Caudals Don't Work for Chronic Radic

[lobelsteve]

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Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial Full Text
British Medical Journal, 09/22/2011
Iversen T et al. – Analysis adjusted for duration of leg pain, back pain, and sick leave did not change this trend. Caudal epidural steroid or saline injections are not recommended for chronic lumbar radiculopathy.

Haven't read the article yet, but always willing to share good news on a Thursday morning with some gentle thunderstorms over Georgia. We need the rain.

 

[Jcm800]

Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial Full Text
British Medical Journal, 09/22/2011
Iversen T et al. – Analysis adjusted for duration of leg pain, back pain, and sick leave did not change this trend. Caudal epidural steroid or saline injections are not recommended for chronic lumbar radiculopathy.

Haven't read the article yet, but always willing to share good news on a Thursday morning with some gentle thunderstorms over Georgia. We need the rain.

but its from england, they dont pain the way we do. they are molecularly very different animals.

 

[epidural man]

Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial Full Text
British Medical Journal, 09/22/2011
Iversen T et al. – Analysis adjusted for duration of leg pain, back pain, and sick leave did not change this trend. Caudal epidural steroid or saline injections are not recommended for chronic lumbar radiculopathy.

Haven't read the article yet, but always willing to share good news on a Thursday morning with some gentle thunderstorms over Georgia. We need the rain.

Lots of flaws...

If you use the Modified Cochrane Methodologic Quality Assesment Criteria - commonly used criteria for assesing pain interventional literature for a RCT, this study probably scores less than 50 (out of 100).

Here is the article.

Here is a good editorial by SP Cohen.

 

[epidural man]

Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial Full Text
British Medical Journal, 09/22/2011
Iversen T et al. – Analysis adjusted for duration of leg pain, back pain, and sick leave did not change this trend. Caudal epidural steroid or saline injections are not recommended for chronic lumbar radiculopathy.

Haven't read the article yet, but always willing to share good news on a Thursday morning with some gentle thunderstorms over Georgia. We need the rain.

Their conclusion should read

"Caudal Epidural steroid injections with 30cc's and the extremely low dose fo 40mg of triamcinolone, not using contrast to confirm spread, and also not using MRI to help confirm pathology that is concordant with reported pain, should not be recommened."

To which we would all reply - "NO **** SHERLOCK. WHY REPORT THAT ANYWAY!?"

In addition, the conlcusion might be better served adding this line as well

"IN addition, we the authors conclude that in the future, research that is severly underpowered, and that doesn't reach the enrollement endpoints should probably forgo publication."

 

[drf]

I thought the same. Placebo vs placebo is no different.

This reminds me of the ortho doc who was giving 20 ml or so of lidocaine, some NS, and dexamethasone 10 mg. Then surgery cause conservative care failed.

On point, what do people put in caudals? Catheter?

I used to use 10 ml of some combination of local, dye, and at least Kenalog 80. However once I managed to procure some nice radio opaque catheters I simply place it at the target and give 2-3 ml.

 

[lobelsteve]

Here AR some responses on the bmj website:





A well-designed but unfortunately irrelevant and misleading study on an unspecific therapy for leg pain of unknown origin
Christof Birkenmaier, Orthopaedic Spinal Surgeon Andreas Veihelmann, Sportklinik Stuttgart
Dept. of Orthopaedics, University of Munich (LMU), Grosshadern Campus
It is rather suprising that this paper passed the BMJ's review process and this even more so if the editorial reflects the opinion of the BMJ.

The relevant facts:

1. Leg pain was clinically examined and MRIs were done but the leg pain was not required to match a morphologic lesion / nerve root compression on MRI. This means that a high rate of pseudoradicular / referred pain (eg from the SI-joint) might have been included.

2. Relevant disc herniations (> 50% spinal canal diameter) and some other possible reasons for radiculopathy were excluded.

3. The caudal epidural approach is not the approach of choice for nerve root lesions higher than S1. Targeted and fluoroscopy-guided transforaminal injections are most frequently used for this application.

4. The volume (and in consequence also the concentration of steroid) in the non-sham groups has more to do with a lavage than with the application of a pharmacological agent.

5. No local anesthetic was used in either group.

6. A transhiatal injection without fluoroscopy and contrast guidance has a serious chance of being either parahiatal or intravascular (despite a negative aspiration test) and the injectate might to a large extent simply exit via the sacral foramina without ever reaching anywhere higher than L5/S1.

In summary:
The authors treated leg pain of unconfirmed and likely heterogeneous origin with 2 almost identical types of an uncontrolled transhiatal lavage or a sham injection, neither of which are representative of what is commonly used to treat sciatica.

The results between the 3 groups surprisingly were not very different, despite adequate statistical power.

The most likely conclusion:
The natural history of leg pain of unclear origin was studied.

Competing interests: None declared

Submit rapid response
Published 20 September 2011
Caudal Epidural study
Ranganathan Iyer, Consultant pain Medicine
Heatherwood & Wexham Park NHS Trust
Dear Sir

I read with interest the article of Iversen et all.

I am surprised that they did a study injecting medications in the epidural space without any radiological guidance.

It is quite well documented, that with advancing age the access to the epidural space by the caudal route cannot be relied on just on surface landmarks. A signifigant proportion could be false positives. The faculty of pain medicine of the RCA as well as the British Pain Society advocate radiological guidance and confirmation with a water soluble dye before injecting a therapeutic medication.

Another point of interest I note was the volumes used in the study was more then used in clinical practice.

Yours sincerely

R Iyer

Competing interests: I practice Pain Management and do this procedure several times a week

Submit rapid response
Published 18 September 2011

 

[Aether2000]

Rest assured, insurance and WC carriers will jump onto this crap study to pontificate about the uselessness of caudal injections. Bookmark the painrounds counterarguments here for future reference. The findings are only relevant if you practice pain medicine like an OR anesthesiologist rather than as a conscientious pain physician....use fluoro for spine procedures, PERIOD.

 

[PinchandBurn]

Rest assured, insurance and WC carriers will jump onto this crap study to pontificate about the uselessness of caudal injections. Bookmark the painrounds counterarguments here for future reference. The findings are only relevant if you practice pain medicine like an OR anesthesiologist rather than as a conscientious pain physician....use fluoro for spine procedures, PERIOD.

either that, or it's a better reason to do TFESI.

either way, totally agree with NOT doing caudals blind. I dare to ask who does that....

 

[Jcm800]

either that, or it's a better reason to do TFESI.

either way, totally agree with NOT doing caudals blind. I dare to ask who does that....

how the hell do we as a profession allow a study in 2011 to published doing BLIND CAUDALS. are 3 months old and having a circ? if not then, do not understand a blind caudal under ANY circumstance.

oi vey. this crap gets published. whats worse is someone that this study was A GOOD IDEA TO STUDY...