Treating Sciatica with Epidural Intervention
Lower back pain or sciatica is often treated with epidural injections that include corticosteroids. These injections provide fast relief for acute cases and can be an alternative to spinal surgery for patients who are unable or unwilling to undergo the procedure.
Some individuals with chronic pain regularly visit pain clinics to receive repeated injections for their condition.
History
Around 1900 in Paris, epidural injections were first administered using cocaine instead of corticosteroids. This research paper investigates the origins and development of these injections, specifically examining their transformation from a modest laboratory procedure to a widely embraced medical treatment worldwide.
The primary goal is not solely to delve into historical facts but to comprehend how this therapy has flourished despite ongoing discussions about its efficacy and safety concerns.
The question of who treated the first patient with an epidural pain injection in the lower back is a subject of debate, with two competing claims. Jean-Anasthase Sicard made the first public mention of these injections during his address to the SocietƩ de Biologie in Paris on April 20, 1901.
However, prior to Sicard’s speech, Fernand Cathelin from Paris had already been administering epidural injections to patients for several months. Both Sicard and Cathelin did not invent these techniques outright but rather refined existing anesthetic methods that were previously described by James Corning from the United States and August Bier from Germany.
It’s worth noting that Figure 1 displays portraits of both individuals.
Corning is often acknowledged for performing the first direct spinal puncture in a living person in 1885. In an attempt to alleviate the effects of “spinal weakness and seminal incontinence” caused by habitual masturbation,
Corning injected a cocaine solution into the epidural space at the T11-T12 level. In 1895, Bier successfully induced lower body anesthesia by injecting a cocaine solution into the intrathecal space of one of his residents.
Unfortunately, this procedure resulted in complications, as the individual experienced a prolonged and severe headache lasting over a week due to low intracranial pressure.
Joining the laboratory of neurologists Fulgence Raymond and Edouard Brissaud at the renowned HĆ“pital de La SalpetriĆØre in 1896, Sicard embarked on his spinal research.
His project had two primary aims: first, to approach the study of the spine from a clinical standpoint rather than focusing solely on anatomy or physiology, and second, to introduce the practice of injecting medicinal fluids into the spine instead of extracting cerebrospinal fluid through lumbar puncture.
Sicard’s work was influenced by the prior contributions of Corning and Bier in the field, shaping his approach to spinal research.
Utilizing animal experimentation as a starting point, Sicard ventured into his research. By injecting a small amount of cocaine, he achieved successful lower body anesthesia in dogs.
Unlike Bier’s approach, Sicard adopted the “caudal route,” bypassing lumbar vertebrae and instead accessing the sacral roots through the first dorsal sacral foramen. This method involved carefully preserving the outer layer of the meninges and specifically targeting the epidural space.
To refine his skills, Sicard replicated these injections on human cadavers. Eventually, he progressed to administering such injections to patients suffering from pain, applying his expertise in a practical setting.
Sicard shared the clinical outcomes of nine patients during a SocietƩ de Biologie meeting in Paris on April 20, 1901. Among these cases, two individuals were afflicted with syphilitic myelopathy, two suffered from low back pain, and four presented with sciatica. Notably, the treatment administered by Sicard was not only devoid of pain and risk but also yielded significant success.
Famed as a prominent “pain doctor,” Sicard made significant contributions in the field. During World War I, he conducted alcoholizations to alleviate peripheral nerve injuries, specifically targeting causalgia.
Sicard’s pioneering work extended to contrast radiology, where he collaborated with Jacques Forestier to perform the first epidurogram. In contrast, Cathelin’s interests lay primarily in surgery and anesthesia, with less emphasis on pain management.
In 1925, Viner from Montreal adopted the caudal approach, substituting cocaine with novocain. He administered multiple injections to patients suffering from sciatica, leading to notable pain relief and favorable results.
Notably, the herniated disc, which is now widely recognized as a common cause of sciatica, was not widely acknowledged until 1934, when Mixter and Barr introduced this understanding.
In 1930, Evans employed the caudal injection technique with normal saline and procaine hydrochloride to treat 40 patients diagnosed with “idiopathic sciatica.” This treatment resulted in complete relief for 24 patients and notable improvement for 6 patients.
Evans’s innovative approach included the use of larger volumes, showcasing the diffusion of 100 ml of fluid throughout the spinal canal by injecting it at the base of the sacrum.
Cortisone, or “compound E,” was discovered in the early 1920s through Mayo Clinic research. Post-World War II, corticosteroid treatment yielded remarkable results for rheumatoid arthritis.
Italian rheumatologists Robecchi and Capra suggested that inflammation could also contribute to low back pain and sciatica. Successful cases involved hydrocortisone infiltration into the first sacral nerve root.
Further studies, such as Lievre et al.’s use of hydrocortisone for sciatica and Goebert et al.’s report on epidural corticosteroids in the United States, followed.
Uncontrolled trials between 1950 and 1990, summarized in Table 2 [21-29], focused on epidural corticosteroid administration for sciatica treatment. Intrathecal injections declined due to meningitis risk. Despite limitations, these studies influenced corticosteroid use for sciatica.
Conflicting results emerged from the first randomized controlled studies in the 1970s. A consistent positive response to epidural corticosteroids for sciatica remains elusive.
Present Status
The technique and applications of epidural injections have evolved over time, with variations in anesthetics and glucocorticoids used. The trend has shifted towards interlaminar and transforaminal injections guided by fluoroscopy.
