Literature References Supporting the Technique EPIDURAL STEROID LIT REFERENCES EFFICACY AND FLUORO USE Spine J. 2004 Sep-Oct;4(5):495-505. The effect of spinal steroid injections for degenerative disc disease. Buttermann GR. Midwest Spine Institute, 1950 Curve Crest Boulevard, Stillwater, MN 55082, USA. butte011@umn.edu BACKGROUND: No conclusive evidence exists to determine that spinal steroid injections give lasting improvement in patients with predominantly axial low back pain resulting from lumbar degenerative disc disease (DDD). PURPOSE: The objectives of the study were to determine the effect of epidural steroid injections (ESIs) and intradiscal steroid injections (ISIs) in patients who exhibit DDD symptoms for more than 1 year and to determine whether patients with inflammatory end-plate changes are a unique subgroup of DDD patients in terms of treatment response. STUDY DESIGN: Pain and function in patients with DDD were prospectively assessed by an outcomes questionnaire before and after various spinal injections. Further correlation was made with end-plate inflammatory (Modic Type 1) changes identified on magnetic resonance imaging (MRI). PATIENT SAMPLE: ESI was performed in 232 patients who were referred for treatment of DDD, and discography with or without intradiscal steroid was performed in 171 patients who were possible spinal arthrodesis candidates. OUTCOME MEASURES: Pain and function were determined by a self-administered outcomes questionnaire that consisted of a visual analog pain scale, pain drawing, Oswestry Disability Index, use of pain medication and opinion of treatment success. METHODS: ESI was performed in 93 patients with DDD and inflammatory end-plate changes and in 139 patients without inflammatory end-plate changes. Patients with inflammatory end-plate changes (n=78) or without inflammatory end-plate changes (n=93), all of whom were considered fusion candidates, underwent discography with or without intradiscal steroid in a randomized fashion. Pain and function were prospectively determined by a self-administered outcomes survey (VAS pain, Oswestry Disability index [ODI], pain diagram [PD] and opinion of success) before and after the patients' injection for a 2-year follow-up period. MRI and discography results were correlated with patient outcomes scores. RESULTS: ESI was effective in improving pain and function, as assessed by outcomes scores at short-term follow-up. However, at 2 years, less than one-third had not had additional invasive treatment. Patients with inflammatory end-plate changes had greater improvement in ODI and PD scores in the first 6 months than did those patients without the end-plate changes. Intradiscal steroid injections into discs with concordant pain at the time of discography led to significant improvement in patients with inflammatory end-plate changes in all outcomes scales, but only minimal temporary improvement in patients without the end-plate changes. Disc pressure manometry at the time of discography found that discs with adjacent inflammatory end-plate changes reproduced symptoms at pressures significantly lower than those in other types of discs. CONCLUSIONS: Spinal steroid injections, both ESI and ISI, are beneficial for a small number of patients with advanced DDD and chronic low back pain. For those patients in whom a beneficial effect is found, spinal steroid injection is a low-risk and rapid treatment option. Spinal steroid injections are more effective in patients with MRI findings of discogenic inflammation, specifically adjacent inflammatory end-plate changes. Bull Hosp Jt Dis. 2003;61(3-4):127-31. The role of caudal epidural injections in the management of low back pain. Banaszkiewicz PA, Kader D, Wardlaw D. Elective Orthopaedic Unit, Woodend Hospital, Aberdeen, United Kingdom. The value of caudal epidural steroid injections (CEI) in treatment of low back pain and sciatica is controversial. It is believed that CEI are mainly effective in treating acute radiculopathy at intermediate term follow up and have no long-term benefit. The objective of this study was to evaluate the role of CEI in the management of low back pain. This study reviews all patients with low back pain and sciatica treated with CEI in a one-year period (1997) in the orthopaedic department at Aberdeen. The case notes of 163 out of a possible 175 patients (87 female 76 male) with mean age of 51 years (range: 17 to 88 years) were reviewed. Data