Lumbosacral radicular pain is a condition where pain originating in the lower back radiates down through the hips, buttocks and legs. While lumbosacral radicular pain primarily affects an individual’s physical wellbeing, it can also have important social and economic implications. Additionally, the prevalence of lumbosacral pain is increasing worldwide. The epidural injections are an alternative approach to treat lumbosacral radicular pain instead of surgical therapy. Epidural steroid injections are often combined with local anesthetic and injected to reduce pain associated with conditions that cause inflammation and pain in the spine. It’s worth noting that while epidural steroid injections can provide significant pain relief for many people, they are associated with potential risks and side effects. Epidural steroid injections can occasionaly lead to allergic reactions in some individuals. If it is not possible to administer steroids in the epidural space due to patient’s allergy, then we can administer only local anesthetic. Case report: A 70 years old woman came to our clinic complaining with acute pain in her left lumbar back and left leg related to her L5-S1 radiculopathy. The patient reported skin rash and angioedema after a previous epidural with only triamcinolone. Method: After signing the consent form, in a aseptic technique, the patient receives only the local anesthetic (bupivacaine 5 mg and ropivacaine 4 mg diluted with physiological solution for a total volume of 6 ml) in the lumbar epidural space at L4-L5 via interlaminar approach. Clinical evaluation was performed before the procedure, immediately after the injection and at one, three and six months after injection using Numeric Rating Scale (NRS) and Oswestry Disability Index (ODI). Results: The patient reports an immediate pain reduction (NRS 10 before local anesthetic injection, NRS 4 immediately after the injection). Still after three months post injection, the patient reports a reduction of pain intensity (NRS 3) with 30 % ODI index. Conclusion: Epidural steroid injections have been widely used for over 50 years in the treatment of low-back pain with radiculopathy but many doctors do not believe in the efficacy of corticosteroids administered in the epidural space. Recent reviews have disclosed controversial results and have questioned the effectiveness of epidural steroid injections. Injecting only local anesthetic in the epidural space eliminates the side effects associated with corticosteroids; therefore, it is possible to repeat injection more frequently. Further studies are needed to evaluate the true role of local anesthetic in the epidural level.
| Published in | American Journal of Life Sciences (Volume 11, Issue 4) |
| DOI | 10.11648/j.ajls.20231104.13 |
| Page(s) | 64-71 |
| Creative Commons |
This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited. |
| Copyright |
Copyright © The Author(s), 2023. Published by Science Publishing Group |
Steroid, Local Anesthetic, Epidural Injection
| [1] | Bogduk N Epidural steroids. Spine (Phila PA 1976) 195; 20 (7): 845-848. |
| [2] | Cuckler JM, Bernini PA, Wiesel SW, Booth RE. Jr, Rothman RH, Pickens GT. The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study. J Bone Joint Surg Am 1985; 67 (1): 63-66. |
| [3] | Derby R, Kine G, Saal JA, Reynolds J, Goldthwalte N, White AH, et al. Response to steroid and duration of radicular pain as predictors outcome. Spine (Phila Pa 1976) 1992; 17 (6) Suppl: S176-S183. |
| [4] | Van Tulder MW, Koes BW, Bouter LM Conservative treatment of acute and chronic nonspecific low back pain. A systematic review of randomized controlled trials of the most common interventions. Spine (Phila Pa 1976) 1997; 22 (18): 2128-2156. |
| [5] | Ji Seon Chae, Won-joong Kim, Se Hee Choi Effects of Local Anesthetics With or Without Steroids in Hig-Volume. Transforaminal Epidural Blocks for Lumbar Disc Herniation: A Randomized Double-Blind, Controlled Trial. Journal of Korean Medical Science 2022 May 2; 37 (17): e 137. |
| [6] | Pengfei Yu, Feng Mao, Jingyun Chen, Xiaoying Ma, Yuxiang Dai, Guanhong Liu, Feng Dai and Jingtao Liu Characteristics and mechanisms of resorption in lumbur disc herniation Arthrites Res Ther 2022; 24: 205. |
| [7] | Crystian B Oliveira, Christopher G Maher, Manuela L Ferreira, Mark J Hancock, Vinicius Cunha Oliveira, Andrew J McLachlan, Bart W Koes, Paulo H Ferreira, Steven P Cohen, Rafael Zambelli Pinto (2020) Epidural corticosteroid injections for lumbosacral radicular pain Cochrane Database Syst Rev. 2020 Apr; 2020 (4): CD013577. |
| [8] | Mulleman D, Mammou S, Griffoul I, Watier H, Goupille P. Pathophysiology of disk-related sciatica. I.--Evidence supporting a chemical component. Joint Bone Spine. 2006; 73: 151–8. |
