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International Orthopaedics

, Volume 43, Issue 8, pp 1883–1889 | Cite as

Fluoroscopically guided caudal epidural steroid injections for axial low back pain associated with central disc protrusions: a prospective outcome study

  • James J. Lee
  • Elizabeth T. Nguyen
  • Julian R. Harrison
  • Caitlin K. Gribbin
  • Nicole R. Hurwitz
  • Jennifer Cheng
  • Kwadwo Boachie-Adjei
  • Eric A. Bogner
  • Peter J. Moley
  • James F. Wyss
  • Gregory E. LutzEmail author
Original Paper
  • 120 Downloads

Abstract

Purpose

To determine if axial low back pain (LBP) associated with central disc protrusions can be improved by caudal epidural steroid injections (ESIs).

Methods

Adults with chronic (> 3 months) moderate-to-severe axial LBP with L4–5 and/or L5-S1 central disc protrusions were enrolled in this prospective study. Participants underwent caudal ESIs under standard-of-care practice. The numerical rating scale (NRS) pain score, modified North American Spine Society satisfaction, and Roland Morris Disability Questionnaire (RMDQ) were collected at one week, one month, three months, six months, and one year post-injection. Pre-injection magnetic resonance images were assessed by a musculoskeletal radiologist.

Results

Sixty-eight participants (42 males, 26 females) were analyzed. There were statistically significant improvements in all outcome measures at all follow-up time points, with the exception of NRS best pain at six months. Clinically significant improvements in outcomes were observed at various time points: at three months and one year for current pain; at one week, one month, three months, six months, and one year for worst pain; and at one month and one year for RMDQ. The proportion of satisfied participants ranged from 57 to 69% throughout the study. No adverse events were observed.

Conclusions

This study demonstrated significant improvements in pain and function following caudal ESIs in a cohort of axial LBP with associated central disc protrusions. Further studies, including the use of randomized controlled trials, are needed to determine the ideal subset of candidates for this treatment and to explore additional applications that caudal ESIs may have for chronic LBP.

Keywords

Low back pain Caudal epidural steroid injection Axial Central disc protrusion Outcomes 

Notes

Acknowledgments

We thank Dr. Paul Cooke, Dr. Jennifer Solomon, Dr. Vincenzo Castellano, Dr. Matthew Diamond, Elizabeth LaSalle, and Kristen Santiago for their contributions to this study.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

References

  1. 1.
    Frank JW, Kerr MS, Brooker AS, DeMaio SE, Maetzel A, Shannon HS, Sullivan TJ, Norman RW, Wells RP (1996) Disability resulting from occupational low back pain. Part I: what do we know about primary prevention? A review of the scientific evidence on prevention before disability begins. Spine (Phila Pa 1976) 21(24):2908–2917.  https://doi.org/10.1097/00007632-199612150-00024 CrossRefGoogle Scholar
  2. 2.
    Frymoyer JW, Cats-Baril WL (1991) An overview of the incidences and costs of low back pain. Orthop Clin N Am 22(2):263–271Google Scholar
  3. 3.
    Cassidy JD, Cote P, Carroll LJ, Kristman V (2005) Incidence and course of low back pain episodes in the general population. Spine (Phila Pa 1976) 30(24):2817–2823.  https://doi.org/10.1097/01.brs.0000190448.69091.53 CrossRefGoogle Scholar
  4. 4.
    Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N (1995) The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine (Phila Pa 1976) 20(17):1878–1883.  https://doi.org/10.1097/00007632-199509000-00007 CrossRefGoogle Scholar
  5. 5.
    Saal JA (1996) Natural history and nonoperative treatment of lumbar disc herniation. Spine (Phila Pa 1976) 21(24 Suppl):2s–9s.  https://doi.org/10.1097/00007632-199612151-00002 CrossRefGoogle Scholar
  6. 6.
    Deyo RA, Weinstein JN (2001) Low back pain. N Engl J Med 344(5):363–370.  https://doi.org/10.1056/nejm200102013440508 CrossRefPubMedGoogle Scholar
  7. 7.
    Suseki K, Takahashi Y, Takahashi K, Chiba T, Yamagata M, Moriya H (1998) Sensory nerve fibres from lumbar intervertebral discs pass through rami communicantes. A possible pathway for discogenic low back pain. J Bone Joint Surg (Br) 80(4):737–742.  https://doi.org/10.1302/0301-620X.80B4.0800737 CrossRefGoogle Scholar
  8. 8.
    Jensen TS, Albert HB, Soerensen JS, Manniche C, Leboeuf-Yde C (2006) Natural course of disc morphology in patients with sciatica: an MRI study using a standardized qualitative classification system. Spine (Phila Pa 1976) 31(14):1605–1612; discussion 1613.  https://doi.org/10.1097/01.brs.0000221992.77779.37 CrossRefGoogle Scholar
  9. 9.
    Conn A, Buenaventura RM, Datta S, Abdi S, Diwan S (2009) Systematic review of caudal epidural injections in the management of chronic low back pain. Pain Physician 12(1):109–135PubMedGoogle Scholar
  10. 10.
    Lee JH, Shin KH, Bahk SJ, Lee GJ, Kim DH, Lee CH, Kim DH, Yang HS, Lee SH (2018) Comparison of clinical efficacy of transforaminal and caudal epidural steroid injection in lumbar and lumbosacral disc herniation: a systematic review and meta-analysis. Spine J.  https://doi.org/10.1016/j.spinee.2018.06.720
  11. 11.
    Banaszkiewicz PA, Kader D, Wardlaw D (2003) The role of caudal epidural injections in the management of low back pain. Bull Hosp Jt Dis 61(3–4):127–131PubMedGoogle Scholar
  12. 12.
    Barre L, Lutz GE, Southern D, Cooper G (2004) Fluoroscopically guided caudal epidural steroid injections for lumbar spinal stenosis: a restrospective evaluation of long term efficacy. Pain Physician 7(2):187–193PubMedGoogle Scholar
  13. 13.
    Southern D, Lutz GE, Cooper G, Barre L (2003) Are fluoroscopic caudal epidural steroid injections effective for managing chronic low back pain? Pain Physician 6(2):167–172PubMedGoogle Scholar
  14. 14.
    Cha SO, Jang CH, Hong JO, Park JS, Park JH (2014) Use of magnetic resonance imaging to identify outcome predictors of caudal epidural steroid injections for lower lumbar radicular pain caused by a herniated disc. Ann Rehabil Med 38(6):791–798.  https://doi.org/10.5535/arm.2014.38.6.791 CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Pfirrmann CW, Metzdorf A, Zanetti M, Hodler J, Boos N (2001) Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine (Phila Pa 1976) 26(17):1873–1878.  https://doi.org/10.1097/00007632-200109010-00011 CrossRefGoogle Scholar
  16. 16.
    Modic MT, Masaryk TJ, Ross JS, Carter JR (1988) Imaging of degenerative disk disease. Radiology 168(1):177–186.  https://doi.org/10.1148/radiology.168.1.3289089 CrossRefPubMedGoogle Scholar
  17. 17.
