The lumbar spine is a complex structure providing support and flexibility, but its intricacy makes it prone to injury and pain, which ranges from mild discomfort to severe debilitation and has a high incidence and prevalence.Low back pain (LBP) is one the most persistent pain and experienced in almost 60%–80% of the population at some point in their lifetime¹. Andersson estimated the annual worldwide incidence of low back pain in adults is 15% and the point prevalence is 30%. Moreover, some studies have demonstrated that LBP is one of the most common causes of visits to a physician with no sex discrimination with mild, moderate or severe disability^2-4. Low back pain affects approximately 60- 85% of people during some point of their life^5-7. For the large majority of individuals, symptoms subside within few weeks⁸.Chronic low back pain (CLBP), defined as pain symptoms persisting beyond 3 months and affects 15-45% of population^9-11. Low back pain encompasses a wide spectrum of conditions, ranging from self-limited episodes to chronic, disabling pain caused by degenerative disorders, infection, inflammation, trauma, or tumors, with degenerative lumbar spine disorders being a significant global cause of disability¹². Lumbar disc herniation is a common cause of low back pain, with corticosteroids providing relief by inhibiting pro-inflammatory mediators and reducing nerve sensitivity. While oral pain medication is the usual initial treatment and symptoms often resolve spontaneously, recurrence rates are high within a year^13-14. Caudal epidural steroid injection, performed under fluoroscopic guidance, is an effective nonsurgical treatment for low back and radicular pain from herniated discs or stenosis, providing pain relief, improved function, and reduced surgical need. Combining intermittent fluoroscopy with epidurography ensures accurate localization within the epidural space^15-19.Caudal epidural steroid injections, when performed without fluoroscopic guidance, have a high incidence of incorrect needle placement, and fluoroscopy with epidurography ensures accurate delivery, making it a reliable treatment for chronic pain management despite anatomical challenges²⁰.

AIM

To study the efficacy of fluoroscopic guided caudal epidural steroid injection in management of low back pain.

A hospital-based prospective study was conducted in the Department of Orthopaedics and Trauma Centre at Sardar Patel Medical College, Bikaner, over a one-year period from May 2023 to April 2024, starting from ethical clearance until the completion of the sample size. The study received approval from the ethical committee at the beginning of the research. Patients were fully informed about the study procedures, and detailed written information was provided to explain the entire process.The study focused on patients suffering from chronic lower back pain, treated at the same institution. Inclusion criteria required patients to have unilateral lumbar radiculopathy lasting for more than 12 weeks, with leg pain radiating from the back to below the knee, which was comparable or worse in intensity than the back pain. Participants were aged between 19 and 70 years and had provided informed consent. Exclusion criteria included cauda equina syndrome, intraspinal pathology, severe paresis or pain, a history of spinal surgery or deformity, degenerative spondylolisthesis, pregnancy, ongoing breastfeeding, treatment with non-steroidal anti-inflammatory drugs or oral steroids, arterial vascular disease, psychiatric conditions with possible secondary gain, severe comorbidities, and patients not willing to participate.

SAMPLING TECHNIQUE: Consecutive sampling

SAMPLE SIZE

Minimum 50 cases of lower backache who attends OPD at

Department of Orthopaedics and Trauma centre, Sardar Patel Medical College, Bikaner.

As per study of Anderson et al.2 reported prevalence of lower backache was 15% with 5% error and 95% Confidence interval the minimum sample size was 50.

Formula used to estimate sample size:

 N=Z2 p (1-p)/d2

Here Z = Is standard normal variate (at 5% type I error (P<0.05) it is 1.96). p = as per previous studies prevalence of lower back ache is 15%.

d = Absolute error (10%)

 n= (1.96)2*15*85/(10)2

    =50.

Table 1. Age Distribution

Out of 55 cases maximum 49.09% were in 41-60 yrs age group and minimum 12.73% were in 61-80 yrs. The mean age of study population was 45.38 ± 12.13 with age range of 20- 80 yrs.

Table 2. Distribution of case according to chief complaints

All cases had pain and restriction of Range of movements as chief complaint

Table 3:Distribution of case according to conservative treatment before treatment

Prior to caudal epidural block all patients had form of conservative treatment as NSAIDs, and physiotherapy (58.18%).  

Table 4:Distribution according to Gait

We also examined the patient for gait and found that maximum 70.91% had normal gait whereas 29.09% had antalgic gait.

Graph 1:Distribution of case according to Range of movement (forward flexion in degree) and Pre procedure SLRT in degrees

When we clinically examine the cases we found that maximum 36.36% had forward flexion up to 60° followed by 30.91% up to 50° and 27.27% up to 40° whereas minimum 30° in 5.45% cases.  When we clinically examine the cases we found that maximum 36.36% had SLRT up to 30°followed by 34.55% up to 40° and 18.18% up to 20° whereas minimum 60° in 1.82% cases followed by 9.09% had SLRT up to 50°. 

Table 5 Distribution of case according to Modified schober test and  Reverse Lasegue Test

When we clinically examine the cases we found that Modified schober test was positive in 16 cases (19.09%) and Reverse Lasegue Test was positive in 13 cases (23.64%).