| [9] | Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990; 72: 403–8. |
| [10] | Boos N, Rieder R, Schade V, Spratt KF, Semmer N, Aebi M. 1995 Volvo Award in clinical sciences. The diagnostic accuracy of magnetic resonance imaging, work perception, and psychosocial factors in identifying symptomatic disc herniations. Spine (Phila Pa 1976) 1995; 20: 2613–25. |
| [11] | Min Soo Lee and Ho Sik Moon Safety of epidural steroids: a review Anesth Pain Med (Seoul) 2021 Jan 31; 16 (1): 16–27. |
| [12] | McLain RF, Kapural L, Mekhail NA. Epidural steroid therapy for back and leg pain: mechanisms of action and efficacy. Spine J. 2005; 5: 191–201. |
| [13] | Kuslich SD, Ulstrom CL, Michael CJ. The tissue origin of low back pain and sciatica: a report of pain response to tissue stimulation during operations on the lumbar spine using local anesthesia. Orthop Clin North Am. 1991; 22: 181–7. |
| [14] | Olmarker K, Størkson R, Berge OG. Pathogenesis of sciatic pain: a study of spontaneous behavior in rats exposed to experimental disc herniation. Spine (Phila Pa 1976) 2002; 27: 1312–7. |
| [15] | Maria Bauer, John E. George III, John Self and Ehab Farag (2012) Recent Advances in Epidural Analgesia Anesthesiol Res Pract. 2012; 2012: 309219. |
| [16] | McClure JH. Ropivacaine. British Journal of Anaesthesia. 1996; 76 (2): 300–307. |
| [17] | Lirk P, Hollmann MW, Strichartz G. The science of local anesthesia: basic research, clinical application, and future directions. Anesth Analg. 2018; 126 (4): 1381–1392. |
| [18] | Hermanns H, Hollmann MW, Stevens MF, Lirk P, Brandenburger T, Piegeler T, et al. Molecular mechanisms of action of systemic lidocaine in acute and chronic pain: a narrative review. Br J Anaesth. 2019; 123 (3): 335–349. |
| [19] | Lawal FM, Adetunji A. A comparison of epidural anaesthesia with lignocaine, bupivacaine and a lignocaine-bupivacaine mixture in cats. J S Afr Vet Assoc (2009) 80: 243–6. |
| [20] | Nath S, Haggmark S, Johansson G, Reiz S. Differential depressant and electrophysiologic cardiotoxicity of local anesthetics: an experimental study with special reference to lidocaine and bupivacaine. Anesth Analg (1986) 65: 1263–70. |
| [21] | Arthur GR, Feldman HS, Covino BG. Comparative pharmacokinetics of bupivacaine and ropivacaine, a new amide local anesthetic. Anesth Analg (1998) 67: 1053–8. |
| [22] | Gomez de Segura IA, Menafro A, Garcia-Fernandez P, Murillo S, Parodi EM. Analgesic and motor-blocking action of epidurally administered levobupivacaine or bupivacaine in the conscious dog. Vet Anaesth Analg (2009) 36: 485–94. |
| [23] | Leone S, Di Cianni S, Casati A, Fanelli G. Pharmacology, toxicology, and clinical use of new long acting local anesthetics, ropivacaine and levobupivacaine. Acta Biomed (2008) 79: 92–105. |
| [24] | Derby R, Lee SH, Date ES, Lee JH, Lee CH. Size and aggregation of corticosteroids used for epidural injections. Pain Med. 2008; 9 (2): 227–234. |
| [25] | Tobias J. Dietrich, Reto Sutter, Johannes M. Froehlich, Christian W. A. Pfirrmann Particulate versus non-particulate steroids for lumbar transforaminal or interlaminar epidural steroid injections: an update Skeletal Radiology volume 44, pages149–155 (2015). |
| [26] | U. S. Food and Drug Administration. Epidural steroid injections (ESI) and the risk of serious neurologic adverse reactions in: Anesthetic and Analgesic Drug Products Advisory Committee, ed Anesthetic and Analgesic Drug Products Advisory Committee: Briefing Document. Silver Spring, MD: US Food and Drug Administration; 2014: 8-56. |
| [27] | Racoosin JA, Seymour SM, Cascio L, Gill R. Serious neurologic events after epidural glucocorticoid iniection—the FDA’s risk assessment . N Engl Med. 2015; 373: 2299-2301. |
| [28] | Koen Van Boxem, Mienke Rijsdijk, Guy Hans, Jasper de Jong, Jan Willem Kallewaard, Kris Vissers, Maarten van Kleef, James P. Rathmell and Jan Van Zundert. Safe Use of Epidural Corticosteroid Injections: Recommendations of the WIP Benelux Work Group Pain Pract 2019 Jan; 19 (1) 61-92. |
| [29] | Breivik H, Borchgrevink PC, Allen SM, et al. Assessment of pain. British Journal of Anaesthesia. 2008; 101 (1): 17-24. |
| [30] | Hjermstad MJ, Fayers PM, Haugen DF, et al. Studies comparing numerical rating scales, verbal rating scales, and visual analogue scales for assessment of pain intensity in adults: a systematic literature review. Journal of Pain and Symptom Management. 2011; 41 (6): 1073-1093. |
| [31] | Michelle Costa, L. Marshman Sex life and the Oswestry Disability Index The spinal journal 2015, Volume 15, Issue 6, 1 June 2015, Pages 1225-1232. |
