Original Article
Selective nerve root blocks vs. caudal epidural injection for single level prolapsed lumbar intervertebral disc – A prospective randomized study

https://doi.org/10.1016/j.jcot.2016.02.001Get rights and content

Abstract

Background

Chronic lumbar radiculopathy has a lifetime prevalence of 5.3% in men and 3.7% in women. It usually resolves spontaneously, but up to 30% cases will have pronounced symptoms even after one year.

Aims

A prospective randomized single-blind study was conducted to compare the efficacy of caudal epidural steroid injection and selective nerve root block in management of pain and disability in cases of lumbar disc herniation.

Methods

Eighty patients with confirmed single-level lumbar disc herniation were equally divided in two groups: (a) caudal epidural and (b) selective nerve root block group, by a computer-generated random allocation method. The caudal group received three injections of steroid mixed with local anesthetics while selective nerve root block group received single injection of steroid mixed with local anesthetic agent. Patients were assessed for pain relief and reduction in disability.

Results

In SNRB group, pain reduced by more than 50% up till 6 months, while in caudal group more than 50% reduction of pain was maintained till 1 year. The reduction in ODI in SNRB group was 52.8% till 3 months, 48.6% till 6 months, and 46.7% at 1 year, while in caudal group the improvement was 59.6%, 64.6%, 65.1%, and 65.4% at corresponding follow-up periods, respectively.

Conclusions

Caudal epidural block is an easy and safe method with better pain relief and improvement in functional disability than selective nerve root block. Selective nerve root block injection is technically more demanding and has to be given by a skilled anesthetist.

Introduction

Chronic lumbar radiculopathy is defined as a clinical syndrome of back and leg pain accompanied by sensory, reflex, or motor deficits in a nerve root distribution lasting for more than 12 weeks.1, 2, 3, 4 The lifetime prevalence of lumbar radiculopathy has been reported to be 5.3% in men and 3.7% in women.5, 6 Lumbar radiculopathy due to a prolapsed disc resolves spontaneously in 23–48% of patients, but up to 30% will still have pronounced symptoms after one year, 20% will be out of work, and 5–15% will undergo surgery.7, 8, 9, 10

Section snippets

Aims

A prospective randomized single-blind study was conducted to compare the efficacy of caudal epidural steroid injection and lumbar steroid injection (selective nerve root block) in management of pain associated with prolapsed lumbar intervertebral disc in patients who were not relieved by nonsurgical treatment modalities.

Materials and methods

The study was conducted in tertiary care hospital from December 2013 to December 2014. Patients of lumbar disc herniation at one level with backache and radiculopathy, who failed to respond to conservative therapy for duration of 6 weeks, were included in the study. The diagnosis of lumbar disc herniation was confirmed clinically and radiologically by MRI. The exclusion criteria included patients with prior back surgery, cauda equina syndrome, back pain or radiculopathy due to other causes

Results

There were a total of 80 patients (49 men and 31 women). Each group had 40 patients. The average age was 36.48 ± 10.5 (range: 18–62) years in SNRB group while it was 36.98 ± 11.3 in caudal group. The average height was 173.7 ± 8.1 cm (range: 152–187 cm) in SNRB group and 170.17 ± 9.02 in caudal group. The average weight was 79.93 ± 8.7 (range: 68–99) kg in SNRB group and 80.12 ± 9.6 kg in caudal group. The average duration of pain was 15.07 ± 3.3 months in SNRB group and 11.08 ± 3.8 in caudal group (Table 1). The

Discussion

Epidural steroid injections for lumbar radiculopathy have been used since 1953.11 Along with mechanical compression of nerve roots, lumbar radiculopathy can be triggered by different proinflammatory chemical agents, causing ectopic neuron firing.12, 13, 14, 15, 16 Steroids injected into the epidural space or around the affected nerve root are thought to inhibit these inflammatory mediators. It is believed that epidural steroid injection reduces inflammatory edema of the injured nerve roots,

Conclusions

Our study has shown that caudal epidural block is an easy and safe method with better short-term, midterm, and long-term pain relief and improvement in functional disability than selective nerve root block in cases of lumbar intervertebral disc herniation and can be given by an orthopedic surgeon. Selective nerve root block injection is technically more demanding and has to be given by a trained physician.

Conflicts of interest

The authors have none to declare.

References (40)

  • V.B. Vad et al.

    Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study

    Spine (Phila Pa 1976)

    (2002)
  • K. Bush et al.

    The natural history of sciatica associated with disc pathology. A prospective study with clinical and independent radiologic follow-up

    Spine (Phila Pa 1976)

    (1992)
  • H. Weber et al.

    The natural course of acute sciatica with nerve root symptoms in a double-blind placebo-controlled trial evaluating the effect of piroxicam

    Spine (Phila Pa 1976)

    (1993)
  • H.W. Goebert et al.

    Painful radiculopathy treated with epidural injections of procaine and hydrocortisone acetate: results in 113 patients

    Anesth Analg

    (1961)
  • B. Rydevik et al.

    Pathoanatomy and pathophysiology of nerve root compression

    Spine (Phila Pa 1976)

    (1984)
  • R.A. Autio et al.

    Effect of periradicular methylprednisolone on spontaneous resorption of intervertebral disc herniations

    Spine (Phila Pa 1976)

    (2004)
  • T. Muramoto et al.

    The action of prostaglandin E2 and triamcinolone acetonide on the firing activity of lumbar nerve roots

    Int Orthop

    (1997)
  • O.P. Nygaard et al.

    The inflammatory properties of contained and non-contained lumbar disc herniation

    Spine (Phila Pa 1976)

    (1997)
  • L. Ng et al.

    The efficacy of corticosteroids in periradicular infiltration for chronic radicular pain: a randomized, double-blind, controlled trial

    Spine (Phila Pa 1976)

    (2005)
  • N.A. Quraishi

    Transforaminal injection of corticosteroids for lumbar radiculopathy: systematic review and meta-analysis

    Eur Spine J

    (2012)
  • Cited by (20)

    • Comparison of clinical efficacy of transforaminal and caudal epidural steroid injection in lumbar and lumbosacral disc herniation: A systematic review and meta-analysis

      2018, Spine Journal
      Citation Excerpt :

      This property seriously lowered clinical efficacy and duration of effectiveness [18]. Among the four selected RCTs in our study, the report by Singh et al. indicated that CESI was superior to TFESI [23], although the other three studies favored TFESI over CESI [18,19,22]. Singh et al.’s study injected 32 mL of medication.

    View all citing articles on Scopus
    View full text