Epidural Steroid Injection – Pain on Lumbar Extension Determines Extent of Benefit

In Chronic Low Back Pain and Radiculopathy (sciatica) epidurals are used with varying success.
“The mean length of relief duration is 38.37 weeks for individuals without painful lumbar extension and 14.68 weeks for individuals with painful lumbar extension.”

CONCLUSIONS:: The mean length of relief following a caudal injection is reduced by 62% in patients who exhibit pain with lumbar extension.

Clin Spine Surg. 2017 Jul;30(6):E833-E838.
doi: 10.1097/BSD.0000000000000454.
Predictive Factors of the Effectiveness of Caudal Epidural Steroid Injections in Managing Patients With Chronic Low Back Pain and Radiculopathy.
Billy GG et al.
https://www.ncbi.nlm.nih.gov/pubmed/27764056

  • low back pain has lifetime prevalence between 40% and 70%.
  • Most are acute, but “about 30% will develop significant recurrences or chronic pain, lasting over 3 months”
  • 136 patients average age 66 and average duration symptoms 64 week; 46% male

Treatment:

  • low back pain with radiculopathy
  • caudal blocks
  • used flouroscopy to not go beyond s2 thru sacral hiatus
  • 4 mL of Lidocaine 1% local freezing
  •  5 ml saline and 40 mg methylprednisolone acetate epidurally

Immediate reaction – are you kidding me? nerve root injections experts pride themselves in getting steroid close to nerve root. This approach will only bring steroid up to L5 if that. Sweet caudals started out with 10 mls but have now graduated to 20 ml. This 5 ml approach was scheduled to fail… The lack of local anesthetic is also an issue. Many years ago, a study was done in NEJM on lumbar facet injections without local and showed no benefit. It has taken years to be away of the need for local anesthesia as well.

Results:

Sweet caudal block can give a 38% reduction in pain
Sweet Epidural Caudal Sugar-Water Injections Cut Back Pain Longterm
http://painmuse.org/?p=5195

So Steroid addition got it 20% better. 53 weeks relief is over 4 months so could easily be repeated.  It should be noted that 40 mg has been found as good as 80 mg:
Sciatica Back Epidural or Caudal – 40 mg Steroid as Good as 80 mg.
http://painmuse.org/?p=1693

Cases that did not do well include:

  • NOT depression
  • Not sciatic notch tenderness (piriformis?)
  • Yes to longlasting problems – each week of the duration of symptoms, the percentage of improvement was decreased by 0.

Pain on extension clear problem

“The mean length of relief duration is 38.37 weeks for individuals without painful lumbar extension and 14.68 weeks for individuals with painful lumbar extension”

Where do we get pain on extension?

  • Modic I changes in disc can give extension pain and may respond to steroids, pamidronate infusions , and long term antibiotics
    Eur Spine J. 2014 Mar;23(3):493-7. doi: 10.1007/s00586-013-3036-6.
    Inflammatory pain pattern and pain with lumbar extension associated with Modic 1 changes on MRI: a prospective case-control study of 120 patients.
    Bailly F, Maigne JY et al
    https://www.ncbi.nlm.nih.gov/pubmed/24221918
  • Facet disease responding to facet blocks
  • Thoracolumbar facets= Maigne’s TL syndrome

Comment – looks like an easy procedure for even office given lack of blood pressure lowering anesthetic. Could be used in first sweet caudal and then subsequently just D5W sweet caudals until 4 moths is up. Pain on extension would signify either work on facets (lumbar of thoracolumbar) or Modic type 1 treatment – steroids, IV pamidronate or long term antibiotics

 

 

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