition of collagen, and cicatrization.52 Saal and colleagues53 determined that material from lumbar disk herniations has “…phospholipase A2 activity [that] is from 20-to 100,000-fold more active than any other phospholipase A2 that has been described.” According to these
Approach To The Epidural Space
No prospective studies have compared the efficacies of the caudal versus the lumbar approach to the epidural space. The caudal needle is inserted through the sacral hiatus into the caudal canal, which is continuous with the lumbar epidural space. The site of scars, adhesions, and affected nerve roots may dictate the best approach. For example, Popat and associates61 reported a case of a lumbar epidural corticosteroid injection at L1-2 in which the local anesthetic (and presumably the
Corticosteroid Diluent
Corticosteroids can be injected into the epidural space undiluted or diluted with varying amounts of local anesthetic or preservative-free isotonic saline. No studies have compared administration of a diluted preparation with an undiluted preparation. In the only randomized prospective study that compared isotonic saline with local anesthetic as diluent, Yates26 found no particular benefits of local anesthesia other than comfort during the injection. Retrospectively, Swerdlow and Sayle-Creer36
Volume
Practitioners use widely varying volumes for epidural corticosteroid injections,20 and no studies have compared different volumes. In an analysis of several studies, the effect of the corticosteroid seems to be independent of the total volume of the injectant.66 The volume of the injectant must be at least sufficient to transport the corticosteroid to the affected spinal level. 9 In addition, the epidural spread of a medication increases with the volume.67, 68 Therefore, the closer an injection
Number Of Injections
No studies have measured the efficacy of different numbers of epidural corticosteroid injections; however, some patients apparently respond to the second or third injection even if they did not respond to the first.19, 37 Brown32 found no additional benefit with more than three injections, and no published information suggests that this is incorrect. Indeed, with repeated injections, cumulative deleterious systemic72 and local73 effects of corticosteroids may occur, and thus the number of
Interval Between Injections
Swerdlow and Sayle-Creer36 suggested that epidurally injected MPA may remain in situ for more than 2 weeks. Whether a beneficial cumulative effect can occur by repeating the injection in less than 2 weeks is unknown. On the basis of data from Green and associates33 on patients who had relief of pain after epidural corticosteroid injections, improvement was noted in 2 days or less in 37% and in 4 to 6 days in 63%. Therefore, the disadvantage of repeating the injection in less than 6 days is that
Alternatives
For low-back or radicular leg pain (or both), many alternatives and adjuncts to epidural corticosteroid injections are available.42, 74 Such options include pain medications, bed rest, physical therapy and rehabilitation, myofascial injections, sympathetic blockade, sensory modulation techniques (that is, massage, heat and cold application, transcutaneous electrical nerve stimulation, and spinal cord stimulators), and surgical treatment. The costs and benefits of these various therapies in
Contraindications
On the basis of a study by Bromage75 that discussed epidurally administered analgesia, localized and systemic infections and severe clotting deficiencies were among the absolute contraindications to epidural injection.
Although bleeding diatheses and anticoagulant therapy are almost always contraindications to epidural injection, management is controversial when the patient has a history of aspirin use.76 This issue is pertinent because use of aspirin or nonsteroidal anti-inflammatory drugs is
Minor Complications
Minor complications of lumbar epidural corticosteroid injections are many and varied, and they can be nonspecific.50 Such problems include dural puncture4, 32, 37 and postdural puncture headache,32 unintentional subdural or subarachnoid injection,32, 36, 82 weight gain in conjunction with salt and water retention3 possibly exacerbating congestive heart failure or hypertension, local discomfort,18, 49 mild exacerbation of radicular pain during injection,31, 49 vasovagal reactions to the needle,50
Hypothalamic-Pituitary-Adrenal Axis
Only a few reports have described Cushing's syndrome due to epidural corticosteroid injections.85 Knight and Burnell86 reported this problem in 2.2% of 181 cases of epidural corticosteroid injections. The patients had received between 280 and 400 mg of MPA during a period of several days. Goebert and colleagues3 described one case of congestive heart failure in which the patient had received 125 mg of hydrocortisone three times in 1 week. They attributed this condition to salt and water
Major Complications
Only a few case reports have described major complications from epidural corticosteroid injections. The actual incidence of these problems is, of course, unknown.
Infectious complications have occurred. Elliott and Collett89 reported a case of septicemia delayed by 9 days after a lumbar epidural corticosteroid injection; however, a direct causal relationship may not have existed.90 The two reported cases of bacterial meningitis were described in 1978 by Dougherty and Fraser.91 One case occurred
Efficacy
Most of the information available about the use and efficacy of epidural corticosteroid injections is abstracted from the noncontrolled studies and case reports described herein. This information is useful albeit limited because of the methods, including the lack of control subjects, lack of a blind design, limited verification of detail, and retrospective nature.
Noncontrolled Studies.—A literature search of studies of percutaneous caudal or lumbar epidural corticosteroid injections disclosed
Future Directions
Research is needed to address the limitations of the controlled studies described herein. Optimally, such research should have specific diagnostic criteria for patient enrollment in the studies and should have a sufficient number of patients to attain appropriate statistical power. Studies should evaluate and compare short-, intermediate-, and long-term results with clinically applicable well-defined outcome measures.
The following questions could be answered in controlled, randomized,
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