INTRODUCTION: Epidural steroid injections are an integral part of nonsurgical management of radicular pain from lumbar spine disorders. We studied the effect of dexamethasone 8 mg epidural injections on the hypothalamic-pituitary-adrenal axis and serum glucose control of Asian patients. METHODS: 18 patients were recruited: six diabetics and 12 non-diabetics. Each patient received a total of dexamethasone 8 mg mixed with a local anaesthetic solution of lignocaine or bupivacaine, delivered into the epidural space. Levels of plasma cortisol, adrenocorticotropic hormone (ACTH), serum glucose after an overnight fast and two-hour postprandial glucose, as well as weight, body mass index, blood pressure and heart rate were measured within one week prior to the procedure (baseline) and at one, seven and 21 days after the procedure. RESULTS: Median fasting blood glucose levels were significantly higher on post-procedure Day 1 than at baseline. However, there was no significant change in median two-hour postprandial blood glucose from baseline levels. At seven and 21 days, there was no significant difference in fasting or two-hour postprandial glucose levels. Both ACTH and serum cortisol were significantly reduced on Day 1 compared to baseline in all patients. There was no significant difference in ACTH and serum cortisol levels from baseline at Days 7 and 21. CONCLUSION Our study shows that epidural steroid injections with dexamethasone have a real, albeit limited, side effect on glucose and cortisol homeostasis in an Asian population presenting with lower back pain or sciatica.
Adrenocorticotropic Hormone ; blood ; Adult ; Aged ; Blood Glucose ; analysis ; Body Mass Index ; Dexamethasone ; administration & dosage ; therapeutic use ; Diabetes Mellitus ; therapy ; Endocrine System ; drug effects ; Female ; Glucocorticoids ; administration & dosage ; Humans ; Hydrocortisone ; blood ; Hypothalamo-Hypophyseal System ; drug effects ; Injections, Epidural ; methods ; Male ; Middle Aged ; Pituitary-Adrenal System ; drug effects ; Postprandial Period ; Singapore ; Young Adult

BACKGROUND: Patient-controlled epidural analgesia (PCEA) is known to provide good postoperative analgesia in many types of surgery including laparoscopic surgery. However, no study has compared PCEA with patient-controlled intravascular analgesia (PCIA) in laparoscopic radical prostatectomy (LARP). In this study, the efficacy and side effects of PCEA and PCIA after LARP were compared. METHODS: Forty patients undergoing LARP were randomly divided into two groups: 1) a PCEA group, treated with 0.2% ropivacaine 3 ml and 0.1 mg morphine in the bolus; and 2) a PCIA group, treated with oxycodone 1 mg and nefopam 1 mg in the bolus. After the operation, a blinded observer assessed estimated blood loss (EBL), added a dose of rocuronium, performed transfusion, and added analgesics. The numeric rating scale (NRS), infused PCA dose, and side effects were assessed at 1, 6, 24, and 48 h. RESULTS: EBL, added rocuronium, and added analgesics in the PCEA group were less than those in the PCIA group. There were no significant differences in side-effects after the operation between the two groups. Patients were more satisfied with PCEA than with PCIA. The NRS and accumulated PCA count were lower in PCEA group. CONCLUSIONS: Combined thoracic epidural anesthesia could induce less blood loss during operations. PCEA showed better postoperative analgesia and greater patient satisfaction than PCIA. Thus, PCEA may be a more useful analgesic method than PICA after LARP.
Administration, Intravenous ; Analgesia ; Analgesia, Epidural ; Analgesia, Patient-Controlled ; Analgesics ; Anesthesia, Epidural ; Humans ; Injections, Epidural ; Laparoscopes ; Laparoscopy ; Methods ; Morphine ; Nefopam ; Oxycodone ; Pain Measurement ; Pain, Postoperative ; Passive Cutaneous Anaphylaxis ; Patient Satisfaction ; Pica ; Prostatectomy ; Thoracic Vertebrae

