Korean J Pain.  2010 Dec;23(4):254-257. 10.3344/kjp.2010.23.4.254.

Single Shot Epidural Injection for Cervical and Lumbosaccral Radiculopathies: A Preliminary Study

• Nawani DP
• Agrawal S
• Asthana V

• KMID: 1454709
• DOI: http://doi.org/10.3344/kjp.2010.23.4.254

Abstract

BACKGROUND
Epidural steroid injection is an established treatment modality for intervertebral disc prolapse leading to radiculopathy. In cases where two levels of radiculopathy are present, two separate injections are warranted. Herein, we present our experience of management of such cases with a single epidural injection of local anaesthetic, tramadol and methylprednisolone, and table tilt for management of both radiculopathies.
METHODS
50 patients of either sex aged between 35-65 years presenting with features of cervical and lumbar radiculopathic pain were included and were subjected to single lumbar epidural injection of local anaesthetic, tramadol and methylprednisolone, in the lateral position. The table was then tilted in the trendelberg position with a tilt of 25 degrees, and patients were maintained for 10 minutes before being turned supine. All patients were administered 3 such injections with an interval of 2 weeks between subsequent injections, and pain relief was assessed with a visual analogue scale. Immediate complications after the block were assessed.
RESULTS
Immediate and post procedural complications observed were nausea and vomiting (20%), painful injection site (4%), hypotension (10%) and high block (4%). Pain relief was assessed after the three injections by three grades: 37 (74%) had complete resolution of symptoms; 18% had partial relief and 8% did not benefit from the procedure.
CONCLUSIONS
This technique may be used as an alternative technique for pain relief in patients with unilateral cervical and lumbar radiculopathies.

Keyword

cervical; epidural; lumbar; radiculopathy; steroid; tramadol

MeSH Terms

Aged
Humans
Hypotension
Injections, Epidural
Intervertebral Disc
Methylprednisolone
Nausea
Prolapse
Radiculopathy
Tramadol
Vomiting
Methylprednisolone
Tramadol

Reference

1. Côté P, Cassidy JD, Carroll L. The Saskatchewan Health and Back Pain Survey. The prevalence of neck pain and related disability in Saskatchewan adults. Spine. 1998; 23:1689–1698. PMID: 9704377.

2. Bovim G, Schrader H, Sand T. Neck pain in the general population. Spine. 1994; 19:1307–1309. PMID: 8066508.

3. Linton SJ, Halldén K. Can we screen for problematic back pain? A screening questionnaire for predicting outcome in acute and subacute back pain. Clin J Pain. 1998; 14:209–215. PMID: 9758070.

4. Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain. 1994; 117:325–335. PMID: 8186959.

5. Goebert HW Jr, Jallo SJ, Gardner WJ, Wasmuth CE. Painful radiculopathy treated with epidural injections of procaine and hydrocortisone acetate: results in 113 patients. Anesth Analg. 1961; 40:130–134. PMID: 13706221.

6. Berman AT, Garbarino JL Jr, Fisher SM, Bosacco SJ. The effects of epidural injection of local anesthetics and corticosteroids on patients with lumbosciatic pain. Clin Orthop Relat Res. 1984; 188:144–151. PMID: 6236001.

7. Catchlove RF, Braha R. The use of cervical epidural nerve blocks in the management of chronic head and neck pain. Can Anaesth Soc J. 1984; 31:188–191. PMID: 6704782.

8. Pawl RP, Anderson W, Shulman M. Cervero F, editor. Effect of epidural steroids in the cervical and lumbar region on surgical intervention for diskogenic spondylosis. Proceedings of the Fourth World Congress on Pain (Advances in Pain Research and Therapy). 1985. 9th ed. New York: Raven Press;p. 791–798.

9. Shulman M, Nimmagadda U, Valenta A. Cervical epidural steroid injection for pain of cervical spine origin. Anesthesiology. 1984; 61:A223.

10. Malhotra G, Abbasi A, Rhee M. Complications of transforaminal cervical epidural steroid injections. Spine. 2009; 34:731–739. PMID: 19333107.

