Low back pain Epidural steroid injections

1. Low back pain Epidural steroid injections Ayman Al-Dahshan, MD. Pain Fellow, Anesthesia department Jordan Hospital & Medical center

3. Direct health care costs attributable to low back pain in the U.S. were estimated at $26.3 billion in 1998 Luo X, Pietrobon R, Sun SX, Liu GG, Hey L. Spine. 2004;29:79-86

4. Overview of Differential Diagnosis of low Back Pain. Rheumatologic conditions Seronegative spondyloarthropathies Ankylosing spondylitis Psoriatic arthritis Reactive spondyloarthropathy, including Reiter syndrome and enteropathic arthritis Rheumatoid arthritis Polymyalgia rheumatica Nonarticular rheumatic disorders (eg, myofascial pain) Cancer Primary tumors of the spine Multiple myeloma Other bone or cartilage tumors, such as osteoid osteoma Metastatic spinal disease Infections Osteomyelitis Discitis Epidural abscess Herpes zoster Vascular conditions Abdominal aortic aneurysm causes pain by rupture, erosion of adjacent structures, or dissection Epidural hematoma Hemoglobinopathy (eg, sickle cell disease) Metabolic disorders Osteoporosis (primary or secondary) Paget disease Referred pain Pelvic disorders Endometriosis Torsion of organ or structure Pelvic inflammatory disease Prostatitis Cystitis Abdominal disorders Pancreatitis or cancer of the pancreas Duodenal ulcers Renal pathology or stones Spine structure problems Facet joints Spinal stenosis Paraspinal muscles Sacroiliac joint Spondylolysis or spondylolisthesis Nonspecific back pain Other causes Hip joint Costovertebral joints Trochanteric bursa Guillain-Barr?© syndrome Meningeal irritation Fibromyalgia syndrom Psychological factors (myriad of different diagnoses)

5. Nonspecific spinal pain Radicular pain Potential serious spinal condition causing pain

6. Although we know something of the pathophysiology of low back and leg pain due to disk protrusion or mechanical instability, we do not have good evidence for the causes of nonspecific low back pain, which is the only diagnosis possible for more than 80% of our patients. Stanley J. Bigos ,Gerd Müller ;Bonica's management of pain

7. Total of 80% to 90% of low back pain will recover in 6 weeks irrespective of the administration or type of treatment Waddell G. 1987. Spine 1987;12:632–644

8. 37% of a population with no spinal or radicular pain were found to have disk abnormalities on myelographic imaging, so one must ask what is the association between radiological pathology and pain Hitselberger WE, Witten RM.. J Neurosurg 1968;28:204–206.

9. 1956 Kelly challenged the idea of pain due to pressure , pressure causes loss of function .

10. 1951 Lindahl and Rexed found evidence of an inflammatory response

11. Nerve root No perineurium No perilemma Poor lymphatic drainage Murphy RW. Clin Orthop 1977;129:46–60

12. 1953 French team of Lievre et al. reported the first use of epidural steroids for the treatment of sciatica Lievre JA, Bloch-Michel H, Pean G, et al. 1953;20:310–311

13. ESIs are one of the commonest procedures performed in the UK 45 948 ESIs recorded in the National Health Service in 2002/2003

14. Efficacy of this procedure has not been established, and its benefit seems to be only of short duration This is in part because of the absence of clinical criteria or guidance for the selection of patients who are most likely to benefit from such treatment The lack of solid clinical guidance for patient selection can be explained by the fact that neither the pathogenesis of sciatica (compression versus inflammation) nor the mechanisms by which epidural steroids produce their analgesic effects have been elucidated Anesth Analg 2003;97:828-832 ; 2003

15. Different techniques utilized Interlaminar Caudal Transforaminal

16. 1995 ; Systematic review Koes et al. reviewed 12 randomized clinical trials on the efficacy of epidural steroid injections for low back pain and sciatica. Half of the trials reported positive outcomes half reported negative outcomes

17. 2003 ; Prospective , double-blind Randomized trial Compared the efficacy of transforaminal versus interspinous corticosteroid injection in treating radicular pain in 31 patients. Better pain reduction in the transforaminal group at 30 days. Better pain relief and increased daily activity levels 6 months after injection. Further validation by a larger controlled trial. Thomas E, Cyteval C, Abiad L, et al Clin Rheumatol 2003, 22:299–304

18. 2004 ; Degenerative lumbar spinal stenosis n=58, median age 71 yr The findings of epiduroscopy corresponded to the symptoms. Epiduroscopy may reduce low back and leg pain in elderly patients with degenerative lumbar spinal stenosis, particularly those with radiculopathy British Journal of Anaesthesia 2004 93(2):181-187; doi:10.1093/bja/aeh201

19. 2005 ; prospective randomized trial Wilson-MacDonald et al. conducted a study of epidural steroid injection compared with intramuscular steroid injection in 93 patients with pain due to lumbar nerve root compression. No difference in the longer-term effects (determined at a 2-year follow- up examination). Eighteen percent of patients in the epidural group and 15% of those in the control group underwent surgical decompression during the 2-year follow-up period Wilson-MacDonald J, Burt J, Griffi n D, Glynn C, J Bone Joint Surg Br 2005, 87:352–355.

20. 2005 ; The WEST studylarge multicenter randomized trial , 228 patients Three lumbar ESIs of triamcinolone acetonide or three interligamentous injections The active group received ESIs via the lumbar route of 80 mg triamcinolone acetonide and 10 ml of 0.25% bupivacaine at weeks 0, 3 and 6. Epidural steroid injections afforded patients earlier relief of pain but no long-term decrease in pain or the need for surgery.

21. 2007 ; prospective randomized trial The Efficacy of Lumbar Epidural Steroid Injections in Patients with Lumbar Disc Herniations At 24 wk from the initiation of this study, Pain relief was as follows Anesth Analg 2007;104:1217-1222 ,William E. Ackerman, III, MD*, and Mahmood Ahmad, MD

22. 2009 Evaluation of the therapeutic results of epiduroscopic adhesiolysis for failed back surgery syndrome 28 FBSS patients Progressive epidural imaging after adhesiolysis suggested that pain was caused by re-adhesion around the nerve root. Since re-adhesion of the nerve root required some time, the effect of adhesiolysis was maintained for extended periods in these cases. We suggest that epiduroscopic adhesiolysis is an effective therapy for FBSS patients, and that adhesiolysis of the nerve root may exhibit the long-term (24 weeks) efficacy in patients with pain. British Journal of Anaesthesia 2009 102(3):400-407; doi:10.1093/bja/aen383 

23. Preliminary results ; observational study 4/2008 -10/2008 13 patients with low back and leg pain , 3-36 months duration 7 males , 6 females , 8 patients sciatica, 3 patients L4-L5 , 2 patients multisegmental .

24. Complications of epidural injections Needle placement, Infectious complications include epidural abscess, Meningitis osteomyelitis/ discitis. Epidural hematomas Neurological injuries Dural puncture Pneumocephalus Increased pain Subdural air Drug administration Seizures, Chemical meningitis Suppression of pituitary adrenal axis, Hypercorticism, Cushing’s syndrome, Osteoporosis, Avascular necrosis Steroid myopathy, Epidural lipomatosis, Weight gain Fluid retention, Hyperglycemia.

25. 2001 ; Closed claims study , USA Injuries Associated with Epidural Steriods and Associated Agents (n=93)

26. why epidural steroids do not produce an effect in all patients with radicular symptoms Pain is not truly radicular in origin Chronic nerve inflammation which results in intraneural and perineural fibrosis. Brown F.. Clin Orthop 1977;129:72–78.