STUDY DESIGN: Prospective study. OBJECTIVES: This study compared the early postoperative analgesic effects and the postoperative nausea and vomiting (PONV) associated with 3 methods of pain control after posterior spinal decompression. SUMMARY OF LITERATURE REVIEW: Spinal surgery causes severe postoperative pain. Efficient and safe methods for postoperative analgesia after spinal surgery are necessary. MATERIALS AND METHODS: To determine the clinical symptoms and to assess improvements in postoperative pain, 52 patients in whom single-level posterior lumbar decompression was planned were randomly assigned to 3 groups. For postoperative pain control, 18 patients received a preoperative single-shot epidural injection (SEI), 16 patients received a postoperative continuous epidural injection (CEI), and 18 patients received only postoperative intravenous patient-controlled analgesia (IV-PCA). Patient ratings of pain intensity (visual analog scale score from 0 [no pain] to 10 [most severe pain]), nausea (from 0 [no nausea] to 5 [severe nausea]), and vomiting (from 0 [no vomiting] to 5 [severe vomiting]) were recorded immediately after the operation and at 4 hours, 12 hours, 1 day, and 2 days postoperatively. RESULTS: The CEI group showed significantly enhanced analgesic effects, followed by the SEI group and the IV PCA group (p < 0.05). PONV due to postoperative pain control was more severe in the IV PCA group than in the other 2 groups (p < 0.05). CONCLUSIONS: Continuous epidural injection (CEI) is effective for postoperative pain control and minimizes the occurrence of PONV after posterior spinal decompression.
Analgesia ; Analgesia, Patient-Controlled ; Decompression ; Humans ; Injections, Epidural ; Methods ; Nausea ; Pain, Postoperative ; Passive Cutaneous Anaphylaxis ; Postoperative Nausea and Vomiting ; Prospective Studies ; Spinal Stenosis ; Vomiting

OBJECTIVETo assess the early curative effect of epidural or intravenous administration of steroids during a percutaneous endoscopic lumbar discectomy (PELD).

METHODS28 consecutive patients who underwent PELD due to large lumbar disc herniation between November 2014 and January 2016 were followed up for 6 months. These patients were divided into two groups according to the treatment they received after PELD. 14 patients (Group A) were treated by PELD and epidural steroids, while the other 14 patients (Group B) were treated by PELD and intravenous steroids. We evaluated the effectiveness by the preoperative and postoperative visual analogue scale (VAS) scores for back and leg pain, and the postoperative Oswestry disability index (ODI) at 3 weeks after surgery via the clinical charts and telephone interview. Postoperative hospital stay and time return to work were investigated as well.

RESULTSThere is a significant decrease in VAS (back, leg), ODI, and time return to work (p < 0.05). For VAS (back), Group A showed a significant decrease compared with Group B at 1 day and 1 week after surgery (p = 0.011, p = 0.017). As for VAS (leg), Group A showed a significant decrease compared with Group B at 1 day, 1 week, 3 weeks, and 3 months follow-up examinations (p = 0.002, p = 0.006, p < 0.001, p < 0.001). For ODI, Group A showed a notable decrease compared with Group B (p < 0.001). The postoperative hospital stay in two groups was not statistically different (p = 0.636). But the time return to work in Group A was significantly shorter than that in Group B (p = 0.023).

CONCLUSIONPatients who underwent PELD with epidural steroid administration for large lumbar disc herniation showed favorable curative effect compared with those who underwent PELD with intravenous steroid administration.

Adult ; Betamethasone ; administration & dosage ; Diskectomy, Percutaneous ; methods ; Endoscopy ; Female ; Glucocorticoids ; administration & dosage ; Humans ; Injections, Epidural ; Injections, Intravenous ; Intervertebral Disc Displacement ; surgery ; Length of Stay ; Lumbar Vertebrae ; surgery ; Male ; Pain Measurement ; Retrospective Studies