11. Raj PP. Intervertebral disc: anatomy-physiology-pathophysiology-treatment. Pain Pract. 2008; 8:18–44. PMID: 18211591.

12. Koes BW, Scholten RJ, Mens JM, Bouter LM. Efficacy of epidural steroid injections for low-back pain and sciatica: a systematic review of randomized clinical trials. Pain. 1995; 63:279–288. PMID: 8719528.

13. Koes BW, Scholten RJ, Mens JM, Bouter LM. Efficacy of spinal steroid injection for low back ache and sciatica: an updated systemic review of randomized control trial. Pain Digest. 1999; 9:241–247.

14. Bogduk N, McGuirk B. Monotherapy. Medical management of acute and chronic low back pain. 2002. 13th ed. Netherlands: Elsevier Science;p. 143–162.

15. Abdi S, Datta S, Lucas LF. Role of epidural steroids in the management of chronic spinal pain: a systematic review of effectiveness and complications. Pain Physician. 2005; 8:127–143. PMID: 16850050.

16. Abdi S, Datta S, Trescot AM, Schultz DM, Adlaka R, Atluri SL, et al. Epidural steroids in the management of chronic spinal pain: a systematic review. Pain Physician. 2007; 10:185–212. PMID: 17256030.

17. Driessen B, Reimann W. Interaction of the central analgesic, tramadol, with the uptake and release of 5-hydroxytryptamine in the rat brain in vitro. Br J Pharmacol. 1992; 105:147–151. PMID: 1596676.

18. Raffa RB, Friderichs E, Reimann W, Shank RP, Codd EE, Vaught JL. Opioid and non-opioid components independently contribute to the mechanism of action of tramadol, an 'atypical' opioid analgesic. J Pharmacol Exp Ther. 1992; 260:275–285. PMID: 1309873.

19. Tsai YC, Chang PJ, Jou IM. Direct tramadol application on sciatic nerve inhibits spinal somatosensory evoked potentials in rats. Anesth Analg. 2001; 92:1547–1551. PMID: 11375844.

20. Pang WW, Huang PY, Chang DP, Huang MH. The peripheral analgesic effect of tramadol in reducing propofol injection pain: a comparison with lidocaine. Reg Anesth Pain Med. 1999; 24:246–249. PMID: 10338176.

21. Derby R, Lee SH, Kim BJ, Chen Y, Seo KS. Complications following cervical epidural steroid injections by expert interventionalists in 2003. Pain Physician. 2004; 7:445–449. PMID: 16858486.

22. Botwin KP, Castellanos R, Rao S, Hanna AF, Torres-Ramos FM, Gruber RD, et al. Complications of fluoroscopically guided interlaminar cervical epidural injections. Arch Phys Med Rehabil. 2003; 84:627–633. PMID: 12736872.

23. Scanlon GC, Moeller-Bertram T, Romanowsky SM, Wallace MS. Cervical transforaminal epidural steroid injections: more dangerous than we think? Spine. 2007; 32:1249–1256. PMID: 17495784.

24. Apostolou GA, Zarmakoupis PK, Mastrokostopoulos GT. Spread of epidural anesthesia and the lateral position. Anesth Analg. 1981; 60:584–586. PMID: 7196172.

25. Makki D, Nawabi DH, Francis R, Hamed AR, Hussein AA. Is the outcome of caudal epidural injections affected by patient positioning? Spine. 2010; 35:E687–E690. PMID: 20535042.

26. Setayesh AR, Kholdebarin AR, Moghadam MS, Setayesh HR. The trendelenburg position increases the spread and accelerates the onset of epidural anesthesia for cesarean section. Can J Anaesth. 2001; 48:890–893. PMID: 11606347.

27. Coppejans HC, Hendrickx E, Goossens J, Vercauteren MP. The sitting versus right lateral position during combined spinal-epidural anesthesia for cesarean delivery: block characteristics and severity of hypotension. Anesth Analg. 2006; 102:243–247. PMID: 16368837.