collected included primary symptoms, presentation time, presumed diagnosis, MRI diagnosis, grade of the surgeon ordering and performing the procedure, the quality and duration of response, and final outcome. Patients were regarded as having an Excellent response if they had good or excellent pain relief for more than 3 months, a Good response (6 weeks to 3 months), Fair (4 to 6 weeks), Brief (any pain relief for less than 4 weeks), and No relief. Forty-one percent of patients had either an excellent/good response to CEI while 34% were no better or worse. Patients presenting acutely or with predominantly leg pain symptoms did not respond any better to the CEI than chronic presentations or low back pain alone. Only 36 of 73 patients who were discharged had an Excellent/Good response. Therefore the response to CEI did not influence the decision to discharge half of the patients. The experience of the surgeon performing the procedure did not make a difference in the outcome. We found that the outcome of CEI was unpredictable. The clinical value of CEI remains unproven. The decision to perform the procedure may well remain a matter of personal choice and experience. J Bone Joint Surg Am. 2004 Apr;86-A(4):670-9. Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy. A prospective, randomized study. Buttermann GR. Midwest Spine Institute, 1950 Curve Crest Boulevard, Stillwater, MN 55082. BACKGROUND: Epidural steroid injection is a low-risk alternative to surgical intervention in the treatment of lumbar disc herniation. The objective of this study was to determine the efficacy of epidural steroid injection in the treatment of patients with a large, symptomatic lumbar herniated nucleus pulposus who are surgical candidates. METHODS: One hundred and sixty-nine patients with a large herniation of the lumbar nucleus pulposus (a herniation of >25% of the cross-sectional area of the spinal canal) were followed over a three-year period. One hundred patients who had no improvement after a minimum of six weeks of noninvasive treatment were enrolled in a prospective, non-blinded study and were randomly assigned to receive either epidural steroid injection or discectomy. Evaluation was performed with the use of outcomes scales and neurological examination. RESULTS: Patients who had undergone discectomy had the most rapid decrease in symptoms, with 92% to 98% of the patients reporting that the treatment had been successful over the various follow-up periods. Only 42% to 56% of the fifty patients who had undergone the epidural steroid injection reported that the treatment had been effective. Those who did not obtain relief from the injection had a subsequent discectomy, and their outcomes did not appear to have been adversely affected by the delay in surgery resulting from the trial of epidural steroid injection. CONCLUSIONS: Epidural steroid injection was not as effective as discectomy with regard to reducing symptoms and disability associated with a large herniation of the lumbar disc. However, epidural steroid injection did have a role: it was found to be effective for up to three years by nearly one-half of the patients who had not had improvement with six or more weeks of noninvasive care. Arch Phys Med Rehabil. 2004 Mar;85(3):479-84. Treatment of lumbar spinal stenosis with epidural steroid injections: a retrospective outcome study. Delport EG, Cucuzzella AR, Marley JK, Pruitt CM, Fisher JR. Christiana Spine Center, Newark, DE, USA. OBJECTIVE: To determine patient satisfaction, relief of pain, frequency of injections, change of function, and subsequent surgical rate in patients who received epidural steroid injections (ESIs) for the diagnosis of lumbar spinal stenosis (LSS). DESIGN: Retrospective review conducted using a standard set of questions asked over the telephone, 6 to 36 months after the patient received an ESI. SETTING: An outpatient spine center. PARTICIPANTS: One hundred forty patients at or over the age of 55 years diagnosed with LSS who received ESI(s). INTERVENTION: Transforaminal or caudal fluoroscopically guided ESIs with 60 to 100mg of triamcinalone in combination with local anesthetic or normal saline.Main outcome measures Duration and amount of pain relief, change in functional status, patient satisfaction, and surgical rate, assessed by a 5-item questionnaire. RESULTS: Of the 140 participants, 32% reported more than 2 months of pain relief, 39% reported less than 2 months of pain relief, and 29% reported no relief from the injection(s). Twenty percent subsequently had surgery. Fifty-three percent reported improvement in their functional abilities. Seventy-four percent where at least somewhat satisfied with ESI as a form of treatment. CONCLUSIONS: ESI is a reasonable treatment for LSS, providing one third of our patient population with sustained relief and more than half with sustained improvement in function. AJR Am J Roentgenol. 