Epidural steroid injection (ESI), which is commonly used for treatment of low back pain with lumbosacral radicular pain, can be performed via transforaminal, interlaminar, or caudal routes. The transforaminal route is generally regarded as more effective than the interlaminar route due to its high level of drug delivery to the ventral epidural space. However, in some postoperative patients, use of the transforaminal route may be difficult. Thus, there is an urgent need for technology that can offer more effective drug delivery to the ventral epidural space with fewer complications. In this context, we describe a case about our new method where patient has undergone oblique interlaminar lumbar epidural steroid injection (OIL-ESI) instead of transforaminal ESI. We treated a patient with OIL-ESI instead of transforaminal ESI. Patient was symptomatic improved at postoperative visits. Based on our findings, OIL-ESI may be a suitable alternative to transforaminal ESI.
Epidural Space ; Fluoroscopy ; Humans ; Injections, Epidural ; Low Back Pain* ; Methods ; Pain Management

Epidural steroid injection (ESI), which is commonly used for treatment of low back pain with lumbosacral radicular pain, can be performed via transforaminal, interlaminar, or caudal routes. The transforaminal route is generally regarded as more effective than the interlaminar route due to its high level of drug delivery to the ventral epidural space. However, in some postoperative patients, use of the transforaminal route may be difficult. Thus, there is an urgent need for technology that can offer more effective drug delivery to the ventral epidural space with fewer complications. In this context, we describe a case about our new method where patient has undergone oblique interlaminar lumbar epidural steroid injection (OIL-ESI) instead of transforaminal ESI. We treated a patient with OIL-ESI instead of transforaminal ESI. Patient was symptomatic improved at postoperative visits. Based on our findings, OIL-ESI may be a suitable alternative to transforaminal ESI.
Epidural Space ; Fluoroscopy ; Humans ; Injections, Epidural ; Low Back Pain* ; Methods ; Pain Management

Lumbar radicular pain is conventionally treated with transforaminal epidural injection under the guidance of fluoroscopy or computer tomography. However, fluoroscopic radiation can be hazardous in certain populations, including pregnant women. An adjustment of the amount of local anesthetic is required in this population. An alternative method of lumbar root block using ultrasound (US) guidance has recently been introduced. Here, we present the case of a pregnant woman with worsening lumbar radicular pain during her pregnancy and the management of her pain using US-guided pararadicular block.
Female ; Fluoroscopy ; Humans ; Injections, Epidural ; Low Back Pain* ; Methods ; Pregnancy ; Pregnant Women* ; Ultrasonography

OBJECTIVE: To estimate and compare radiation exposure during transforaminal fluoroscopy-guided epidural steroid injection (TFESI) at different vertebral levels. MATERIALS AND METHODS: Fluoroscopy-guided TFESI was performed in 181 patients. The patients were categorized into three groups according to the injected lumbosacral nerve level of L2-4, L5, or S1. Fluoroscopy time (FT) and dose area product (DAP) were recorded for all patients; correlations between FT and DAP were determined at each level, and both FT and DAP were compared between the different vertebral levels. RESULTS: The numbers of patients who received ESI at L2-4, L5, and S1 were 29, 123, and 29. Mean FT was 44 seconds at L2-4, 33.5 seconds at L5, and 37.7 seconds at S1. Mean DAP was 138.6 microGy.m2 at L2-4, 100.6 microGy.m2 at L5, and 72.1 microGy.m2 at S1. FT and DAP were positively correlated in each group (p values < 0.001). FT was significantly shorter at L5 than that at L2-4 (p = 0.004) but was not significantly different between S1 and L2-4 or L5 (p values = 0.286 and 0.532, respectively). DAP was significantly smaller at L5 and S1 than that at L2-4, but L5 and S1 were not significantly different. After correcting for FT, DAP was significantly smaller at S1 than that at either L2-4 or L5 (p values = 0.001 and 0.010). CONCLUSION: The radiation dose was small during a single procedure of ESI and showed differences between different lumbosacral spine levels.
Adult ; Aged ; Aged, 80 and over ; Female ; Fluoroscopy/*methods ; Humans ; Injections, Epidural ; Low Back Pain/drug therapy ; Lumbosacral Region/*innervation ; Male ; Middle Aged ; *Radiation Dosage ; Young Adult

