Caudal Epidural Steroid Injections

by Nicole Berardoni M.D, Paul Lynch M.D, and Tory McJunkin M.D

Caudal Epidural Steroid Injections are a combination of a steroid and a local anesthetic that is delivered to your lower back to treat chronic back and lower extremity pain.

The most common conditions treated are:

Herniated_DiscSciatica/Lubar Radiculitis -This is a condition that is characterized by pain, weakness, or sensory changes along the
sciatic nerve pathway in the lower extremity. Pain typically radiates down the back of the buttock into the lower extremity. Some people describe the sensory changes as “pins and needles” and the pain is described as “sharp shooting pain”.

Herniated/Bulging Disc (most common cause of sciatica) – Separating each individual vertebrae (spine bones) are
discs that act as cushions that minimize the impact that the spinal column receives. Since the discs are designed to be pliable and provide support, they have a tendency to herniate backwards through the outer ligaments and causing
irritation to adjacent nerves. Disk disease is one of the most common causes of chronic lower back pain and accounts for approximately 10% of all low back pain complaints.

Degenerative Lumbar Spinal Stenosis (DLSS) – A disorder due to narrowing of the spinal canal diameter causing
nerve impingement. Spinal stenosis can result in persistent pain in the lower back and lower extremities. Those affected often complain of difficulty walking, chronic back and leg pain, decreased sensation in the lower extremities, and decreased physical activity. Many people with spinal stenosis present with bilateral (both left and right) lower extremity pain radiation.

Procedure

Caudal-Steroid-InjectionCaudal epidural steroid injections involves injecting a steroid into the epidural space, where the irritated nerve roots are located. The caudal injection is performed through the sacral opening and is used to treat low back pain. This injection includes both a long-lasting steroid and an anesthetic (Lidocaine, Bupivacaine). The steroid reduces inflammation and irritation, while the anesthetic interrupts the pain-spasm cycle and nociceptor transmission (Boswell 2007). The medicines spread to the most painful levels of the spine, reducing inflammation and irritation. The entire procedure usually takes less than 15 minutes.

The most important and greatest success achieved with the use of epidural steroid injections is the rapid relief of
symptoms. This often allows patients to experience enough relief to become active and resume their normal daily
activities.

A large study in 2005 included two hundred and twenty-eight patients with a clinical diagnosis of unilateral sciatica were randomized to either three lumbar epidural steroid injections or a placebo injection at intervals of three weeks. After three weeks of epidural steroid treatments, the group demonstrated a 75% pain improvement in pain over the placebo group (Arden 2005).

The technique can be combined with other medications and a small catheter. If this is performed the technique is call
Epidural Lysis of Adhesions, or the Racz Procedure. This was designed to destroy scar tissue in the epidural space.
Scar tissue often results from prolonged irritation, inflammation, or previous surgery in the area.

Benefits

Low-Back-PainLow back pain (LBP) is one of the most difficult conditions for physicians to treat. Commonly LBP goes into remission with periods of decreased or absent symptoms however, the pain often returns and can causes a chronic pain syndrome.

Treatment for LBP is specific to the type of injury that is present. There are several options available ranging from
surgery to acupuncture to physical therapy.

Surgical procedures are typically done when conservative options are exhausted and are not successful in reducing pain. Surgery is also indicated when the LBP is causing new weakness, bowel or bladder incontinence, spinal instability, or infection. Potential causes for these changes include severe lumbar disc herniation, vertebral body fracture or displacement, and progressive spinal stenosis.

Degenerative lumbar spinal stenosis (DLSS) is the most common reason adults over the age of sixty-five receive spinal
surgery (Barre 2004). More recently, a large study has shown that fluoroscopically (x-ray) guided, caudal epidural
injections represent a relatively safe option for the management of DLSS generated pain (Barre 2004).

Risks

Many people do not want to undergo spinal surgery because of the risks associated with it. Caudal epidural steroid injections do have risks, but they are typically low. This pain treatment is considered an appropriate non surgical treatment for many patients who suffer from pain. Complications of the injection can include bleeding, infection, headaches, and nerve damage. The medications used can also cause pharmacological complications. These risks include allergic reaction, high blood sugars, decreased immune response, and the potential for weight gain. Along with proper technique, the procedural risks are reduced by using fluoroscopic guidance (x-ray) to position the needle and watch the medication spread during the procedure.

Outcome

Many of the patients who receive these injections for management of their chronic back pain enjoy improved function and diminished pain for years and can benefit from additional procedures for prolonged relief (Barre 2004).

If your pain has lasted longer than four weeks or is severe in nature you should see a pain specialist about the most
appropriate treatment options. Early intervention may decrease the chances of developing a worsening chronic pain
syndrome.

Articles

Fluroroscopically Guided Caudal Epidural Steroid Injections for Lumbar Spinal Stenosis: A Retrospective Evaluation of
Long Term Efficacy. Barre, Lisha. Pain Physician 2004; 7:187-193.

Rheumatology (Oxford). 2005 Nov;44(11):1399-406. Epub 2005 Jul 19 Arden NK, Price C, Reading I, Stubbing J,
Hazelgrove J, Dunne C, Michel M, Rogers P, Cooper C; WEST Study Group. Rheumatology (Oxford). 2005 Nov;44(11):
1399-406. Epub 2005 Jul 19 PMID: 16030082

Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Boswell MV,
Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB,
Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood
JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L; American Society of Interventional Pain
Physicians. Pain Physician. 2007 Jan;10(1):7-111 PMID: 17256025