Fluoroscopic caudal epidural injections in managing chronic axial low back pain without disc herniation, radiculitis, or facet joint pain

Journal of Pain Research Dovepress open access to scientific and medical research O r i g i n al R esearc h Journal of Pain Research downloaded from https://www.dovepress.com/ by 189.15.120.225 on 23-Jun-2020 For personal use only. Open Access Full Text Article Fluoroscopic caudal epidural injections in managing chronic axial low back pain without disc herniation, radiculitis, or facet joint pain This article was published in the following Dove Press journal: Journal of Pain Research 11 October 2012 Number of times this article has been viewed Laxmaiah Manchikanti 1,2 Kimberly A Cash 1 Carla D McManus 1 Vidyasagar Pampati 1 Pain Management Center of Paducah, Paducah, 2Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA 1 Background: Chronic low back pain without disc herniation is common. Various modalities of treatments are utilized in managing this condition, including epidural injections. However, there is continued debate on the effectiveness, indications, and medical necessity of any treatment modality utilized for managing axial or discogenic pain, including epidural injections. Methods: A randomized, double-blind, actively controlled trial was conducted. The objective was to evaluate the ability to assess the effectiveness of caudal epidural injections of local anesthetic with or without steroids for managing chronic low back pain not caused by disc herniation, radiculitis, facet joints, or sacroiliac joints. A total of 120 patients were randomized to two groups; one group did not receive steroids (group 1) and the other group did (group 2). There were 60 patients in each group. The primary outcome measure was at least 50% improvement in Numeric Rating Scale and Oswestry Disability Index. Secondary outcome measures were employment status and opioid intake. These measures were assessed at 3, 6, 12, 18, and 24 months after treatment. Results: Significant pain relief and functional status improvement (primary outcome) defined as a 50% or more reduction in scores from baseline, were observed in 54% of patients in group 1 and 60% of patients in group 2 at 24 months. In contrast, 84% of patients in group 1 and 73% in group 2 saw significant pain relief and functional status improvement in the successful groups at 24 months. Conclusion: Caudal epidural injections of local anesthetic with or without steroids are effective in patients with chronic axial low back pain of discogenic origin without facet joint pain, disc herniation, and/or radiculitis. Keywords: chronic axial low back pain, discogenic pain, disc herniation, caudal epidural injections Introduction Correspondence: Laxmaiah Manchikanti 2831 Lone Oak Road, Paducah, KY 42003, USA Tel +1 270 554 8373 ext 101 Fax +1 270 554 8987 Email submit your manuscript | www.dovepress.com Dovepress http://dx.doi.org/10.2147/JPR.S35924 Powered by TCPDF (www.tcpdf.org) Discogenic low back pain is nonradicular and occurs in the absence of spinal deformity, instability, and signs of nerve root irritation, and arises from the disc itself. Its mechanism of production is uncertain.1–3 In the absence of evidence of disc herniation, it may be impossible to localize a painful disc from the symptoms and signs elicited on physical examination. Axial low back pain without radiculitis is similar to the pain produced by zygapophyseal joints, the sacroiliac joint, or a musculoligamentous origin of pain.4–14 In fact, a year after the description of lumbar disc herniation as causation of low back and lower extremity pain by Mixter and Barr,15 Mixter and Ayers16 showed that radicular pain can occur without disc herniation. Multiple studies have found that lumbar disc herniation is not the major cause of low back pain, and that discogenic Journal of Pain Research 2012:5 381–390 381 © 2012 Manchikanti et al, publisher and licensee Dove Medical Press Ltd. This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited. Dovepress Journal of Pain Research downloaded from https://www.dovepress.com/ by 189.15.120.225 on 23-Jun-2020 For personal use only. Manchikanti et al pain caused by annular disruption is one of the most important causes.17,18 The complex mechanism of discogenic pain has been well described, with chemical nociception leading to low back pain without disc herniation, along with internal disc disruption.1,4,7,8,19–24 The research in animals has shown that upregulation of various pain-regulated molecules, such as calcitonin gene-related peptide and substance P, in the dorsal root ganglion neurons innervates degenerated intervertebral discs.25,26 Nonspecific low back pain constitutes 80%–90% of low back pain without identifiable causes, with a large proportion having chronic axial low back pain secondary to progressive degenerative disc disease.1,5,6,8,27,28 Further, the majority of patients with axial low back pain improve with conservative management, and various types of interventions described provide highly variable and mostly poor outcomes.28–40 Even though not well known, and continually debated, epidural injections are one of the most common interventions performed for managing axial low back pain without disc herniation.37,38,40–51 Despite emerging evidence,37,38,45–61 epidural injections in general, and their role in managing axial or discogenic low back pain in particular, have been questioned.37,38,40,42,43,45,62–64 However, in evaluating axial low back pain, some studies have failed to rule out facet joint, sacroiliac joint, or other sources of pain prior to treating with epidural injections. This study sought to evaluate the role of caudal epidural injections in patients with chronic low back pain without disc herniation, radiculitis, facet joint pain, sacroiliac joint pain, or other sources of chronic low back pain who were shown to be negative for facet joint and sacroiliac joint pain by controlled comparative local anesthetic blocks; myofascial pain was ruled out by physical examination. This report is the final report of 120 patients at 2-year follow-up, after a previous preliminary publication,65 and one-year follow-up report.37 Materials and methods This randomized, double-blind, controlled trial was conducted in the US in a private interventional pain practice and specialty referral center based on Consolidated Standards of Reporting Trials guidelines.66 The protocol was approved by the local institutional review board, and registered with the US Clinical Trial Registry (NCT00370799). The study was conducted within the principles of the Declaration of Helsinki, with informed consent approved by the institutional review board and signed by all participants. This study was conducted with the internal resources of the practice without any external funding either from industry or elsewhere. 382 Powered by TCPDF (www.tcpdf.org) submit your manuscript | www.dovepress.com Dovepress All par (...truncated)