PURPOSE: Total knee replacement is one of the most painful orthopedic procedures, and effective pain relief is essential for early mobility and discharge from hospital. The aim of this study was to evaluate whether addition of single-injection femoral nerve block to epidural analgesia would provide better postoperative pain control, compared to epidural analgesia alone, after total knee replacement. MATERIALS AND METHODS: Thirty-eight patients received a single-injection femoral nerve block with 0.25% levobupivacaine (30 mL) combined with epidural analgesia (femoral nerve block group) and 40 patients received epidural analgesia alone (control group). Pain intensity and volume of patient-controlled epidural analgesia medication and rescue analgesic requirements were measured in the first 48 hours after surgery at three time periods; 0-6 hours, 6-24 hours, and 24-48 hours. Also, side effects such as nausea, vomiting, and pruritus were evaluated. RESULTS: Median visual analog scale at rest and movement was significantly lower until 48 hours in the femoral nerve block group. Patient-controlled epidural analgesia volume was significantly lower throughout the study period, however, rescue analgesia requirements were significantly lower only up to 6 hours in the femoral nerve block group. The incidences of nausea and vomiting and rescue antiemetic requirement were significantly lower in the femoral nerve block group up to 6 hours. CONCLUSION: The combination of femoral nerve block with epidural analgesia is an effective pain management regimen in patients undergoing unilateral total knee replacement.
Aged ; Analgesia, Epidural/*methods ; Analgesia, Patient-Controlled/*methods ; Anesthetics, Local/administration & dosage/therapeutic use ; Arthroplasty, Replacement, Knee/*methods ; Bupivacaine/administration & dosage/analogs & derivatives/therapeutic use ; Female ; Femoral Nerve/*drug effects ; Humans ; Injections ; Male ; Middle Aged ; Nerve Block/*methods

OBJECTIVE: The present study was undertaken to evaluate the effectiveness of transforaminal epidural steroid injection (TFESI) with using a preganglionic approach for treating lumbar radiculopathy when the nerve root compression was located at the level of the supra-adjacent intervertebral disc. MATERIALS AND METHODS: The medical records of the patients who received conventional TFESI at our department from June 2003 to May 2004 were retrospectively reviewed. TFESI was performed in a total of 13 cases at the level of the exiting nerve root, in which the nerve root compression was at the level of the supra-adjacent intervertebral disc (the conventional TFESI group). Since June 2004, we have performed TFESI with using a preganglionic approach at the level of the supra-adjacent intervertebral disc (for example, at the neural foramen of L4-5 for the L5 nerve root) if the nerve root compression was at the level of the supra-adjacent intervertebral disc. Using the inclusion criteria described above, 20 of these patients were also consecutively enrolled in our study (the preganglionic TFESI group). The treatment outcome was assessed using a 5-point patient satisfaction scale and by using a VAS (visual assessment scale). A successful outcome required a patient satisfaction scale score of 3 (very good) or 4 (excellent), and a reduction on the VAS score of > 50% two weeks after performing TFESI. Logistic regression analysis was also performed. RESULTS: Of the 13 patients in the conventional TFESI group, nine showed satisfactory improvement two weeks after TFESI (69.2%). However, in the preganglionic TFESI group, 18 of the 20 patients (90%) showed satisfactory improvement. The difference between the two approaches in terms of TFESI effectiveness was of borderline significance (p = 0.056; odds ratio: 10.483). CONCLUSION: We conclude that preganglionic TFESI has the better therapeutic effect on radiculopathy caused by nerve root compression at the level of the supra-adjacent disc than does conventional TFESI, and the diffence between the two treatments had borderline statistical significance.
Triamcinolone Acetonide/*administration & dosage ; Spinal Stenosis/complications ; Retrospective Studies ; Radiculopathy/*drug therapy/etiology ; Patient Satisfaction ; Pain Measurement ; Middle Aged ; Male ; Lumbosacral Region ; Logistic Models ; Intervertebral Disk Displacement/complications ; Injections, Epidural/*methods ; Humans ; Glucocorticoids/*administration & dosage ; Fluoroscopy ; Female ; Bupivacaine/administration & dosage ; Anesthetics, Local/administration & dosage ; Aged ; Adult ; Adolescent