2003 Nov;181(5):1255-8. Efficacy of epidural injections of Kenalog and Celestone in the treatment of lower back pain. Stanczak J, Blankenbaker DG, De Smet AA, Fine J. Department of Radiology, Division of Musculoskeletal Imaging, University of Wisconsin Hospitals and Clinics, Clinical Science Center E3/311, 600 Highland Ave., Madison, WI 53792-3252, USA. jefferystanczak@hotmail.com OBJECTIVE: Epidural corticosteroid injections have been used extensively to treat lower back pain, but the relative effectiveness of one corticosteroid versus another has never been reported in a large patient series. We retrospectively reviewed 597 patients who had epidural corticosteroid injections to determine any difference in Kenalog or Celestone efficacy. MATERIALS AND METHODS: We reviewed charts and self-reported pain score evaluations of 597 patients who received either Kenalog or Celestone Soluspan as an epidural injection for the treatment of lower back pain from 1997 to 2002 at our university hospital and affiliated Veterans Affairs hospital. Kenalog was used for the initial 2 years and Celestone was used for the next 3 years. Fluoroscopic guidance was used to confirm epidural location, and each patient was injected with a mixture of 5 mL of 0.5% preservative-free lidocaine and 2 mL of either Kenalog 40 mg/mL (triamcinolone acetonide injectable suspension) or Celestone Soluspan 6 mg/mL (betamethasone sodium phosphate and betamethasone acetate injectable suspension). Each patient was given a standardized pain evaluation sheet that used an 11-point scale for initial pain severity. Scoring of pain compared with baseline during the following 14 days was based on a 5-point scale of pain improvement or worsening. RESULTS: On days 0-3 after the procedure, no statistical significance in improvement of lower back and buttock pain was seen between groups. On day 7, 59% of Celestone recipients and 73% of Kenalog recipients showed improvement in lower back pain (p = 0.002, Pearson's chi-square test), and 58% of Celestone recipients and 75% of Kenalog recipients had improvement in leg or buttock pain (p < 0.001). On day 14, 54% of Celestone recipients and 71% of Kenalog recipients showed improvement in lower back pain (p < 0.001), and 54% of Celestone recipients and 71% of Kenalog recipients had improvement in leg or buttock pain (p < 0.001). CONCLUSION: The epidural injection of Celestone Soluspan and Kenalog reduced lower back and radicular pain in more than half the patients, although Kenalog reduced pain in a significantly larger number of patients than Celestone Soluspan at 1 and 2 weeks after injection. J Orthop Surg (Hong Kong). 2000 Jun;8(1):39-44. Epidural steroid injection for sciatica: An analysis of 526 consecutive cases with measurements and the whistle test. Loy TT. Consultant Orthopaedic Surgeon, St. Paul's Hospital, Causeway Bay, Hong Kong. The effects of epidural injections of triamcinolone acetonide and bupivacaine in the treatment of sciatica were analyzed in a retrospective series of 526 consecutive cases with measurements. A new test (the whistle test) is described. There is a paucity of measureable parameters in reports on the subject in the literature, and many are not specific or symptom-oriented to sciatica. The procedure was performed by the same operator and reviewed one week post-operatively with measurements. 491 patients (93.35%) achieved excellent to good pain relief, backed by appropriate increases of straight-leg-raise measurements. But 17 patients (3.46%) of this group required surgery later. It is concluded that epidural steroid injection is a simple, cost-effective and minimally invasive treatment for sciatica, especially in the acute. It also serves as a method for crisis intervention and as a prognosticator. Am J Phys Med Rehabil. 