What is the role of epidural injections in the treatment of low back pain (LBP)?

Updated: Aug 22, 2018
  • Author: Jasvinder Chawla, MD, MBA; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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Answer

Answer

Epidural injections have been widely used in direct placement near the involved nerve root or by midline presentation, including caudal entry, and combining corticosteroids and local anesthetics of varying volumes. An intralaminar entry is directed more closely to the site of assumed pathology and requires less injectate than a caudal route. However, the caudal entry is usually considered a safer approach with only a small risk for inadvertent puncture of the dura or a neural structure. Transforaminal corticosteroid injections are more target-specific and require the least volume of injectate to reach the presumed pathoanatomic site or primary pain generator, by an approach through the ventral lateral epidural space.

When considering an epidural injection, each approach has its advantages and disadvantages. The caudal approach requires a large fluid volume, thus resulting in greater dilution of the active ingredient within the injectate. Because the needle cannula is initially threaded at a relatively parallel plane to the spinal canal, the risk of intravascular, subcutaneous, subperiosteal, or interosseous needle puncture is greater.

Disadvantages of the intralaminar approach can include overdilution of the injectate, extra-epidural or intravascular placement of the needle, preferential cranial and posterior flow of the solution, and dural puncture. The intralaminar approach is also more difficult in postsurgical patients and below the L4-5 level. [137] The transforaminal approach is difficult in the presence of a surgical osseous fusion or when spinal instrumentation is present. Other risks include intraneural or intravascular injection and spinal cord trauma. The use of fluoroscopy to direct needle placement and observe contrast flow should be a requirement to reduce the risk of these potential adverse events. [137, 138]


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