Sweet Epidural Caudal Sugar-Water Injections Cut Back Pain Longterm

Re back  pain and sciatica – Astoundingly, you can get 50% back pain reduction short term and 30% relief long term with repeated simple injection of D5W sugar water given caudally. Caudal injection has been dumbed down to a simple vertical injection into hiatus.

I considered this article so important that although you can see in in referred site I have reproduced it in total because referred sites often disappear:

Smigel, L. R., Reeves, K. D., Lyftogt, J., & Rabago, D. P. (2016). Poster 385 Caudal Epidural Dextrose Injections (D5W) for Chronic Back Pain with Accompanying Buttock or Leg Pain: A Consecutive Patient Study with Long-Term Follow-up. PM&R, 8(9), S286-S287.

http://www.pmrjournal.org/article/S1934-1482(16)30595-0/fulltext?rss=yes

Assess short and long-term effects on pain and function following caudal epidural injection of 5% dextrose (D5W) for low back pain (LBP) and either buttock or leg pain. A prior randomized study documented short-term pain reduction compared to saline control.
Design:
Consecutive participant open-label trial.
Setting:
Outpatient pain medicine practice.
Participants:
Adults with chronic, moderate-to-severe, non-surgical LBP and either gluteal or leg pain.
Interventions:
Four biweekly epidurography-confirmed caudal epidural injections of 10 ml of D5W and then as needed for 1 year.
Main Outcome Measures: Numerical Rating Scale (NRS) (0-10) for pain before and 15 minutes, 2, 4 and 48 hours following each injection, and at 6, 12 and 41 months; Oswestry Disability Index (ODI) at 0, 6, 12, and 41 months; the fraction of participants with 50% reduction in NRS for pain.
Results:
Thirty-three participants (55 +/- 10.3 years old; 10 female) with moderate-to-severe LBP (6.7 +/- 1.3 points) for 11.16  +/-10.6 years were enrolled. Diagnoses included lumbar spinal stenosis (n ¼ 11), nonspecific low back pain (n = 11), lumbar radiculopathy (n= 7) and “other  diagnoses of low back pain” (n = 4). They received 3.6 +/-1.6 injections of D5W during the first 3 months, and 2.4 +/- 2.3 injections from months 3-12.

A post-injection analgesic response was consistently demonstrated. Pain (NRS) and disability measures (ODI) improved by 3.8 +/- 2.3 points (56%) and 18.5  +/- 15.9 % respectively at 12 months.

Long-term data showed pain (NRS) and disability measures (ODI) improved by 2.5 +/- 3.5 points (38%) and 13.3 +/- 22.7% respectively. The fraction of participants with 50% reduction in pain on the NRS was 70% at 1 year and 45% at 41 months.
Conclusions:
D5W demonstrated consistent analgesic responses and resulted in a long-term improvement in pain and disability when injected in the caudal space of consecutive participants with moderate-to-severe chronic non-surgical low back pain and radiation to either buttock or leg areas

Comment -Initially they published how short term it had benefit – just in press now:

Short Term Analgesic Effects of 5% Dextrose Epidural Injections for Chronic Low Back Pain: A Randomized Controlled Trial
Liza Maniquis-Smigel 1 ; Kenneth Dean Reeves 2, * ; Howard Jeffrey Rosen 3 ; John Lyftogt 4 ; Cassie Graham-Coleman 5 ; An-Lin Cheng 6 ; and David Rabago 7
Anesthesiology and Pain Medicine. In press(In press): e42550 , DOI: 10.5812/aapm.42550
http://anesthpain.com/?page=article&article_id=42550v

found 50% short term pain reduction effect with one shot

I use this technique in Low Back Pain and it helps but author is now using 20 mls D5W  and I add 2ooo ug preservative free B12.
An old article found B12 spinally improved nerve pain from diabetic neuropathy:

Clin Ther. 1987;9(2):183-92.
Clinical usefulness of intrathecal injection of methylcobalamin in patients with diabetic neuropathy.  Z
Ide H, Fujiya S et al
https://www.ncbi.nlm.nih.gov/pubmed/3568063

 

If there is serious back pain issues without sciatica, I would add 2 mg midazolam to 20 mls of caudal solution (but given epidural when caudal).

Serrao, Juliet M., et al.
Intrathecal midazolam for the treatment of chronic mechanical low back pain: a controlled comparison with epidural steroid in a pilot study.
Pain 48.1 (1992): 5-12.
http://www.sciencedirect.com/science/article/pii/030439599290125U

I have discussed this before:
Midazolam Augmentation of Lumbar Steroid Injections – Use, in Just Mechanical Back Pain
http://painmuse.org/?p=370

Worked better than epidural methyl prednisolone (80 mg) and lasted at least 2 months.

I have wrote about midazolam injection benefits in herpes zoster and failed post laminectomy patients

Confirmed – Intrathecal (Spinal) Midazolam Gives 1-3 Months Relief in Chronic and Failed Back Pain
http://painmuse.org/?p=478

Midazolam Augmentation of Lumbar Steroid Injections – Use, in Just Mechanical Back Pain
http://painmuse.org/?p=370

Miracle Treatment – Low Back Post Herpetic (Post Shingles)Neuralgia Treated With Epidural Steroid and Spinal Midazolam Without Local Can Give Significant Relief For Over 3 Months
http://painmuse.org/?p=351

Older people find caudal blocks painful but not if they are given though a vertical placement of needle through caudal canal insertion point:

Anesth Pain Med. 2016 May 10;6(3):e35340. eCollection 2016.
Vertical Small-Needle Caudal Epidural Injection Technique.
Maniquis Smigel L1, Dean Reeves K2, Jeffrey Rosen H3, Patrick Rabago D4.
https://www.ncbi.nlm.nih.gov/pubmed/27826539

  • use a 25 gauge 3.7 cm hypodermic needle
  • if placement is not right it will be hard inject but a simple adjustment on the hole will make it work better and then patient will feel the pressure in back higher up as it goes in
  • use 20 mls solution

This is very exciting news as even elderly can tolerate a vertically placed injection of D5W. Had one elderly recently express gratitude over shot  – (mine you, I work on her impacted ribs, Quadratus lumborum spasms,  piriformis, thoracolumbar syndrome, cluneal nerve tract pains, SI joint, gluteal triggers and so on as well)

 

Addendum – an article comparing caudal blocks of lidocaine or lidocaine plus steroid.

Manchikanti, Laxmaiah, et al. “Fluoroscopic caudal epidural injections in managing chronic axial low back pain without disc herniation, radiculitis, or facet joint pain.” Journal of pain research 5 (2012): 381.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3474158/

“A total of 120 participants were assigned to one of two groups, with group 1 patients receiving caudal epidural injections with local anesthetic (lidocaine 0.5%, 10 mL) and group 2 patients received caudal epidural injections with 9 mL of 0.5% lidocaine mixed with 1 mL of steroid (either brand name or nonparticulate betamethasone [6 mg] or methylprednisolone [40 mg]). Each injection was flushed with a 2 mL solution of 0.9% sodium chloride solution. ”

Not much difference between two as used short acting steroid. Relief in just back pain is however, real. Average of 6 procedures over 2 years

Comment – with D5W there was a 3.8 drop in pain so addition of local/steroid does not look much difference.

Repeated sweet caudals show additional benefit

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One Response to Sweet Epidural Caudal Sugar-Water Injections Cut Back Pain Longterm

  1. Pingback: Epidural Steroid Injection – Pain on Lumbar Extension Determines Extent of Benefit | Pain Medical Musing

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