2002 Dec;81(12):898-905. Fluoroscopically guided lumbar transformational epidural steroid injections in degenerative lumbar stenosis: an outcome study. Botwin KP, Gruber RD, Bouchlas CG, Torres-Ramos FM, Sanelli JT, Freeman ED, Slaten WK, Rao S. Florida Spine Institute, Clearwater, Florida 33765, USA. OBJECTIVE: To identify the short- and long-term therapeutic benefit of fluoroscopically guided lumbar transforaminal epidural steroid injections in patients with radicular leg pain from degenerative lumbar stenosis. DESIGN: This prospective cohort study performed at a multidisciplinary spine center. There were a total of 34 patients who met our inclusion criteria for the treatment of unilateral radicular pain from degenerative lumbar spinal stenosis who underwent fluoroscopically guided lumbar transforaminal epidural injections. Patients with radiculopathy, who did not respond to physical therapy, antiinflammatories, or analgesics, caused by degenerative lumbar stenosis and confirmed by magnetic resonance imagining received fluoroscopically guided lumbar transforaminal epidural steroid injections at the presumed symptomatic nerve root. The injectant consisted of 12 mg of betamethasone acetate and 2 ml of 1% preservative-free lidocaine HCL. Patients were evaluated by an independent observer and received questionnaires before the initial injection, at 2 mo, and at 12 mo after the injections. Questionnaires included a visual analog scale, Roland 5-point pain scale, standing/walking tolerance, and patient satisfaction scale. RESULTS: A total of 34 patients met our inclusion criteria and were followed for 1 yr. Seventy-five percent of patients had successful long-term outcome, reporting at least a >50% reduction between preinjection and postinjection pain scores, with an average of 1.9 injections per patient. Sixty-four percent of patients had improved walking tolerance, and 57% had improved standing tolerance at 12 mo. CONCLUSION: Fluoroscopically guided transforaminal epidural steroid injections may help reduce unilateral radicular pain and improve standing and walking tolerance in patients with degenerative lumbar spinal stenosis. J Spinal Disord Tech. 2002 Aug;15(4):269-72. Epidural injections for the treatment of symptomatic lumbar herniated discs. Wang JC, Lin E, Brodke DS, Youssef JA. UCLA Department of Orthopaedic Surgery, UCLA School of Medicine, Los Angeles, California 90095-6902, USA. Epidural steroid injections are widely used as part of the conservative care for symptomatic herniated lumbar discs. There are studies showing their effectiveness, and some studies demonstrating no clinical benefits. The purpose of this study was to evaluate the effectiveness of epidural steroid injections for patients with symptomatic lumbar disc herniations who were surgical candidates. Sixty-nine patients were diagnosed with a herniated disc in the lumbar spine and remained symptomatic despite conservative care, and were treated with an epidural injection in an attempt to avoid surgical discectomy. Of the total group of 69 patients (average age = 44.8 years, range 19-77 years, average follow-up = 1.5 years), 53 (77%) had successful resolution or significant decrease of their symptoms and were able to avoid surgery. Only 16 (23%) patients failed to have significant relief of their symptoms and required surgical treatment of their herniated disc. Epidural steroid injections have a reasonable success rate for the alleviation of radicular symptoms from lumbar herniated discs for up to twelve to twenty-seven months. Patients treated with injections may be able to avoid surgical treatment up to this period and perhaps even longer. Spine. 2002 Mar 1;27(5):509-14. The role of fluoroscopy in cervical epidural steroid injections: an analysis of contrast dispersal patterns. Stojanovic MP, Vu TN, Caneris O, Slezak J, Cohen SP, Sang CN. Interventional Pain Program, MGH Pain Center, Department of Anesthesia and Critical Care, MA General Hospital and Harvard Medical School, Boston, Massachusetts, USA. mstojanovic@partners.org STUDY DESIGN: A multicenter, retrospective analysis of cervical epidurograms. OBJECTIVES: To determine the effectiveness of the loss of resistance (LOR) technique in identifying the cervical epidural space. To delineate the pattern of epidural contrast spread during cervical epidural steroid injections. BACKGROUND: Previous studies have shown that if performed without fluoroscopy, the LOR technique can result in inaccurate needle placement in up to 30% of lumbar epidural steroid injections. To date, no study has examined accuracy of LOR technique and pattern of radiographic