While epidural corticosteroids are commonly administered for various spinal conditions, their effectiveness specifically for sciatica is supported by limited evidence. Safety studies have identified both common side effects and rare severe complications.
The FDA has issued warnings and implemented safety measures, prompting discussions among experts about the associated risks and necessary precautions. The ongoing debate surrounds the class warning for lumbar epidural injections.
The global spread of epidural injections was slow compared to other medical ideas. The introduction of corticosteroids and positive clinical trials in the 1960s and 1970s contributed to their popularity, despite limited scientific evidence.
More data and consideration of safety issues are needed. Severe complications from lumbar epidural injections for back pain and sciatica are rare.
Do you have more questions?Ā
What exactly is a lumbar epidural injection?
A lumbar epidural injection involves delivering medication, typically a corticosteroid with or without an anesthetic, directly into the epidural space around the spinal cord. The goal is to reduce inflammation and pain associated with sciatica.
What types of medication are used in lumbar epidural injections?
The injections usually contain a corticosteroid, such as methylprednisolone or triamcinolone, which reduces inflammation. Sometimes, a local anesthetic like lidocaine or bupivacaine is also included to provide immediate pain relief.
How does a lumbar epidural injection help with sciatica?
The injection helps by delivering anti-inflammatory medication directly to the area of irritation or compression around the nerve roots, which can reduce swelling, relieve pain, and improve function.
How long does it take for the injection to work?
Some patients may experience relief within hours due to the anesthetic. However, the full effects of the corticosteroid may take 2 to 7 days to become apparent.
How long do the effects of a lumbar epidural injection last?
The duration of pain relief varies. Some patients may experience relief for several weeks to months, while others may have a shorter duration of relief.
How many injections will I need?
This depends on your response to the first injection. Some patients may benefit from a series of three injections, spaced a few weeks apart, while others may require fewer or more injections.
Is the procedure painful?
You may feel some discomfort during the procedure, especially when the needle is inserted. However, most patients tolerate the procedure well, and local anesthetics are used to minimize pain.
What are the risks associated with lumbar epidural injections?
Risks are generally low but can include infection, bleeding, headache, nerve damage, or allergic reactions. Rarely, there can be more serious complications like a dural puncture or an epidural hematoma.
Can lumbar epidural injections cure sciatica?
While these injections can significantly reduce pain and inflammation, they do not cure the underlying cause of sciatica, such as a herniated disc or spinal stenosis.
Can I return to normal activities after the injection?
Most patients can return to normal activities the next day, but you should avoid strenuous activities for 24-48 hours after the injection.
Who is a good candidate for a lumbar epidural injection?
Patients with acute or chronic sciatica that hasn’t responded well to conservative treatments like physical therapy, medications, or rest may be good candidates. It’s also suitable for patients looking to delay or avoid surgery.
How effective are lumbar epidural injections for sciatica?
Clinical studies suggest that lumbar epidural injections can provide significant short-term pain relief for many patients. However, the long-term effectiveness is variable, and some patients may not experience significant relief.
What should I expect during the procedure?
During the procedure, you will lie on your stomach or side. After cleaning the injection site, the doctor will numb the area with a local anesthetic. Using X-ray guidance, the doctor will insert a needle into the epidural space and inject the medication.
Are there alternatives to lumbar epidural injections?
Yes, alternatives include physical therapy, oral medications, nerve blocks, radiofrequency ablation, and surgery, depending on the severity and cause of the sciatica.
Will the injection help with back pain as well as leg pain?
Lumbar epidural injections primarily target leg pain (radiculopathy) due to sciatica. They may also help with associated lower back pain, but the primary benefit is usually seen in leg pain relief.
Can I receive an epidural injection if I have other medical conditions?
Patients with certain medical conditions, like uncontrolled diabetes, infections, or blood clotting disorders, may need to discuss their situation with their doctor. In some cases, the procedure may need to be postponed or modified.
Are there any long-term side effects of lumbar epidural injections?
Long-term side effects are rare, but repeated corticosteroid injections can potentially weaken bones or tendons, and increase blood sugar levels in diabetic patients.
What should I do to prepare for the procedure?
Your doctor will give you specific instructions, which may include stopping certain medications before the procedure. You should also arrange for someone to drive you home afterward.
Can I receive a lumbar epidural injection if I am pregnant?
Lumbar epidural injections are generally avoided during pregnancy unless absolutely necessary, due to potential risks to the mother and fetus.
How is the injection site determined?
The injection site is usually determined by your symptoms and MRI or CT scan findings. The doctor uses imaging guidance, such as fluoroscopy, to ensure the needle is correctly placed in the epidural space.
What happens if the injection doesnāt relieve my pain?
If the injection doesnāt provide relief, your doctor may suggest other treatments, such as additional injections, physical therapy, or surgical options depending on the cause of your sciatica.
Will I need imaging tests before getting an epidural injection?
Yes, imaging tests like MRI or CT scans are usually required to pinpoint the exact cause of your sciatica and to help guide the injection.
Can I receive an epidural injection more than once?
Yes, but most doctors limit the number of injections to prevent potential side effects from the corticosteroids. Typically, no more than three injections are given within a six-month period.
What are the signs that I should call my doctor after the injection?
Contact your doctor if you experience severe pain at the injection site, fever, persistent headache, weakness, or loss of bladder/bowel control after the injection. These could be signs of complications requiring immediate attention.
What should I do after the injection to ensure the best results?
After the injection, rest for the remainder of the day. Follow your doctorās instructions, which may include resuming physical therapy or exercises to strengthen the back and reduce the risk of future flare-ups.
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