Department of Orthopaedic Surgery, Cappagh National Orthopaedic Hospital, Finglas, Dublin, Ireland.
Eur Spine J. 2011 May;20(5):804-7. doi: 10.1007/s00586-010-1613-5. Epub 2010 Nov 27.
Epidural steroid injections are an important therapeutic modality employed by spinal surgeons in the treatment of patients with chronic low back pain with or without lumbar radiculopathy. The caudal epidural is a commonly used and well-established technique; however, little is known about the segmental level of pathology that may be addressed by this intervention. This prospective study of over 50 patients aimed to examine the spreading pattern of this technique using epidurography. The effect of variation in Trendelenburg tilt and the eradication of lumbar lordosis on the cephalic distribution of the injectate were investigated. 52 patients with low back pain and radiculopathy underwent caudal epidural. All had 20 ml volume injected, comprised of 5 ml contrast (Ultravist™ Schering) 2 ml Triamcinolone (Adcortyl™ Squibb) and 13 ml local anaesthetic (1% lignocaine). Patients were randomised to either 0° or 30° of Trendelenburg tilt, as referenced from the lumbar spine. Patients were further randomised to presence or absence of lumbar lordosis, which was eradicated using a flexion device placed beneath the prone patient. A lateral image of each sacrum was obtained, to identify variations in sacral geometry particularly resistant to cephalic spread of injectate. The highest segment reached on fluoroscopy was recorded post injection. Fifty-two patients with a mean age of 50 years underwent caudal epidural. Thirty-one were in 0° head tilt, with 21 in 30° of head tilt. In each of these groups, 50% had their lumbar lordosis flattened prior to caudal injection. The median segmental level reached was L3, with a range from T9 to L5. Eradication of lumbar lordosis did not significantly alter cephalic spread of injectate. There was a trend for 30° tilt to extend the upper level reached by caudal injection (p=0.08). There were no adverse events in this series. Caudal epidural is a reliable and relatively safe procedure for the treatment of low back pain. Pathology at L3/4 and L4/5 and L5/S1 can be approached by this technique. Although in selected cases thoracic and high lumbar levels can be reached, this is variable. If pathology at levels above L3 needs to be addressed, we propose a 30° head tilt may improve cephalic drug delivery. The caudal route is best reserved for pathology below L3.
硬膜外类固醇注射是脊柱外科医生治疗慢性下腰痛伴或不伴腰椎神经根病患者的重要治疗方法。骶管硬膜外是一种常用且成熟的技术；然而，对于这种干预可能涉及的节段性病变知之甚少。这项对 50 多名患者的前瞻性研究旨在使用硬膜外造影检查来检查该技术的扩散模式。研究了特伦德伦堡倾斜度的变化以及腰椎前凸的消除对注射剂头侧分布的影响。52 例腰痛伴神经根病患者行骶管硬膜外注射。所有患者均注射 20ml 容积，包括 5ml 造影剂（UltravistTM Schering）、2ml 曲安奈德（AdcortylTM Squibb）和 13ml 局部麻醉剂（1%利多卡因）。患者随机分为特伦德伦堡倾斜 0°或 30°，参考腰椎。进一步随机分为腰椎前凸存在或不存在，使用置于俯卧位患者下方的弯曲装置消除腰椎前凸。获得每个骶骨的侧位图像，以确定对注射剂头侧扩散特别有抵抗力的骶骨几何形状的变化。注射后记录透视下达到的最高节段。52 例平均年龄 50 岁的患者接受骶管硬膜外注射。31 例头部倾斜 0°，30°头部倾斜 21 例。在这些组中，50%的患者在骶管注射前腰椎前凸变平。达到的中位节段水平为 L3，范围从 T9 到 L5。消除腰椎前凸并未显著改变注射剂的头侧扩散。30°倾斜有延长骶管注射达到的上水平的趋势（p=0.08）。该系列无不良事件。骶管硬膜外是治疗下腰痛的可靠且相对安全的方法。该技术可治疗 L3/4、L4/5 和 L5/S1 的病变。虽然在某些情况下可以达到胸段和高腰段水平，但这是可变的。如果需要治疗 L3 以上水平的病变，我们建议 30°头部倾斜可能会改善药物的头侧输送。骶管途径最好保留用于 L3 以下的病变。
