ASIPP Practice Guidelines - Pain Physician

Manchikanti et al • ASIPP Practice Guidelines
52
discussed as such below.
Caudal Epidural Injections: Extensive literature available
on caudal epidural injections includes six controlled
studies (544-549) and numerous uncontrolled reports (543,
550-559).
Breivik et al (544) in a prospective, randomized, crossover
study, evaluated 35 patients with chronic low back
pain, allocated to treatment with up to three caudal epidural
injections of bupivacaine and methylprednisolone or
bupivacaine and normal saline at weekly intervals. The
study followed a parallel, cohort design and allowed patients
who failed to obtain relief with one of the treatments
to receive the reciprocal treatment. During initial therapy
56% of patients receiving methylprednisolone experienced
significant relief, compared to 26% with bupivacaine with
saline. In the crossover, only one of seven patients who
had methylprednisolone therapy got relief from the subsequent
bupivacaine and saline injection (14%), in contrast
to 73% of patients who failed to respond to bupivacaine
and saline injection reported satisfactory relief after receiving
the methylprednisolone injection. While 50% of
the patients treated with steroids returned to work, 20% of
the patients treated with bupivacaine returned to work.
Bush and Hillier (545) in a double-blind, randomized evaluation
studied 23 patients with lumbar radicular pain allocated
either to receive two caudal epidural injections of
either a 25 mL mixture of normal saline, procaine and 80
mg triamcinolone, or 25 mL of normal saline alone. Patients
were assessed for pain levels, improvement in
straight-leg raise, and lifestyle. The follow-up, at four weeks
demonstrated significantly greater pain relief and mobility
with a significantly improved quality of life following triamcinolone
injection. However, at one year follow-up while
the treated patients showed greater improvement than placebo
patients, the significant difference was limited to
straight-leg raise tolerance.
In contrast to the above studies, Beliveau (547) found no
difference in pain relief between 24 patients treated with
caudal injections of 40 mL of 1% procaine and 80 mg (2
mL) of methylprednisolone, and an equal number of patients
treated with 42 mL of procaine alone. The patients
in this study had moderate or severe unilateral sciatica,
thought to be caused by an intervertebral disc lesion with
or without neurological signs. They assessed the effect of
the injection a week later according to the symptoms and
the findings of physical examination. Injections were repeated
if improvement was seen after the first injection,
with a total of 82 injections for 48 patients. One to three
months later they saw complete relief in 42% of the patients
in the steroid group, and in 29% in the normal saline
group. This study demonstrated the efficacy of caudal
epidural injections in sciatica with or without steroids. It
failed, however, to demonstrate superiority of steroids over
local anesthetic except in cases of long standing severe
sciatica.
Yates (549) treated patients with low back pain and sciatica
by epidural injection of normal saline or 0.5% lignocaine,
with or without triamcinolone given at weekly
intervals in random order. Subjective and objective criteria
of progress were measured. Greatest improvement was
noted after the injection containing steroid. Lignocaine
0.5%, and normal saline used individually produced less
marked improvement. No specific benefits of local anesthesia
were found other than comfort during injection. His
report did not address pain relief but focused on improvement
in straight leg raising, which seemed to correlate with
pain relief.
Matthews et al (546) compared the responses of patients
treated with caudal epidural injections of bupivacaine and
methylprednisolone or a control injection of 2 mL of lignocaine
over the sacral hiatus. At assessment after one
month, there was no significant difference between the two
groups. However, at three months, the treated group was
reported to be significantly more pain free.
Czarski (547) evaluated the use of caudal epidural injections
comparing novocaine and hydrocortisone and
procaine hydrochloride alone in the treatment of patients
with prolapsed lumbar intervertebral disc, with 60 patients
in procaine hydrochloride group and 123 patients in
procaine hydrochloride and hydrocortisone group. He
demonstrated statistically significant and clinically significant
differences in outcomes comparing the use of caudal
epidural injections. Unfortunately, however, the duration
of follow-up was not specified even though complete relief
was reported in 22 of the 123 patients, with significant
relief in 64 of 123 patients; whereas marginal relief was
reported in 14 patients with no relief or patients getting
worse on 23 occasions in hydrocortisone group. In comparison,
in procaine hydrochloride group, 8 of 60 patients
obtained significant relief, none of the patients obtaining
complete relief, 35 obtaining marginal relief and 17 patients
getting no relief or becoming worse.
Numerous uncontrolled reports on the use of caudal epi-
Pain Physician Vol. 4, No. 1, 2001