| [32] | Nizar Abdoul jalil, Zaharah Sulaiman, Mohamed Saufi Awang, Mohamarowl Omar Retrospective Review of Outcomes of a Multimodal Chronic Pain Service in a Major Teaching Hospital: A Preliminary Experience in Universiti Sains Malaysia brief communication - Multimodal chronic pain service Malaysian Journal of Medical Sciences, Vol. 16, No. 4, Pg 55-65, October - December 2009. |
| [33] | Manchikanti L., Malla Y., Cash K. A., Pampati V., Hirsch J. A. Comparison of effectiveness for fluoroscopic cervical interlaminar epidural injections with or without steroid in cervical post-surgery syndrome. The Korean journal of pain . 2018; 31 (4): 277–288. |
| [34] | Bang-zhi Li, , Wen-hai Tang, Yang Li, Lei Zhou, Ming-guo Liu and Sheng-Xue Bao Clinical Efficacy of Epidural Injections of Local Anesthetic Alone or Combined with Steroid for Neck Pain: A Systematic Review and Meta-Analysis Biomed Res Int. 2022; 2022: 8952220. |
| [35] | Manchikanti L., Cash K. A., Pampati V., Falco F. J. E. Transforaminal epidural injections in chronic lumbar disc herniation: A randomized, double-blind, active-control trial. Pain Physician. 2014; 17: 489–501. |
| [36] | Manchikanti L., Singh V., Cash K. A., Pampati V., Falco F. J. E. A randomized, double-blind, active-control trial of the effectiveness of lumbar interlaminar epidural injections in disc herniation. Pain Physician. 2014; 17: 61–74. |
| [37] | Lee J. H., Shin K.-H., Park S. J., Lee G. ., Lee C.-H., Kim D. H., Kim D. H., Yang H. S. Comparison of Clinical Efficacy Between Transforaminal and Interlaminar Epidural Injections in Lumbosacral Disc Herniation: A Systematic Review and Meta-Analysis. Pain Physician. 2018; 21: 433–448. |
| [38] | Michel Benoist, Philippe Boulu and Gilles Hayem Epidural steroid injections in the management of low-back pain with radiculopathy: an update of their efficacy and safety (2012) Eur Spine J. 2012 Feb; 21 (2): 204–213. |
| [39] | Manchikanti L, Buenaventura RM, Manchikanti KN, et al. (2012) Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain”. Pain Physician. 2012; 15 (3): E199-245. |
APA Style
Federica Giulietti, Catello Pellegrino, Alessandra Parini, Cristina Scala. (2023). Epidural Injection with Only Local Anesthetic for Lumbosacral Radicular Pain: A Case Report. American Journal of Life Sciences, 11(4), 64-71. https://doi.org/10.11648/j.ajls.20231104.13
ACS Style
Federica Giulietti; Catello Pellegrino; Alessandra Parini; Cristina Scala. Epidural Injection with Only Local Anesthetic for Lumbosacral Radicular Pain: A Case Report. Am. J. Life Sci. 2023, 11(4), 64-71. doi: 10.11648/j.ajls.20231104.13
AMA Style
Federica Giulietti, Catello Pellegrino, Alessandra Parini, Cristina Scala. Epidural Injection with Only Local Anesthetic for Lumbosacral Radicular Pain: A Case Report. Am J Life Sci. 2023;11(4):64-71. doi: 10.11648/j.ajls.20231104.13
Share This Article
Twitter
Linked In
Facebook
Copy
Download@article{10.11648/j.ajls.20231104.13,
author = {Federica Giulietti and Catello Pellegrino and Alessandra Parini and Cristina Scala},
title = {Epidural Injection with Only Local Anesthetic for Lumbosacral Radicular Pain: A Case Report},
journal = {American Journal of Life Sciences},
volume = {11},
number = {4},
pages = {64-71},
doi = {10.11648/j.ajls.20231104.13},
url = {https://doi.org/10.11648/j.ajls.20231104.13},
eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ajls.20231104.13},
abstract = {Lumbosacral radicular pain is a condition where pain originating in the lower back radiates down through the hips, buttocks and legs. While lumbosacral radicular pain primarily affects an individual’s physical wellbeing, it can also have important social and economic implications. Additionally, the prevalence of lumbosacral pain is increasing worldwide. The epidural injections are an alternative approach to treat lumbosacral radicular pain instead of surgical therapy. Epidural steroid injections are often combined with local anesthetic and injected to reduce pain associated with conditions that cause inflammation and pain in the spine. It’s worth noting that while epidural steroid injections can provide significant pain relief for many people, they are associated with potential risks and side effects. Epidural steroid injections can occasionaly lead to allergic reactions in some individuals. If it is not possible to administer steroids in the epidural space due to patient’s allergy, then we can administer only local anesthetic. Case report: A 70 years old woman came to our clinic complaining with acute pain in her left lumbar back and left leg related to her L5-S1 radiculopathy. The patient reported skin rash and angioedema after