contrast spread in cervical epidural levels. METHODS: Epidurograms of 38 cervical epidural steroid injections in 31 patients were reviewed. The number of LOR attempts and pattern of contrast spread was analyzed. The effects of age, gender, MRI results, previous cervical laminectomy, and the physician's level of training were correlated with results. RESULTS: The authors found a 53% rate of false LOR during the first attempt to enter the epidural space. Unilateral epidural contrast spread was found in 51% and ventral epidural spread was found in 28% of cases. The average number of cervical vertebral levels covered with 2 mL of contrast was 3.14, with significantly wider spread noted in those patients who had not undergone previous cervical laminectomy. Other variables did not influence the accuracy of needle placement and pattern of epidural contrast spread. CONCLUSIONS: The loss of resistance technique may not be an adequate method for ensuring accurate needle placement in blindly performed cervical epidural injections. The use of epidurography can improve the accuracy of needle placement and medication delivery to targeted areas of pathology. Spine. 2002 Jan 1;27(1):11-6. Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study. Vad VB, Bhat AL, Lutz GE, Cammisa F. The Hospital for Special Surgery, New York, New York 10021, USA. vadv@hss.edu STUDY DESIGN: A prospective study randomized by patient choice from the private practice of a single physician affiliated with a major teaching hospital was conducted. OBJECTIVES: To compare transforaminal epidural steroid injections with saline trigger-point injections used in the treatment of lumbosacral radiculopathy secondary to a herniated nucleus pulposus. SUMMARY OF BACKGROUND DATA: Epidural steroid injections have been used for more than half a century in the management of lumbosacral radicular pain. At this writing, however, there have been no controlled prospective trials of transforaminal epidural steroid injections in the treatment of lumbar radiculopathy secondary to a herniated nucleus pulposus. METHODS: Randomized by patient choice, patients received either a transforaminal epidural steroid injection or a saline trigger-point injection. Treatment outcome was measured using a patient satisfaction scale with choice options of 0 (poor), 1 (fair), 2 (good), 3 (very good), and 4 (excellent); a Roland-Morris low back pain questionnaire that showed improvement by an increase in score; a measurement of finger-to-floor distance with the patient in fully tolerated hip flexion; and a visual numeric pain scale ranging from 0 to 10. A successful outcome required a patient satisfaction score of 2 (good) or 3 (very good), improvement on the Roland-Morris score of 5 or more, and pain reduction greater than 50% at least 1 year after treatment. The final analysis included 48 patients with an average follow-up period of 16 months (range, 12-21 months). RESULTS: After an average follow-up period of 1.4 years, the group receiving transforaminal epidural steroid injections had a success rate of 84%, as compared with 48% for the group receiving trigger-point injections (P < 0.005). CONCLUSION: Fluoroscopically guided transforaminal injections serve as an important tool in the nonsurgical management of lumbosacral radiculopathy secondary to a herniated nucleus pulposus. Orthopedics. 2001 Feb;24(2):145-9. Treatment of lumbosacral radicular pain with epidural steroid injections. Papagelopoulos PJ, Petrou HG, Triantafyllidis PG, Vlamis JA, Psomas-Pasalis M, Korres DS, Stamos KG. A' Department of Orthopedics, Athens University Medical School, Greece. Fifty patients with an average age of 47 years received epidural steroid injections for lumbosacral radicular pain due to disk herniation or spinal stenosis. All patients had failed previous conservative treatment. Mean follow-up was 24 months (range: 12-36 months). Immediately after injection, all 50 patients reported various degrees of relief from leg and back pain. At the last follow-up examination, 68% of patients were asymptomatic, 20% had no change in preinjection radicular symptoms, and 12% had various degrees of relief. No significant correlation was found between pain relief, age, or number of injections. Early pain relief may be anticipated after epidural steroid injections in 80% of patients with radicular symptoms due to disk herniation or spinal stenosis. Ann Rheum Dis. 2000 Nov;59(11):879-82. Comment