BACKGROUND: A volumetric caudal epidural steroid injection has been advocated to facilitate the delivery of medications to a lesion site. This study was aimed to examine the actual spreading patterns of this technique, using an epidurogram. METHODS: A total of 32 patients with chronic low back pain with a radiculopathy of various causes (degenerative spondylosis, herniated nucleus pulposus, spondylolisthesis, and spinal stenosis) were included. A volumetric caudal epidural injection of a 10 ml mixture of contrast medium 5 ml, 0.5% bupivacaine 1 ml, triamcinolone 1.5 ml (60 mg) and normal saline 2.5 ml was performed. Immediately after the cessation of the first spread, the subsequent solution of another 10 ml of contrast medium 5 ml, 0.5% bupivacaine 1 ml and normal saline 4 ml was injected. This procedure was repeated serially until the total volume equaled 50 ml. Continuous fluoroscopic imaging was obtained after each injection. RESULTS: Average time taken to complete the study was 37 seconds per every 10 ml. The spreading levels of the mixture were distributed mainly at the mid to lower lumbar area in the majority of the investigated patients. During the subsequent injections, these levels did not increase significantly. CONCLUSIONS: We concluded that the multiple small volume caudal epidural injections retraced their own tract repeatedly. This was thought to be due to the minimal resistance in the cephalad direction, anatomic variations and the Starling effect of epidural space.
Bupivacaine ; Epidural Space ; Humans ; Injections, Epidural* ; Low Back Pain* ; Radiculopathy ; Spondylolisthesis ; Spondylosis ; Starlings ; Triamcinolone

BACKGROUND: Hereditary spherocytosis(HS) is a clinically and biochemically very heterogeneous disorder The purpose of this study is to detect erythrocyte membrane protein abnormalities by SDS-PAGE and to investigate the frequency of erythrocyte membrane protein defects in hereditary spherocytosis and correlation between some of the hereditary spherocytosis biochemical subsets and the selected clinical phenotype. METHODS: We evaluated the clinical and laboratory characteristics of 14 normal healthy persons and 23 hereditary spherocytosis patients and 8 their family members. The patients were divided into three groups based on clinical and hematological severity(mild, typical, severe). In addition to routine hematologic determlnatlons, osmotic fragility and autohemolysis, RBC membrane protein analysis were performed in all patients by densitometric tracing of SDS-PAGE(sodium dodecyl sulphate polyacrylamide gel electrophoresis) stained by Coomassle blue utilizing both the discontinuous buffer system of Laemmli with acrylamide linear gradient from 4% to 12% and the continuous buffer system of Fairbank with exponential gradient of acrylamide from 3.5% to 17%. RESULTS: 1) The patients could be seperated into three classes of different clinical severity as mild(3 cases), moderate(16 cases) and severe(4 cases) on the clinical feature. 2) Eighteen patients(82.6%) among 23 hereditary spherocytosis revealed abnormal erythrocyte membrane protein and we detected six patients(26.1%) with spectrin deficiency combined with ankyrin reduction, 4 patients(17.4%) with ankyrin deficiency, 4 patients(17.4%) with isolated spectrin deficiency and 3 patients(13.0%) with band 3 deficiency. Five HS patients(21.7%) showed normal RBC membrane protein. 3) Eight HS and their family members showed same RBC membrane protein deficiency. 4) The type and degree of RBC membrane protein reduction were variale with spectrin at 66~94%, with ankyrin at 48~82% of normal levels. These showed that each patient had different clinical severities according to different RBC membrane protein levels and type. CONCLUSION: RBC membrane protein abnormalities were observed in 82.6% of HS patients. The combined spectrin and ankyrin deficiency is the most common molecular defect in HS. The clinical severity and biochemical expression is heterogeneous. SDS-PAGE analysis of RBC membrane protein was provided the diagnosis of RBC membrane defects and basic molecular studies. We believed that the early identification of the biochemical defect responsible for HS is important because it is helpful starling point for the identification of the primary molecular defect, and it could help to anticipate the clinical outcome of the disease. For these reasons, we consider the SDS-PAGE of the red cell membrane to be of crucial importance for a complete evaluation of children with HS. Further studies with more cases would be to clarify the correlation between clinical and biochemical phenotypes.
Acrylamide ; Ankyrins ; Cell Membrane ; Child ; Diagnosis ; Electrophoresis, Polyacrylamide Gel* ; Erythrocyte Membrane* ; Erythrocytes* ; Erythrocytes, Abnormal ; Humans ; Membrane Proteins ; Membranes ; Osmotic Fragility ; Phenotype ; Population Characteristics* ; Spectrin ; Starlings