Table 6. Distribution of case according to VAS

According to VAS the we found that mean VAS was 7.87 ± 0.77 pre epidural caudal block and 3.38 ± 0.68 post epidural caudal block, and the difference was statistically significant. (p<0.05) 

Table 7 Distribution of case according to Oswestry Disability Index

Before the caudal epidural block, 85.45% of cases had severe disability according to the Oswestry Disability Index, with significant improvement after the procedure, as 89.10% of patients had mild disability at 7 days and 80% at 6 months, with a mean Oswestry Disability Index decreasing from 31.29 ± 3.10 to 10.89 ± 1.76 at 7 days and 8.70 ± 0.99 at 6 months, showing a statistically significant difference (p<0.0001).

Graph 2:Distribution of case according to outcome

In our study, maximum 94.55% cases were cured whereas 5.45% had recurrence.According to Oswestry Disability Index after caudal epidural block maximum 80% had good whereas 14.54% had excellent score and 5.45% had poor Oswestry Disability Index score.

Out of 55 cases maximum 49.09% were in 41 – 60 yr age group and minimum 12.73% were in 61 -80 yr. The mean age of study population was 45.38 ± 12.13 with age range of 20 – 80 yr. Similarly Krishna Kumar Pandey et al. (2023)21 on total 55 cases with the age group from 30 to 75 years with mean age of 51.07 ± 7.95 years.

 In our study, all cases had pain and restriction of Range of movements as chief complaint. We also observed all cases according to duration of chief complaints, they have reported to hospital with maximum 52.73% presented with in 1-2 years of complaints started followed by 23.64% cases presented within 1 year and 2 – 3 year respectively. Prior to caudal epidural block all patients had form of conservative treatment as NSAIDs, and physipotherapy (58.18%). Similarly V G Murakibhavi et al. (2011)22 found that all cases taken previous treatment and 3/4th cases had physiotherapy.

In our study, the patient for gait and found that maximum 70.91% had normal gait whereas 29.09% had antalgic gait. We found that maximum 36.36% had forward flexion up to 60° followed by 30.91% up to 50° and 27.27% up to 40° whereas minimum 30° in 5.45% cases. Maximum 36.36% had SLRT up to 30° followed by 34.55% up to 40° and 18.18% up to 20° whereas minimum 60° in 1.82% cases followed by 9.09% had SLRT up to 50°. Similarly Ibrahim Burak Atci et al. (2013)23 found that Mean straight leg rising degree was 47.82 ± 11.20 before the intervention. On follow-up, it was found to be 61.44 ± 12.20 at the end of the first month, 72.76 ± 11.23 at the end of the third month and 74.60 ± 14.55 at the end of the sixth month. The improvement of straight leg rising degree on follow- up when compared to admission values was statistically significant (P < 0.05)

In our study, modified schober test was positive in 16 cases (19.09%) and reverse Lasegue test was positive in 13 cases (23.64%) and according to VAS the we found that mean VAS was 7.87 ± 0.77 pre epidural caudal block and 3.38 ± 0.68 post epidural caudal block, and the difference was statistically significant. (p<0.05). Euddeum Shim et al. (2016)24 observed that on long-term follow-up rVAS analysis of the patients showed regression at 74% of the cases.

In our study, Oswestry Disability Index pre procedure maximum 85.45% cases had severe disability followed by 12.73% had complete disabled whereas minimum 1.82% had moderate disability. On follow up at 7 days, majority 89.10% cases had mild disability and followed by 10.90 had no disability. At 6 months majority 80% had mild disability followed by 14.54% had no disability and 5.45% had moderate disability.

Mean Oswestry Disability Index before caudal epidural block was 31.29 ± 3.10 whereas 10.89 ± 1.76 after 7 days of epidural block and 8.70 ± 0.99 after 6 months of follow up. (p<0.0001*) Similarly Ameet S. Nagpal et al. (2022)25 observed that rates of functional improvement as measured by mean improvement in Oswestry Disability Index (ODI) ranged from 2% to 55%.

In our study, maximum 94.55% cases were cured whereas 5.45% had recurrence. Similarly Ameet S. Nagpal et al. (2022)25 reported success rates in studies ranged from 40 to 58% at three months, 25%–67% at six months, and 58%–61% at one year.

In our study, according to Oswestry Disability Index after caudal epidural block maximum 80% had good whereas 14.54% had excellent score and 5.45% had poor Oswestry Disability Index score. Similarly Krishna Kumar Pandey et al. (2023)21 observed that majority (93%) were symptomatically better and had good functional outcome after 6 months of follow up, who underwent Caudal epidural steroid injection, while, only 7% had poor results.

Fluoroscopic guided caudal epidural steroid injection offers relatively simple, rapid and easily performed day care procedure that can offer significant pain relief and provides better quality of life. They are easy to perform under fluoroscopic guided technique, less skills demanding and with less complications compared with conservative treatment   and also who refuse surgery. Fluoroscopic guided caudal epidural steroid injections offer an interesting alternative approach in managing chronic low back pain.

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