in: Ann Rheum Dis. 2001 Jul;60(7):718. Comparison of the caudal and lumbar approaches to the epidural space. Price CM, Rogers PD, Prosser AS, Arden NK. Department of Pain Management, Portsmouth Hospitals NHS Trust, UK. Cathyprice@freeuk.com OBJECTIVES: To investigate the accuracy of placement of epidural injections using the lumbar and caudal approaches. To identify which factors, if any, predicted successful placement. METHODS: 200 consecutive patients referred to a pain clinic for an epidural injection of steroid were randomly allocated to one of two groups. Group L had a lumbar approach to the epidural space and group C a caudal approach to the epidural space. Both groups then had epidurography performed using Omnipaque and an image intensifier to determine the position of the needle. RESULTS: Body mass index (BMI), grade of operator, and route of injection were predictors of a successful placement. 93% of lumbar and 64% of caudal epidural injections were correctly placed (p< 0.001). 97% of lumbar and 85% of caudal epidural injections clinically thought to be correctly placed were confirmed radiographically. For epidural injections where the clinical impression was "maybe", 91% of lumbar injections, but only 45% of caudal injections were correctly placed. Obesity was associated with a reduced chance of successful placement (odds ratio (OR) 0.34 (95% confidence interval (CI) 0.17 to 0.72) BMI >30 v BMI <30). A more senior grade of operator was associated with a reduced chance of successful placement (OR 0.16 (95% CI 0.03 to 0.89) consultant v other). However, small numbers may have accounted for the latter result. CONCLUSIONS: The weight of the patient and intended approach need to be considered when deciding the method used to enter the epidural space. In the non-obese patient, lumbar epidural injections can be accurately placed without x ray screening, but caudal epidural injections, to be placed accurately, require x ray screening no matter what the weight of the patient. J Radiol. 1999 Sep;80(9):917-25. [Evaluation of the efficacy of foraminal infusions of corticosteroids guided by computed tomography in the treatment of radicular pain by foraminal injection] [Article in French] Berger O, Dousset V, Delmer O, Pointillart V, Vital JM, Caille JM. Service de Radiologie, Hopital d'Instruction des Armees Robert Picque, Bordeaux-Armees, France. PURPOSE: To evaluate the efficacy of foraminal steroid injections performed under CT guidance for the management of radicular pain. METHODS: Periganglionic infiltrations were performed in 160 patients with radicular pain refractory to medical treatment. Imaging showed either degenerative foraminal stenosis, herniated disk or postsurgical fibrosis. RESULTS: 102 patients (63.8%) had significant pain reduction. Pain relief was lasting in 68 (66.6%). CT showed the position of the needle tip, as well as the diffusion of the therapeutic compounds. CONCLUSION: We consider that CT-guided periganglionic steroid injections should be an integral part of the management strategy for radicular pain resistant to medical treatment. Spine. 2000 Jan 15;25(2):197-203; discussions 203-4. Nonoperative treatment for lumbar spinal stenosis. Clinical and outcome results and a 3-year survivorship analysis. Simotas AC, Dorey FJ, Hansraj KK, Cammisa F Jr. Physical Medicine and Rehabilitation Service, Hospital for Special Surgery, New York, New York, USA. simotas@hss.edu STUDY DESIGN: A cohort study of nonoperatively treated patients with lumbar spinal stenosis. OBJECTIVE: To assess the effectiveness of aggressive nonsurgical treatment for lumbar spinal stenosis. BACKGROUND DATA: While surgical treatment of lumbar spinal stenosis has been widely accepted, the natural history of this condition is poorly documented. Moreover, the effect of other available therapies is unclear. METHODS: Forty-nine patients meeting radiographic and clinical criteria for spinal stenosis underwent nonsurgical intervention consisting of therapeutic exercises, analgesics, and epidural steroid injections. Patients were followed for an average of 33 months. Outcome was assessed using a recently developed patient questionnaire for assessment of patients with lumbar spinal stenosis. Survival analysis was used to assess the probability of surgical intervention over the follow-up period. RESULTS: At 3 years following treatment, 9 of the 49 patients had undergone surgical intervention. Of the remaining 40 unoperated patients, it is reported that two suffered significant motor deterioration, one of whom still reported overall symptoms as mild improvement, and the other as definite worsening. Five of the 40 unoperated patients reported feeling overall symptoms as probably or definitely worse, 12 reported no change, 11 reported only mild improvement, and 12 reported sustained improvement. Twelve of the 40 unoperated patients also had none or only mild pain. CONCLUSIONS: The authors conclude that aggressive nonoperative treatment for spinal stenosis remains a reasonable option. Arch Dermatol. 1999 Nov;135(11):1359-64. The effects of epidural blockade on the acute pain in herpes zoster. Hwang SM, Kang YC, Lee YB, Yoon KB, Ahn SK, Choi EH. Department of Dermatology, Yonsei University Wonju College of Medicine, South Korea. OBJECTIVE: To evaluate the relief of acute pain and possible preventive effects on postherpetic neuralgia through the use of an epidural blockade in the acute stage of herpes zoster. DESIGN: Prospective, nonrandomized, comparative clinical trial. SETTING: A dermatologic clinic in a university hospital. PATIENTS: Sixty-five consecutive patients with pain due to acute herpes zoster were treated for a 7-day hospitalization period from July 1, 1996, through June 30, 1997. INTERVENTION: The consecutive patients were divided into 2 groups. Group A consisted of 30 patients who were seen from July 1, 1996, through December 31, 1996, and who were treated with intravenous acyclovir (5 mg/kg) for 7 days. Group B consisted of 35 patients who were seen from January 1, 1997, through June 30, 1997, and who were treated with intravenous acyclovir (5 mg/kg) and an epidural blockade for 7 days. The changes in the intensity of pain and the total duration of pain in both groups were assessed for 12 to 18 months. MAIN OUTCOME MEASURES: The number of days required for relief of pain and the total duration of pain. RESULTS: The mean +/- SD number of days required for relief of pain, which was rated on a scale of 100 (worst pain) to 0 (no pain), was significantly fewer in group B than in group A: it took 2.6 +/- 1.1 days to go from 100 to 50 on the relief-of-pain scale in group B, but 3.8 +/- 1.1 days in group A (P = .03), and 12.5 +/- 6.4 days to go from 100 to 10 in group B, but 20.1 +/- 14.6 days in group A (P = .04). The duration of late residual pain was significantly shorter in group B (5.9 +/- 5.8 days) than in group A (11.9 +/- 7.5 days) (P = .03). The total duration of pain was also significantly shorter in group B (18.5 +/- 9.3 days) than in group A (31.6 +/- 17.6 days) (P = .04). CONCLUSIONS: We believe that an epidural blockade combined with an antiviral agent is a very effective treatment modality for the pain of acute herpes zoster, and we recommend its use for the prevention of postherpetic neuralgia, with a view to shortening the total duration of pain, especially late residual pain. J Spinal Disord. 1999 Aug;12(4):331-40. Effects of epidural steroids on lumbar dura material properties. Slucky AV, Sacks MS, Pallares VS, Malinin TI, Eismont FJ. Department of Orthopedics and Rehabilitation, University of Miami School of Medicine, Florida, USA. Epidural steroid injections are commonly used in the treatment of low back pain and radiculopathy based on their antiinflammatory and analgesic benefits. However, steroids are known to affect collagen synthesis, material strength, and tissue healing. The purpose of this study was to assess the effects of serial epidural steroid injections on the material properties of the lumbar dura mater. Serial epidural steroid injections of saline or methylprednisolone at 2-week intervals were performed in three paired groups of canines; a separate noninjected group was used as controls. Postmortem, dural sample testing to failure and histologic analysis was performed. Mechanical failure testing revealed no clinically significant change in the transverse dorsal dura tensile strength between all saline-injected, steroid-injected, or noninjected controls. Histologic analysis demonstrated no overt disruption of collagen matrix organization; however, electron microscopy demonstrated a significant decrease in the number of intracytoplasmic mitochondria of dural fibroblasts in steroid-injected animals, suggesting a metabolic inhibitory effect within steroid-injected dura mater. In the clinical time frame of this study, serial epidural steroid injections appeared to produce no significant material or matrix changes in the lumbar dura. AJNR Am J Neuroradiol. 