a previous epidural with only triamcinolone. Method: After signing the consent form, in a aseptic technique, the patient receives only the local anesthetic (bupivacaine 5 mg and ropivacaine 4 mg diluted with physiological solution for a total volume of 6 ml) in the lumbar epidural space at L4-L5 via interlaminar approach. Clinical evaluation was performed before the procedure, immediately after the injection and at one, three and six months after injection using Numeric Rating Scale (NRS) and Oswestry Disability Index (ODI). Results: The patient reports an immediate pain reduction (NRS 10 before local anesthetic injection, NRS 4 immediately after the injection). Still after three months post injection, the patient reports a reduction of pain intensity (NRS 3) with 30 % ODI index. Conclusion: Epidural steroid injections have been widely used for over 50 years in the treatment of low-back pain with radiculopathy but many doctors do not believe in the efficacy of corticosteroids administered in the epidural space. Recent reviews have disclosed controversial results and have questioned the effectiveness of epidural steroid injections. Injecting only local anesthetic in the epidural space eliminates the side effects associated with corticosteroids; therefore, it is possible to repeat injection more frequently. Further studies are needed to evaluate the true role of local anesthetic in the epidural level.},
year = {2023}
}
TY - JOUR T1 - Epidural Injection with Only Local Anesthetic for Lumbosacral Radicular Pain: A Case Report AU - Federica Giulietti AU - Catello Pellegrino AU - Alessandra Parini AU - Cristina Scala Y1 - 2023/08/31 PY - 2023 N1 - https://doi.org/10.11648/j.ajls.20231104.13 DO - 10.11648/j.ajls.20231104.13 T2 - American Journal of Life Sciences JF - American Journal of Life Sciences JO - American Journal of Life Sciences SP - 64 EP - 71 PB - Science Publishing Group SN - 2328-5737 UR - https://doi.org/10.11648/j.ajls.20231104.13 AB - Lumbosacral radicular pain is a condition where pain originating in the lower back radiates down through the hips, buttocks and legs. While lumbosacral radicular pain primarily affects an individual’s physical wellbeing, it can also have important social and economic implications. Additionally, the prevalence of lumbosacral pain is increasing worldwide. The epidural injections are an alternative approach to treat lumbosacral radicular pain instead of surgical therapy. Epidural steroid injections are often combined with local anesthetic and injected to reduce pain associated with conditions that cause inflammation and pain in the spine. It’s worth noting that while epidural steroid injections can provide significant pain relief for many people, they are associated with potential risks and side effects. Epidural steroid injections can occasionaly lead to allergic reactions in some individuals. If it is not possible to administer steroids in the epidural space due to patient’s allergy, then we can administer only local anesthetic. Case report: A 70 years old woman came to our clinic complaining with acute pain in her left lumbar back and left leg related to her L5-S1 radiculopathy. The patient reported skin rash and angioedema after a previous epidural with only triamcinolone. Method: After signing the consent form, in a aseptic technique, the patient receives only the local anesthetic (bupivacaine 5 mg and ropivacaine 4 mg diluted with physiological solution for a total volume of 6 ml) in the lumbar epidural space at L4-L5 via interlaminar approach. Clinical evaluation was performed before the procedure, immediately after the injection and at one, three and six months after injection using Numeric Rating Scale (NRS) and Oswestry Disability Index (ODI). Results: The patient reports an immediate pain reduction (NRS 10 before local anesthetic injection, NRS 4 immediately after the injection). Still after three months post injection, the patient reports a reduction of pain intensity (NRS 3) with 30 % ODI index. Conclusion: Epidural steroid injections have been widely used for over 50 years in the treatment of low-back pain with radiculopathy but many doctors do not believe in the efficacy of corticosteroids administered in the epidural space. Recent reviews have disclosed controversial results and have questioned the effectiveness of epidural steroid injections. Injecting only local anesthetic in the epidural space eliminates the side effects associated with corticosteroids; therefore, it is possible to repeat injection more frequently. Further studies are needed to evaluate the true role of local anesthetic in the epidural level. VL - 11 IS - 4 ER -
Email: