Introduction and Aims: Caudal and lumbar epidural steroid injections have had a contentious history in the treatment of lumbar radiculopathy. We set out to assess the efficacy of these injections with relation to key discriminators and to assess the safety of these injections.

Method: After a literature search highlighted several possible discriminators regarding outcomes for lumbar radiculopathy and surgery we undertook a pilot study to assess the above aims. This took the form of a retrospective telephone interview. When our pilot study reached statistical significance after only 25 patients, we undertook a retrospective study of all 138 patients who had received a caudal or epidural steroid injection for radiculopathy in the last eight years. This took the form of a postal questionnaire, with telephone interview follow-up. Appropriate statistical analysis was performed for the paired and non-paired data collected.

Results: Of the 138 patients, 105 could be traced and of these it was possible to compare caudal vs. lumbar epidural in 75. All other comparisons were made on the full available population (105). We showed a statistically significant difference in the following: (i) an overall reduction in pain scores from 7.78 to 5.16 (mean values, difference –2.62, p< 0.0001); (ii) an overall increase in march tolerance from 804m to 1788m (mean values, difference 984m, p,0.0001); (iii) smokers had a higher level of pain overall before, immediately after and longer term than non(N)smokers (mean values smokers vs. non are; before 8.25:7.4, immediately 5.75:4.269, long-term 6.708:5.173, p< 0.01). We found no significant difference between sexes, activity-provoked pain, cough/impulse pain, unemployment due to pain or number of injections received. We had only one serious complication (anaphylactoid reaction) and 10 minor complications including headaches (five), pain at injection site (two), dizziness (one), hot flushes (one) and one diabetic patient had different insulin requirements for two days.

Conclusion: Although more research, ideally in the form of a randomised, controlled, double-blind trial is indicated, we have concluded that by either route these injections are a safe and effective measure of temporary pain relief for lumbar radiculopathy and that smoking is associated with higher levels of pain.

Background: Current treatment for Perthes disease aims at preventing deformation of the femoral head during the active stage of the disease by obtaining containment of the femoral head. To effectively pre-empt femoral head deformation, one needs to know, when during the disease irreparable femoral head deformation occurs. This study was undertaken to attempt to clarify this.

Methods: Records and 2634 pairs of radiographs (AP and lateral) of 610 patients with Perthes’ disease were reviewed. The evolution of the disease was divided into seven stages (Stages Ia, Ib, IIa, IIb, IIIa, IIIb & IV) based on plain radiographic appearances. Intra-observer and inter-observer reproducibility of this new classification system was assessed. The duration of each stage of the disease was noted. The stage at which epiphyseal extrusion and widening of the metaphysis occurred and the stage at which metaphyseal and acetabular changes appeared were identified. The shape and the size of the femoral head, the extent of trochanteric overgrowth and the radius of the acetabulum were assessed in hips that had healed.

Results: The reproducibility of the new classification system of the evolution Of Perthes’ disease was good. The median duration of each stage varied between 95 and 326 days. Epiphyseal extrusion and metaphyseal widening was modest in Stages Ia, Ib and IIa but increased dramatically after Stage IIb. > 20% extrusion occurred in 70% of the hips by Stage IIIa. Metaphyseal changes were most frequently encountered in Stage IIb, while acetabular changes were most prevalent in Stage IIIa. At healing, only 24% of untreated patients had spherical femoral heads, while 52% had irregular femoral heads.

Conclusions: The new classification of the stages of evolution of Perthes’ disease helps to identify when crucial events occur during the course of the disease. The timing of epiphyseal extrusion, metaphyseal widening and the appearance of adverse metaphyseal and acetabular changes suggest that femoral head deformation occurs by Stage IIIa in untreated hips. Hence, if containment were to succeed, it should be achieved before this stage.

Background: Femoral varus osteotomy for Perthes’ disease aims at achieving Containment to prevent femoral head deformation. Theoretically, ontainment is most likely to succeed if it is achieved before the femoral head extrudes and is subjected to deforming stresses. It would follow that the timing of the procedure is an important factor in determining the outcome. This study was undertaken to verify this.

Methods: Records and radiographs of 610 patients with Perthes’ disease were analysed. The data of 302 patients who underwent femoral osteotomy were compared with those of non-operated patients. A new modification of the Elizabthtown classification of the stages of evolution of the disease with seven stages (Stages Ia, Ib, IIa, IIb, IIIa, IIIb & IV) was used to identify the timing of surgery and to monitor the progress of the disease following surgery. The results of treatment were assessed at healing by Mose’s criteria. Multivariate analysis was used to identify variables that influenced the shape and size of the femoral head at healing.

Results: 22 patients among 86 who were operated in Stage Ia or Ib by-passed the stage of fragmentation. The extent of metaphyseal widening was considerably less in operated children. At healing, spherical femoral heads were seen in 72% of operated hips as compared to 24% of non-operated hips. The variables that influenced the shape of the femoral head at healing were, metaphyseal width, sex, age at onset, epiphyseal extrusion and the stage at surgery. Patients who were operated before Stage IIb had significantly better results than those operated later.

Conclusions: The results of the study support the impression that the timing of containment is an important factor that influences the outcome in Perthes’ disease. The best results are obtained if containment is achieved before Stage IIb.