The Anaesthesiologist’s role in fluoroscopic guided epidural steroid injections for low back pain

Karthickraja,

Senior Consultant, Department of Anaesthesia and Pain, Kauvery Hospital, Chennai

*Correspondence: +91 98426 69145; drkarthickraja@gmail.com

Background

Low back pain (LBA) is a disease of chronic wear and tear mechanism that involves spine and neural complexes. Even though numerous causes of LBA have been documented, disc disease and facet joint arthritis contribute to half of the LBA populations. Hence, the focus on these diseases and its pain relief options are utmost important. Since 19th century a choice for pain management of chronic low-back pain has been epidural steroids. Among the various spine related pain relief procedures, the epidural steroid was the commonest one. In perioperative analgesic techniques epidural was the best in that category. Among epidural techniques interlaminar was the commonest to performed by the anesthetists. In low back ache the effectiveness of various epidural steroid injections techniques has been well studied. The different epidural techniques and the technical support to perform these procedures have evolved over time.

Case Presentation

Case 1

low-back-pain-1

Fig. 1. Transforaminal epidural (dye spread).

An octogenarian male came to pain clinic with pain on the right buttock which extended all along the back of thigh till the leg. The pain was associated with numbness and aggravated on walking and relieved by rest (Neuro claudication). Clinically he had positive SLR (straight leg raise) on right side. The MRI showed L3 to L5 disc degeneration, L5 sacralization, canal stenosis, and added to that, degenerative scoliosis of lower lumbar spine. Patient had CAD with severe LV dysfunction, on permanent pacemaker, and borderline kidney function, along with DM and SHT.

With proper investigations and adequate discussion with family we planned to go for epidural steroid for pain relief. We had planned for fluoroscopic guided transforaminal epidural with or without L3-4, L4-5 right median branch block. With the patient in prone position, and under fluoroscopic guidance to the the corresponding neural foramen, the needle was advanced into the epidural space via Kambins triangle. The space was confirmed with typical dye spread noted in the epidural space. Once the space was confirmed then the steroid with local anaesthetic were injected. Procedure was uneventful. Patient was observed over 2 hrs and assessed for immediate pain relief by SLR. Patient was able to do SLR without difficulty and walked back home comfortably. At 2 weeks follow-up, the patient had satisfactory pain relief and was further followed up for 3 months.

Case 2

A 66- years- aged gentle man came with pain at the lower back, right buttock area, and extending up to thigh. Clinically SLR was negative, pain not extending beyond knee, and aggravated on sitting. He also had lower lumbar paramedian tenderness.

MRI showed degenerative disc disease, spondylolytic changes of L3-4-5 spine with bilateral L4-5 facet joint arthritis R>L, and no nerve root compression.

Facet joint arthritis is a common disease in aged people and indicated desiccated disc disease.

low-back-pain-2

Fig. 2. Facet joint (dye spread).

Under fluoroscopy guidance facet joints on both sides were identified in corresponding oblique views. The joint was approached under fluoroscopic guidance and L4-5 facet joint was confirmed with 0.25 ml of dye injection. After confirmation, 1-2ml steroid with local anaesthetics was injected on each side. Procedure was uneventful. Patient had good pain relief and went back home comfortably. At 2 weeks follow-up patient reported excellent pain relief.

Discussion

Earlier mechanical compression over the nerve roots by the prolapsed disc and the inflamed facet joint was thought to be the mechanism of LBA. Many studies since then proved that leakage of the inflammatory contents of nucleus pulposus from the disc and the inflammatory neurotransmitters were the more probable causes of LBA. Thus, the steroids became the initial mode of pain-relieving technique in LBA. It is hypothesized that the steroid acts by inhibiting the synthesis of inflammatory substances thereby reducing the intra-neural edema and venous congestion.

In our patient, in view of multiple comorbid diseases, we chose to give him the benefit of a minimally invasive, effective and longstanding pain-relief intervention. Hence, we chose to administer epidural steroid, which was effective, and benefitted him over the other treatment methods.

In this patient the complexity of the disease, degerative scoliosis, along with canal stenosis, made us to choose transforaminal approach over interlaminar to do the epidural for him. Because, in transforaminal epidural the steroid deposition is very near to the nerve root (i.e., anterior epidural space) instead of posterior in interlaminar epidural. In transforaminal epidural the larger quantity of steroid available nearer to the nerve root helps to reduce the nerve root edema and control the release of neurotransmitters, there by relieving the compression and pain more effectively. Hence, in this technique, the effective pain relief and better clinical effect last much longer. While the reduced rate of complications and ease of doing were compared, the interlaminar scores over the other. This could be overcome with the well trained and skilful hands. Our patient who underwent this technique achieved good quality of life which benefited him for more than 6 months.

The second patient was diagnosed to have isolated facet joint arthritis. In patients with low back pain, the second commonest cause is Facet joint arthritis. The treatment options available are intraarticular steroid injection, median branch block injection and radiofrequency ablation (RF). In this patient the disease was in the initial stage, so we chose intraarticular steroid rather than the other two techniques. It has been recommended that in an isolated facet joint disease the first choice should be facet joint injection rather than RF ablation. Because, mostly the facet joint arthritis subsides with single shot articular injection, but in some cases the chronicity of the disease warrants the RF as the treatment of choice. Even though the commonly performed technique was intraarticular facet joint injection, the RF Ablation technique is a more precise and effective and gives long lasting pain relief. Our patient seemed to have had acute and isolated facet disease; he very much benefited with the facet joint steroid.

Conclusion

In epidural steroid administration the well-established and widely practised technique among the anaesthesiologists was interlaminar epidural technique till date. In the modern era, equipments like usg, fluoroscopy and the radiofrequency ablation have revolutionized chronic pain management in LBA. Image guided different epidural techniques have become popular as they provide precise and more effective pain relief. In recent days promising results have been observed with radiofrequency ablation use in the field of facet joint arthritis related low back ache. Every anaesthesiologist needs to get comfortable with these techniques to master spine related pain management.

References

  1. Manchikanti L, et al. Transforaminal epidural injections in chronic lumbar disc herniation: a randomized, double-blind, active-control trial. Pain Physician. 2014.
  2. Manchikanti L, et al. The role of fluoroscopic interlaminar epidural injections in managing chronic pain of lumbar disc herniation or radiculitis: a randomized, double-blind trial. Pain Pract. 2013.
  3. Carassiti M, et al. Epidural steroid injections for low back pain: A narrative review. Int J Environ Res Public Health. 2021.
  4. Patel VB, et al. Interventional therapies for chronic low back pain: a focused review. Anesth Pain Med. 2015.
  5. Manchikanti L, et al. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician. 2012.
  6. Iversen T, et al. Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial. BMJ. 2011.

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