Cephalic spreading levels after volumetric caudal epidural injections in chronic low back pain

Abstract

The volumetric caudal epidural steroid injection has been advocated to facilitate the delivery of medications to the lesion site. This study was aimed to examine the actual spreading patterns of this technique, using epidurogram. A total of 32 patients with chronic low back pain accompanied by radiculopathy of various causes (degenerative spondylosis, herniated nucleus pulposus, spondylolisthesis, and spinal stenosis) were included. The volumetric caudal epidural injection of the 10 mL mixture of contrast medium 5 mL, 0.5% bupivacaine 1 mL, triamcinolone 1.5 mL (60 mg) and normal saline 25 mL was performed. Immediately after the cessation of the first spread, the subsequent solution of another 10 mL of contrast medium 5 mL, 0.5% bupivacaine 1 mL and normal saline 4 mL was injected. This procedure was repeated serially until the total volume to be 50 mL. Continuous fluoroscopic imaging was obtained after each injection. Average time taken to complete the study was 37 sec per every 10 mL. The spreading levels of the mixture were distributed mainly at mid to lower lumbar area in the majority of the patients. During the subsequent injections, the levels were not changed significantly. This was thought to be due to the minimal resistance in cephalad direction, anatomic variations and Starling effect of epidural space.

Comparing the effects of epidural methylprednisolone acetate injected in patients with pain due to lumbar spinal stenosis or herniated disks: a prospective study

“…Kim et al documented epidurographically that a 10-mL solution bolus reaches far enough to mid and lower lumbar area, and extra volumes or repeated injections could not significantly change the blocked level 19. We used a 10-mL corticosteroid bolus for injection of the interlaminar epidural space.…”

The flow patterns of caudal epidural in upper lumbar spinal pathology

“…Although the sacral epidural space is largest it also has the greatest amount of leakage [9]. Kim et al [7] showed that the mid to lower lumbar region of the spine could be consistently treated using caudal epidurals of up to 30 ml. There was no change in the levels attained by subsequent injections.…”

“…Volumetric caudal injections have been examined by epidurography by Kim et al [7] who found no advantage in terms of cephalic migration of injectate, despite using incremental volumes up to 50 ml. They suggest that improved clinical outcome may be a result of mechanical forces generated intradurally and epidurally by the larger volumes.…”

Comparaison entre infiltration épidurale par le hiatus sacrococcygien et anti-inflammatoire non stéroïdien dans le traitement des lomboradiculalgies

“…Les anesthésiques locaux bloquent aussi les fibres afférentes C de la nociception [3,7]. L'infiltration peut agir en faisant disparaître les adhérences et les cicatrices qui peuvent survenir en réponse à l'agression tissulaire, et qui peuvent comprimer les structures nerveuses [8,9]. L'effet volume lié à l'infiltration agit comme tuyau d'arrosage fournissant un jet dans une conduite bouchée dans le but de la dégager [8, 10,11].…”