Ultrasound-Guided vs. Fluoroscopy-Guided Caudal Epidural Steroid Injection for the Treatment of Unilateral Lower Lumbar Radicular Pain

Park, Yongbum; Lee, Ji-Hae; Park, Ki Deok; Ahn, Jae Ki; Park, Jaehyun; Jee, Haemi

doi:10.1097/phm.0b013e318292356b

Cited by 67 publications

(92 citation statements)

References 11 publications

(10 reference statements)

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“…Their results have been confirmed in independent studies by Blanchais [41] and Klocke [42]. An added advantage of using US is potentially reducing the risk of intravascular injection, avoiding exposure to ionizing radiation in patients of reproductive age (especially considering proximity of site of injection to reproductive organs), and helping identify patients with significantly narrowed or closed sacral hiatus [40,[42][43]. Despite these advantages and fairly straightforward technique, US guidance for caudal injections remains unpopular because of the acoustic shadowing artifact that prevents the practitioner from recognizing inaccurate intravascular or intrathecal needle placement prior to injection [5,40,42].…”

Section: Caudal Epidural Steroid Injectionsupporting

confidence: 60%

Ultrasound-Guided Interventional Procedures for Chronic Pain Management

et al. 2015

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Ultrasonography has multiple advantages over traditional radiologic imaging modalities when used for interventional procedures. It allows improved visualization of the anatomy while avoiding ionizing radiation and risks associated with contrast use. It has proved superiority at accuracy of delivery and procedural effectiveness over blind procedures when used in association with interventional pain procedures. Although limited in its ability to see through bony structures, ultrasound has utility in visualizing soft tissues and vascular structures in anatomic regions of interest resulting in increased use for posterior neuraxial, periaxial, peripheral nerve and joint-related structures. Current evidence for use in these settings is presented here. In some cases, optimal utility may be improved by combining ultrasonography with other imaging modalities. KEYWORDS• chronic pain management Advantages of ultrasound imagingInterventional pain procedures were traditionally performed under fluoroscopic (FS), computed tomography (CT) or MRI guidance. The use of ultrasound (US) to perform injections for chronic pain has significantly increased in the past decade [1,2]. This increase is attributed to its multiple advantages over other imaging modalities including ease of performance, absence of ionizing radiation, better visualization of soft tissue (i.e., muscle, ligament) and blood vessels, real time visualization of needle advancement and, at times, the ability to observe the spread of injectate [3]. US Practice points• Use of ultrasound in medicine has grown with smaller size equipment, increased portability and decreased cost.• Ultrasound has multiple advantages over radiographic imaging when used for interventional pain procedures.• Sonography is useful for medial branch blocks and intra-articular facet blocks in the cervical and lumbar spine but there is little evidence to support its use in the thoracic spine.• Ultrasonography is limited in utility for many types of axial injections because of bony and acoustic shadowing artifact but it does show some promise with transforaminal epidurals or selective nerve root blocks.• Ultrasound guidance is effective in preventing soft tissue and vascular injury in stellate ganglion blocks compared with blind techniques. Soft tissue and vascular anomalies can be identified that fluoroscopic technique will miss.• Ultrasound improves accuracy and efficacy in ilioinguinal, iliohypogastric and genitofemoral blocks for inguinal and testicular pain.• Lateral femoral cutaneous nerve injections are more accurate under ultrasound guidance, especially given the anatomic variation the nerve exhibits in cadaver dissections.• Injections into the knee, shoulder and hip joints are more successful when performed using ultrasound.For reprint orders, please contact: reprints@futuremedicine.com

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Section: Caudal Epidural Steroid Injectionsupporting

confidence: 60%

Ultrasound-Guided Interventional Procedures for Chronic Pain Management

et al. 2015

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“…The success rate of 99.5% (198/199) with repositioning (with one aborted due to blood return) compares favorably to the highest success rates reported in fluoroscopic guided literature (5, 13). Our rate of 90% positive epidurography at first needle placement may be attributable to less needle wander due to a short distance of vertical needle advancement.…”

Section: Discussionmentioning

confidence: 50%

“…With use of ultrasound guidance to place the needle with a cephalad orientation through the cornua 9/29 (31%) had initial blood return in one study (14) and at least 5/25 (25%) in another (15). However, although aspiration for blood likely reduces the incidence of intravascular drug injection, it is not sufficient to prevent intravascular injection (5). The rate of intravascular injection ranges from 2.5% to 9% for fluoroscopically-guided caudal epidural injection, (5, 9, 10) compared to 0% in the current study.…”

Section: Discussionmentioning

confidence: 99%

“…However, although aspiration for blood likely reduces the incidence of intravascular drug injection, it is not sufficient to prevent intravascular injection (5). The rate of intravascular injection ranges from 2.5% to 9% for fluoroscopically-guided caudal epidural injection, (5, 9, 10) compared to 0% in the current study.…”

