Fluoroscopic Caudal Epidural Injections in Managing Post Lumbar Surgery Syndrome: Two-Year Results of a Randomized, Double-Blind, Active-Con­trol Trial

Abstract

Study Design: A randomized, active control, double-blind trial. Objective: To evaluate the effectiveness of fluoroscopically directed caudal epidural injections with or without steroids in managing chronic low back and lower extremity pain secondary to post lumbar surgery syndrome. Summary of Background Data: There is a paucity of evidence concerning caudal epidural injections for managing chronic persistent low back pain with or without lower extremity pain caused by post lumbar surgery syndrome.Methods: This active control randomized study included 140 patients with 70 patients in each group. Group I received 0.5% lidocaine, 10 mL; Group II received 9 mL of 0.5% lidocaine mixed with 1 mL of 6 mg of nonparticulate betamethasone. The multiple outcome measures included the numeric rating scale, the Oswestry Disability Index 2.0, employment status, and opioid intake with assessments at 3, 6, 12, 18, and 24 months posttreatment. Primary outcome was defined as at least 50% improvement in pain and Oswestry Disability Index scores. Patients with a positive response to the first 2 procedures with at least 3 weeks of relief were considered to be successful. All others were considered as failures.Results: Overall in Group I, 53% and 47% of the patients and in Group II, 59% and 58% of the patients, showed significant improvement with reduction in pain scores and disability index at 12 months and 24 months. In contrast, in the successful groups, significant pain relief and improvement in function were observed in 70% and 62% of Group I at one and 2 years; in 75% and 69% of Group II at one and 2 years. The results in the successful group showed that at the end of the first year patients experienced approximately 38 weeks of relief and at the end of 2 years Group I had 62 weeks and Group II had 68 weeks of relief. Overall total relief for 2 years was 48 weeks in Group I and 54 weeks in Group II. The average procedures in the successful groups were at 4 in one year and 6 at the end of 2 years.Conclusion: Caudal epidural injections of local anesthetic with or without steroid might be effective in patients with chronic persistent low back and/or lower extremity pain in patients with post lumbar surgery syndrome.

Two-Year Follow-Up Results of Fluoroscopic Cervical Epidural Injections in Chronic Axial or Discogenic Neck Pain: A Randomized, Double-Blind, Controlled Trial

“…The results were also superior to lumbar and cervical spine disc herniation patients in even though lumbar spine improvement was better in the steroid group 14,38,39. The results were superior to those of patients receiving either local anesthetic alone or with steroids in spinal stenosis and post-surgery syndrome in the cervical and lumbar spine 43-46.…”

Preclinical Studies of Low Back Pain

“…Another common finding is that some benefit is obtained from injection of steroids, but that it does not differ significantly from injection of local anesthetic alone (e.g. [64,65]; steroid injections almost always include a local anesthetic to avoid pain from the injection procedure). This finding mirrors the preclinical study by Tachihara et al discussed above.…”

Cost Utility Analysis of Percutaneous Adhesiolysis in Managing Pain of Post‐lumbar Surgery Syndrome and Lumbar Central Spinal Stenosis

“…A reoperation rate of 9.5% to 25% at 4 years has been reported, despite advances in surgical techniques . Thus, surgery performed for various conditions can result in post‐lumbar surgery syndrome, whereas central spinal stenosis may not amenable to conservative management and fluoroscopically directed epidural injections in a significant proportion of patients …”

“…Percutaneous adhesiolysis has been described as a treatment modality for managing patients recalcitrant to conservative management after surgical intervention and in spinal stenosis in patients without significant response to epidural injections performed under fluoroscopic visualization . Percutaneous adhesiolysis has been studied in postsurgery syndrome, central spinal stenosis, and disk herniation .…”