Caudal Steroid Injection
Performed by Top Pain Management Doctors in San Antonio, Texas
Caudal steroid injections (CSI), a specific approach of an epidural steroid injection, are used to diagnose and treat a variety of painful conditions, and under some circumstances, delay the need for surgery (Williams & Park, 2007). With CSI, a needle is guided through the sacrum of the spine to a location suspected of inducing painful stimuli. Once appropriately positioned, a solution can be injected through the needle directly to the site to relieve pain and inflammation. The solution generally consists of an anesthetic, or pain reliever, mixed with a steroid which acts as an anti-inflammatory.
CSI’s are one of the most commonly used interventions for the treatment of chronic pain in the lower back and extremities (Conn & al., 2009). CSI are most often performed with suspected nerve root injury and sciatica, or shooting leg pain, as the result of a herniated disc (Williams & Park, 2007). A herniated disc can cause compression of nearby nerve roots that manifest as shooting pain along the path of the nerve; this condition is known as a radiculopathy.
When a diagnosis is in doubt, CSI can be used to confirm and localize causes of pain (Williams & Park, 2007). However, in many cases, abnormal findings with imaging are simply incidental, and are not the actual cause of pain. By first using an injection to ensure pain relief, CSI serves a diagnostic purpose by confirming that an abnormal finding is, in fact, the cause of pain; especially before any invasive treatment options, such as surgery, are considered.
The spine consists of a column of bones, known as vertebrae, which are stacked atop one another from the pelvis to the base of the skull, protecting the spinal cord (Leonard, 1995). Each of these vertebrae are separated by cartilaginous, inter-vertebral discs composed of a tough, fibrous outer layer and filled with a soft, gelatinous inner layer. These discs support the vertebrae and allow them to shift across one another, facilitating movement of the spine. The fibrous outer layer is called the annulus fibrosus, and the gelatinous inner layer is called the nucleus pulposus. Disc herniation occurs when the nucleus pulposus pushes out through a weakening or tear in the annulus fibrosus (Nidus Information Systems, 2010). The lumbar spine, adjacent to the lower back, is the most common location of disc herniation (Amsterdam & Kilgore, 2009).
CSI are generally performed under fluoroscopic guidance, in which x-rays are used to provide real-time images of the needle passing through the internal structures of a patient. Fluoroscopic guidance is critical, as without it needle misplacement can occur up to 40% of the time (Williams & Park, 2007).
For a CSI, a patient lies draped upon a table on their stomach, while an area of skin from the lower spine to the tailbone is exposed and sterilized with alcohol and iodine (Williams & Park, 2007). The area is then numbed with an anesthetic injection, such as lidocaine, while the fluoroscope is positioned. The tailbone is situated just below several fused vertebrae of the lower spine, called the sacrum, which contains a tunnel (the sacral hiatus) surrounded by two bony protrusions (the sacral cornua). The physician will feel for these protrusions and insert the steroid injection needle inside the tunnel between. Using fluoroscopic guidance, the physician can then guide the needle to the target location before injecting a contrast-dye that registers on the fluoroscope to confirm placement and avoid blood vessels. Once the correct positioning is made, the doctor then injects an anesthetic/steroid solution.
Lower back and extremity pain can be a very difficult condition to treat, and in many cases leads to chronic pain over many years. Treatment for these conditions is specific to the exact cause, and CSI’s have been shown to be very effective for the treatment of sciatica, herniated discs and degenerative spinal stenosis. Many patients receiving CSI’s enjoy improved function and relief of pain for prolonged periods of time. For back pain persisting for six weeks or more, consultation with an interventional pain specialist can lead to early intervention of certain conditions with caudal steroid injections.
In general, CSI can be considered safe as there are few serious complications to receiving CSI (Amsterdam & Kilgore, 2009). Headache and fainting are perhaps the most common side effects. Complications following CSI’s tend to be related to needle placement or the effects of drug administration (Conn & al., 2009). Regarding needle placement, infections and bleeding are potentially worrisome complications. Rarely abscesses can form or the Dura Mater, thick lining of the spinal cord, can be punctured. Adverse reactions can occur to the medications as well, including allergic reactions, temporary hyperglycemia and steroid-related side effects. Proper technique mitigates these risks, as does use of fluoroscopy in guiding needle placement.
To help avoid any potential complications with the procedure, patients should let their physician know about any allergies, medications being used, and any history of bleeding problems, blood clots or other medical problems, as well as any prior surgeries the patient may have undergone (ExitCare, 2012). After undergoing the procedure, patients should also be vigilant and seek medical care for any onset of fever, increase in pain, redness, discharge or swelling at the injection site, or persistent shortness of breath, nausea or vomiting.
There is moderate evidence for the use of CSI’s for chronic lumbar radiculopathy and even failed back surgery syndrome (Heran, et al., 2008). Studies have shown that CSI provides short-term pain relief for up to 80% and long-term pain relief for up to 75% of patients with a lumbar (lower back) radiculopathy (Amsterdam & Kilgore, 2009). CSI has also been reported as beneficial for short- and long-term pain relief in Lumbar Spondylosis, Piriformis Syndrome, and Lumbar Spinal Stenosis (Isaac & Wang, 2008). A systematic review found strong evidence for the use of CSI’s in treating chronic low back and extremity pain as a result of disc herniation, failed back surgery syndrome, spinal stenosis and other discogenic pain without evidence of herniation (Conn & al., 2009). In all, over 40 studies on over 4000 patients have been conducted with the vast majority supporting the effectiveness of CSI’s (Williams & Park, 2007).
- Amsterdam, J., & Kilgore, K. (2009). Lumbar Spinal Stenosis. Retrieved from MD Consult. Bradley: Roberts: Clinical Procedures in Emergency Medicine, 5th Ed.
- Arden, N., et al. (2005). A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: the WEST study. Rheumatology, 1399-406.
- Conn, A., et al. (2009). Systematic Review of Caudal Epidural Injections in the Management of Chronic Low Back Pain. Pain Physician, 109-135.
- ExitCare. (2012). Epidural Steroid Injections. Retrieved April 15, 2012, from MD Consult.
- Heran, M., et al. (2008). Spinal Injection Procedures: A Review of Concepts, Controversies, and Complications. Radiol Clin N Am, 487–514.
- Isaac, Z., & Wang, D. (2008). Lumbar Spinal Stenosis. Retrieved from MD Consult. . Bradley: Roberts: Clinical Procedures in Emergency Medicine, 5th Ed.
- Leonard, R. (1995). Human Gross Anatomy: An Outline Text. Oxford University Press USA.
- Nidus Information Systems. (2010). Herniated Disk. Retrieved April 15, 2012, from MD Consult: http://www.mdconsult.com.ezproxy2.library.arizona.edu/das/patient/body/234155712-5/1108605568/10041/35144.html
- Williams, K., & Park, A. (2007). Epidural Cortisone Injections. Retrieved from MD Consult. Canale & Beaty: Campbell’s Operative Orthopaedics, 11th ed.: http://www.mdconsult.com.ezproxy2.library.arizona.edu/books/page.do?eid=4-u1.0-B978-0-323-03329-9..50042-8–cesec38&isbn=978-0-323-03329-9&sid=1302694986&uniqId=331724931-3#4-u1.0-B978-0-323-03329-9..50042-8–cesec39