Section: Discussionmentioning

confidence: 99%

“…Renfrew et al advocated for use of fluoroscopic guidance after reporting that, despite confirmation of needle placement within the spinal canal and no blood return, the injection resulted in venous placement in 29/316 procedures (9. 2%) (4) Subsequent reports have generally demonstrated lower intravascular injection rates, but the procedure, with a cephalad needle direction; can result in vascular entry despite ideal needle positioning (5). …”

Section: Introductionmentioning

confidence: 99%

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Vertical Small-Needle Caudal Epidural Injection Technique

Smigel

Reeves

Rosen³

et al. 2016

Anesth Pain Med

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BackgroundAnecdotal evidence suggests that a vertical small-needle injection method enters the caudal epidural space with comparable efficacy to cephalad-directed methods, with less intravascular injection.ObjectivesAssess the success rate of vertical caudal epidural injection using epidurography and the frequency of intravascular injection using a vertical small-needle approach.Patients and MethodsParticipants had chronic generalized non-surgical low back pain and either gluteal and/or leg pain and were enrolled in a simultaneous clinical trial assessing the analgesic effect of 5% dextrose epidural injection. A 25 gauge 3.7 cm hypodermic needle was placed at the sacral hiatus using a fingertip-guided vertical technique without imaging assistance, followed by fluoroscopic epidurography. Minimal needle redirection was allowed up to 10 degrees from the vertical plane if the initial epidurogram showed an extradural pattern, followed by repeat epidurography.ResultsFirst needle placement without imaging resulted in blood return in 1/199 participants and positive epidurography in 179/199 (90%). Minimal needle repositioning resulted in a positive epidurogram in the remaining 19 attempts. No intravascular injection patterns were observed.ConclusionsThis compares favorably to published success rates of fluoroscopically-guided technique and was well tolerated. Vertical caudal epidural injection may be suitable for combination with ultrasound-guided methods with Doppler flow monitoring.

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Repression of let‐7b‐5p prevents the development of multifidus muscle dysfunction by promoting vitamin D accumulation via upregulation of electron transfer flavoprotein alpha subunit in a rat model of multifidus muscle injury

Yao

Zhang

et al. 2018

J of Cellular Biochemistry

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Multifidus muscle dysfunction is associated with the multifidus muscle injury (MMI), which ultimately result in the low‐back pain. Increasing evidence shows that microRNAs (miRs) may be involved in multifidus muscle dysfunction. In this study, we tested the hypothesis that downregulation of let‐7b‐5p may inhibit the multifidus muscle dysfunction development and progression. The target prediction program and luciferase activity determination confirmed electron transfer flavoprotein alpha subunit (ETFA) as a direct target gene of let‐7b‐5p. To study the mechanisms and functions of let‐7b‐5p in relation to ETFA in MMI progression, we prepared rats with experimental MMI, and a lentivirus‐based packaging system was designed to upregulate expressions of let‐7b‐5p, and downregulate the expression of ETFA. ETFA was identified as a target gene of let‐7b‐5p. Older age, a longer duration of pain, and higher visual analog scale and Oswestry disability index scores for the patients with chronic low‐back pain were linked to a more severe degree of degenerative muscle atrophy and fatty infiltration. Increased expression of let‐7b‐5p and decreased expression of ETFA and vitamin D receptor (VDR) were positively correlated with multifidus muscle dysfunction. Downregulated let‐7b‐5p could inhibit infiltration of collagen fibers, reverse the ultrastructural changes of multifidus muscle, and induce the VDR expression, thereby repair the MMI. The results provided a potential basis for let‐7b‐5p that could support targeted intervention in multifidus muscle dysfunction. Collectively, this study confirmed that downregulation of let‐7b‐5p has a potential inhibitory effect on the development of the function of the musculus myocytes by upregulating ETFA.

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Ultrasound-Guided vs. Fluoroscopy-Guided Caudal Epidural Steroid Injection for the Treatment of Unilateral Lower Lumbar Radicular Pain

Abstract: The ultrasound approach with color Doppler mode may avoid intravascular injection-induced complications. The results showed similar improvements in short-term pain relief, function, and patient satisfaction with both ultrasound and fluoroscopic guidance.

Cited by 67 publications

References 11 publications

Ultrasound-Guided Interventional Procedures for Chronic Pain Management

Ultrasound-Guided Interventional Procedures for Chronic Pain Management

Vertical Small-Needle Caudal Epidural Injection Technique

Repression of let‐7b‐5p prevents the development of multifidus muscle dysfunction by promoting vitamin D accumulation via upregulation of electron transfer flavoprotein alpha subunit in a rat model of multifidus muscle injury

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