    Weishaupt D, Zanetti M, Boos N, Hodler J (1999) MR imaging and CT in osteoarthritis of the lumbar facet joints. Skelet Radiol 28(4):215–219.  https://doi.org/10.1007/s002560050503 CrossRefGoogle Scholar
  18. 18.
    Childs JD, Piva SR, Fritz JM (2005) Responsiveness of the numeric pain rating scale in patients with low back pain. Spine (Phila Pa 1976) 30(11):1331–1334.  https://doi.org/10.1097/01.brs.0000164099.92112.29 CrossRefGoogle Scholar
  19. 19.
    Stratford PW, Binkley J, Solomon P, Finch E, Gill C, Moreland J (1996) Defining the minimum level of detectable change for the Roland-Morris questionnaire. Phys Ther 76(4):359–365; discussion 366-358.  https://doi.org/10.1093/ptj/76.4.359 CrossRefPubMedGoogle Scholar
  20. 20.
    Carlson BB, Albert TJ (2019) Lumbar disc herniation: what has the spine patient outcomes research trial taught us? Int Orthop 43(4):853–859.  https://doi.org/10.1007/s00264-019-04309-x CrossRefPubMedGoogle Scholar
  21. 21.
    Ajiboye LO, Alimi M, Gbadegesin SA, Oboirien M (2019) Treatment outcome of quality of life and clinical symptoms in patients with symptomatic lumbar degenerative disc diseases: which treatment modality is superior? Int Orthop 43(4):875–881.  https://doi.org/10.1007/s00264-018-4248-5 CrossRefPubMedGoogle Scholar
  22. 22.
    Shin EH, Cho KJ, Kim YT, Park MH (2019) Risk factors for recurrent lumbar disc herniation after discectomy. Int Orthop 43(4):963–967.  https://doi.org/10.1007/s00264-018-4201-7 CrossRefPubMedGoogle Scholar
  23. 23.
    Nie HY, Qi YB, Li N, Wang SL, Cao YX (2018) Comprehensive comparison of therapeutic efficacy of radiofrequency target disc decompression and nucleoplasty for lumbar disc herniation: a five year follow-up. Int Orthop 42(4):843–849.  https://doi.org/10.1007/s00264-017-3661-5 CrossRefPubMedGoogle Scholar
  24. 24.
    Abdi S, Datta S, Trescot AM, Schultz DM, Adlaka R, Atluri SL, Smith HS, Manchikanti L (2007) Epidural steroids in the management of chronic spinal pain: a systematic review. Pain Physician 10(1):185–212PubMedGoogle Scholar
  25. 25.
    Benzakour T, Igoumenou V, Mavrogenis AF, Benzakour A (2019) Current concepts for lumbar disc herniation. Int Orthop 43(4):841–851.  https://doi.org/10.1007/s00264-018-4247-6 CrossRefPubMedGoogle Scholar
  26. 26.
    Liu J, Zhou H, Lu L, Li X, Jia J, Shi Z, Yao X, Wu Q, Feng S (2016) The effectiveness of transforaminal versus caudal routes for epidural steroid injections in managing lumbosacral radicular pain: a systematic review and meta-analysis. Medicine (Baltimore) 95(18):e3373.  https://doi.org/10.1097/md.0000000000003373 CrossRefGoogle Scholar
  27. 27.
    Nakamura SI, Takahashi K, Takahashi Y, Yamagata M, Moriya H (1996) The afferent pathways of discogenic low-back pain. Evaluation of L2 spinal nerve infiltration. J Bone Joint Surg (Br) 78(4):606–612.  https://doi.org/10.1302/0301-620X.78B4.0780606 CrossRefGoogle Scholar
  28. 28.
    Murphey F (1968) Sources and patterns of pain in disc disease. Clin Neurosurg 15:343–351CrossRefGoogle Scholar
  29. 29.
    Edgar MA (2007) The nerve supply of the lumbar intervertebral disc. J Bone Joint Surg (Br) 89(9):1135–1139.  https://doi.org/10.1302/0301-620x.89b9.18939 CrossRefGoogle Scholar
  30. 30.
    McLain RF, Kapural L, Mekhail NA (2005) Epidural steroid therapy for back and leg pain: mechanisms of action and efficacy. Spine J 5(2):191–201.  https://doi.org/10.1016/j.spinee.2004.10.046 CrossRefPubMedGoogle Scholar

Copyright information

© SICOT aisbl 2019

Authors and Affiliations

  • James J. Lee
    • 1
  • Elizabeth T. Nguyen
    • 1
  • Julian R. Harrison
    • 1
  • Caitlin K. Gribbin
    • 1
  • Nicole R. Hurwitz
    • 1
  • Jennifer Cheng
    • 1
  • Kwadwo Boachie-Adjei
    • 1
  • Eric A. Bogner
    • 2
  • Peter J. Moley
    • 1
  • James F. Wyss
    • 1
  • Gregory E. Lutz
    • 1
    Email author
  1. 1.Department of PhysiatryHospital for Special SurgeryNew YorkUSA
  2. 2.Department of Radiology and ImagingHospital for Special SurgeryNew YorkUSA

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