Pain physician
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Caudal epidural administration of corticosteroids is one of the commonly used interventions in managing chronic low back pain. Reports of the effectiveness of all types of epidural steroids have varied from 18% to 90%. Sicard, a radiologist, was the first to describe injection of dilute solutions of cocaine through the sacral hiatus into the epidural space in 1901, to treat patients suffering from severe, intractable sciatic pain or lumbago. ⋯ The clinical effectiveness evaluations fill the literature with various types of reports including randomized clinical trials, prospective trials, retrospective studies, case reports, and meta-analyses. Evidence from all types of evaluations with regards to the clinical and cost-effectiveness of caudal epidural injections is encouraging. This review discusses various aspects of the role of caudal epidural injections in the management of chronic low back pain, including pathophysiology of low back pain, indications, clinical effectiveness and complications.
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This study was designed to evaluate the psychological status of 50 individuals without chronic pain and without psychotherapeutic drug therapy, Group I, the control group; and Group II, a chronic pain group with 100 chronic pain patients. All the participants were tested utilizing Millon Clinical Multiaxial Inventory III (MCMI-III). Results were analyzed and compared for various clinical personality patterns, including personality traits and personality disorders; severe personality pathology for schizotypal, borderline and paranoid personality pathology; and multiple clinical syndromes, including generalized anxiety disorder, somatization disorder, major depression, bipolar manic disorder and dysthymic disorder, etc. ⋯ The prevalence of psychological disorders in the control group was 24%, compared to 55% in chronic pain group. In conclusion, this evaluation showed that clinical personality patterns are present in both groups of patients. Psychological abnormalities such as generalized anxiety disorder, somatization disorder, and major depression are commonly seen in chronic pain patients.
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Chronic low back pain secondary to involvement of the facet joints is a common problem. Facet joints have been recognized as potential sources of back pain since 1911. Multiple authors have described distributions of pain patterns of facet joint pain. ⋯ Multiple studies utilizing controlled diagnostic blocks have established the prevalence of lumbar facet joint involvement in patients with chronic low back pain, as ranging from 15% to 52%, based on type of population and setting studied. Long-term therapeutic benefit has been reported from three types of interventions in managing lumbar facet joint pain, including intraarticular injections, medial branch blocks and neurolysis of medial branches. This review will discuss chronic low back of facet joint origin and covers anatomy, pathophysiology, diagnosis, and various aspects related to treatment, including clinical effectiveness, cost effectiveness, technical aspects and complications.
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The prevalence of persistent low back pain secondary to involvement of lumbosacral facet joints has been described in controlled studies as varying from 15% to 52% based on types of population and settings studied. Previous studies have shown variances in elderly populations, and postlumbar laminectomy patients. But no variations were observed in obese patients or patients with somatization disorder. ⋯ The prevalence of facet joint pain in men was 38% (95% CI, 29% to 47%) compared to 43% (95% CI, 36% to 50%) in women; 43% (95% CI, 33% to 53%) in non-smokers, compared to 41% (95% CI, 30% to 52%) in heavy smokers; and 28% (95% CI, 18% to 38%) in occupational injury patients compared to 44% (95% CI, 36% to 52%) with a history of gradual onset. False-positive rates varied from 28% to 46%. In conclusion, based on the results of this evaluation, women and men, smokers and nonsmokers suffer with similar prevalence rates of facet joint pain in chronic low back pain; whereas occupational injury patients suffer with lesser prevalence (28%) compared to patients with gradual onset (44%) of low back pain.
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Epidural steroid injections are the most commonly used procedures to manage chronic low back pain in interventional pain management settings. The overall effectiveness of epidural steroid injections has been highly variable, and in the role has not been evaluated in patients discographically evaluated. One hundred consecutive patients, without evidence of disc herniation or radiculitis, who had failed to respond to conservative management with physical therapy, chiropractic and/or medical therapy, underwent discography utilizing strict criteria of concordant pain, and negative adjacent discs, after being judged to be negative for facet joint and/or sacroiliac joint pain utilizing comparative local anesthetic blocks. ⋯ The study showed that at 1 month, 100% of the patients evaluated showed significant improvement in both groups; this declined to 86% at 3 months in Group I, but remained at 100% in Group II, declining to 60% and 64% at 6 months in Group I and Group II, respectfully, with administration of one to three injections. Analysis with one to three injections, which included all (62) patients showed significant relief in 71% and 65% of the patients at 1 month, in 67% and 65% at 3 months, and in 47% and 41% at 6 months, in Group I and Group II, respectively. In conclusion, caudal epidural injections with or without steroids is an effective modality of treatment in managing chronic, persistent low back pain failing to respond to conservative modalities of treatments, in patients negative for facet joint and sacroiliac joint pain, whether positive or negative, on evaluation with provocative discography.