1999 Apr;20(4):697-705. Comment in: AJNR Am J Neuroradiol. 1999 Apr;20(4):537. Epidurography and therapeutic epidural injections: technical considerations and experience with 5334 cases. Johnson BA, Schellhas KP, Pollei SR. Center for Diagnostic Imaging, St Louis Park, MN 55416, USA. BACKGROUND AND PURPOSE: Even in experienced hands, blind epidural steroid injections result in inaccurate needle placement in up to 30% of cases. The use of fluoroscopy and radiologic contrast material provides confirmation of accurate needle placement within the epidural space. We describe our technique and experience with contrast epidurography and therapeutic epidural steroid injections, and review the frequency of systemic and neurologic complications. METHODS: Epidural steroid injections were performed in 5489 consecutive outpatients over a period of 5 1/2 years by three procedural neuroradiologists. In 155 cases (2.8%), the injections were done without contrast material owing to either confirmed or suspected allergy. The remaining 5334 injections were performed after epidurography through the same needle. Patients and referring clinicians were instructed to contact us first regarding complications or any problem potentially related to the injection. In addition, the referring clinicians' offices were instructed to contact us regarding any conceivable procedure-related complications. RESULTS: Only 10 patients in the entire series required either oral (n = 5) or intravenous (n = 5) sedation. Four complications (0.07%) required either transport to an emergency room (n = 2) or hospitalization (n = 2). None of the complications required surgical intervention, and all were self-limited with regard to symptoms and imaging manifestations. Fluoroscopic needle placement and epidurography provided visual confirmation of accurate needle placement, distribution of the injectate, and depiction of epidural space disease. CONCLUSION: Epidurography in conjunction with epidural steroid injections provides for safe and accurate therapeutic injection and is associated with an exceedingly low frequency of untoward sequelae. It can be performed safely on an outpatient basis and does not require sedation or special monitoring. Arch Phys Med Rehabil. 1998 Nov;79(11):1362-6. Fluoroscopic transforaminal lumbar epidural steroids: an outcome study. Lutz GE, Vad VB, Wisneski RJ. Department of Physical Medicine and Rehabilitation, Hospital for Special Surgery, New York, NY 10021, USA. OBJECTIVES: To determine the therapeutic value and long-term effects of fluoroscopic transforaminal epidural steroid injections in patients with refractory radicular leg pain. BACKGROUND DATA: Although numerous studies have evaluated the efficacy of traditional transsacral (caudal) or translaminar (lumbar) administration of epidural steroids, to our knowledge no studies have assessed specifically the therapeutic value of fluoroscopic transforaminal epidural steroids. STUDY DESIGN: A prospective case series that investigated the outcome of patients with lumbar herniated nucleus pulposus and radiculopathy who received fluoroscopic transforaminal epidural steroid injections. METHODS: Patients who met our inclusion criteria received fluoroscopically guided, contrast-enhanced transforaminal epidural administration of anesthetic and steroid directly at the level and side of their documented pathology. Patients were evaluated by an independent observer and received sequential questionnaires before and after injection, documenting pain level, activity level, and patient satisfaction. RESULTS: Sixty-nine patients met our inclusion criteria and were followed for an average period of 80 weeks (range, 28 to 144 weeks); 75.4% of patients had a successful long-term outcome, reporting at least a >50% reduction between preinjection and postinjection pain scores, as well as an ability to return to or near their previous levels of functioning after only 1.8 injections per patient (range, 1 to 4 injections). Of our patients, 78.3% were satisfied with their final outcomes. CONCLUSIONS: Fluoroscopic transforminal epidural steroids are an effective nonsurgical treatment option for patients with lumbar herniated nucleus pulposus and radiculopathy in whom more conservative treatments are not effective and should be considered before surgical intervention.