We have assessed whether an epidural steroid injection is effective in the treatment of symptoms due to compression of a nerve root in the lumbar spine by carrying out a prospective, randomised, controlled trial in which patients received either an epidural steroid injection or an intramuscular injection of local anaesthetic and steroid. We assessed a total of 93 patients according to the Oxford pain chart and the Oswestry disability index and followed up for a minimum of two years. All the patients had been categorised as potential candidates for surgery. There was a significant reduction in pain early on in those having an epidural steroid injection but no difference in the long term between the two groups. The rate of subsequent operation in the groups was similar

Aims. The aim of this study was to determine the efficacy of repeat epidural steroid injections as a form of treatment for patients with insufficiently controlled or recurrent radicular pain due to a lumbar or cervical disc herniation. Patients and Methods. A cohort of 102 patients was prospectively followed, after an epidural steroid injection for radicular symptoms due to lumbar disc herniation, in 57 patients, and cervical disc herniation, in 45 patients. Those patients with persistent pain who requested a second injection were prospectively followed for one year. Radicular and local pain were assessed on a visual analogue scale (VAS), functional outcome with the Oswestry Disability Index (ODI) or the Neck Pain and Disability Index (NPAD), as well as health-related quality of life (HRQoL) using the 12-Item Short-Form Health Survey questionnaire (SF-12). Results. A second injection was performed in 17 patients (29.8%) with lumbar herniation and seven (15.6%) with cervical herniation at a mean of 65.3 days . (sd. 46.5) and 47 days . (sd. 37.2), respectively, after the initial injection. All but one patient, who underwent lumbar microdiscectomy, responded satisfactorily with a mean VAS for leg pain of 8.8 mm . (sd. 10.3) and a mean VAS for arm pain of 6.3 mm . (. sd. 9) one year after the second injection, respectively. Similarly, functional outcome and HRQoL were improved significantly from the baseline scores: mean ODI, 12.3 (. sd. 12.4; p < 0.001); mean NPAD, 19.3 (. sd. 24.3; p = 0.041); mean SF-12 physical component summary (PCS) in lumbar herniation, 46.8 (. sd. 7.7; p < 0.001); mean SF-12 PCS in cervical herniation, 43 (. sd. 6.8; p = 0.103). Conclusion. Repeat steroid injections are a justifiable form of treatment in symptomatic patients with lumbar or cervical disc herniation whose symptoms are not satisfactorily relieved after the first injection. Cite this article: Bone Joint J 2018;100-B:1364–71

Background. Guidelines recommend epidural steroid injections (ESI) for treating severe disc-related sciatica based on trial data showing modest reductions in leg pain, disability and surgery avoidance. Despite their widespread use, there is no clear evidence about which patients are more likely to benefit from ESI. The aim of this study was to generate consensus on potential predictors of outcome following ESI for disc-related sciatica to include in data collection in a future cohort study. Methods. A list of potential predictors of outcome following ESI was generated from existing literature and a consensus meeting with seven experts. Items were subsequently presented in a two-round on-line modified Delphi study to generate consensus among experts on which items are agreed as potential predictors of outcome from ESI (consensus defined as 70% agreement with ranking of remaining items). Results. An initial list of 53 items was generated and 90 experts were invited from seven countries to participate in the on-line Delphi study. Response rates were 48% (n=44) and 73% (n=33) for round 1 and 2 respectively. Twenty-eight additional items suggested by participants in round 1 were included in round 2. Of the 81 items, 14 reached consensus; across domains of medication use, previous surgery, pain intensity, psychosocial factors, imaging findings and type of injection. Highest ranked of remaining items included work-related and clinical assessment items. Conclusion. Based on expert consensus, items that can be routinely collected in clinical practice were identified as potential predictors of outcomes following ESI. These will be tested in a future multicentre cohort study. Conflicts of interest: No conflicts of interest. Sources of funding: This study is supported by Health Education England and the National Institute for Health Research (HEE/ NIHR ICA Programme Clinical Lectureship, Dr Siobhan Stynes, NIHR300441). The views expressed are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care

Background. Clinical guidelines recommend epidural steroid injection (ESI) as a treatment option for severe disc-related sciatica, but there is considerable uncertainty about its effectiveness. Currently, we know very little about factors that might be associated with good or poor outcomes from ESI. The aim of this systematic review was to synthesize and appraise the evidence investigating prognostic factors associated with outcomes following ESI for patients with imaging confirmed disc-related sciatica. Methods. The search strategy involved the electronic databases Medline, Embase, CINAHL Plus, PsycINFO and reference lists of eligible studies. Selected papers were quality appraised independently by two reviewers using the Quality in Prognosis Studies (QUIPS) tool. Between study heterogeneity precluded statistical pooling of results. Results. 2726 citations were identified; 11 studies were eligible. Overall study quality was low with all judged to have moderate or high risk of bias. Forty-five prognostic factors were identified but were measured inconsistently. The most commonly assessed prognostic factors were related to pain and function (n=7 studies), imaging features (n=6 studies), health and lifestyle (n=5 studies), patient demographics (n=4 studies) and clinical assessment findings (n=4 studies). No prognostic factor was found to be consistently associated with outcomes following ESI. Most studies found no association or results that conflicted with other studies. Conclusions. There is little, and low quality, evidence to guide practice in terms of factors that predict outcomes in patients following ESI for disc-related sciatica. The results can help inform some of the decisions about potential prognostic factors that should be assessed in future well-designed prospective cohort studies. Conflicts of interest: No conflicts of interest. Sources of funding: This study is supported by Health Education England and the National Institute for Health Research (HEE/ NIHR ICA Programme Clinical Lectureship, Dr Siobhan Stynes, NIHR300441). The views expressed are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care

Background. Clinical guidelines recommend epidural steroid injection (ESI) for severe sciatica but there is uncertainty of effectiveness. The POiSE study aims to identify factors, routinely collected in clinical practice that predict outcome in patients who have ESI. This presentation describes characteristics and early clinical outcomes of POiSE participants. Methods. Prospective cohort study in 19 NHS spinal services in England, inviting patients with sciatica listed for an ESI. Participant baseline characteristics and 6-week follow-up outcomes are presented. Outcomes include pain intensity (0–10 NRS), disability (Oswestry Disability Index 0–100) and global change in symptoms. Results. Over 24 months, 693 patients were invited to participate and 353 (51%) completed baseline questionnaires. Mean (SD) age 49.0 years (14.4), 60% female, and 46% (n=101) of those in work had certified time-off for sciatica. Mean pain intensity was 7.2 (2.0) and 6.2 (2.7) for leg and back pain respectively and mean disability (ODI) was 46.5 (18). 60% (n=210) had leg pain for >6 months. Average confidence at baseline (0 to 10) that the ESI would help symptoms was 5.7 (2.4). Of 217 patients reaching 6-week follow-up, mean leg and back pain intensity is 5.0 (2.8) and 4.9 (2.9) respectively and ODI 36.6 (20.4), with 57% reporting improvement (completely recovered/much better/better). Follow-up data collection at 6, 12 and 24-weeks post-ESI is ongoing. Conclusion. Interim analysis shows only just over half of patients are reporting improvement at 6 weeks post ESI. The POiSE cohort study will help better identify the patients with sciatica who are most likely to benefit from this treatment. Conflicts of interest. None. Sources of funding. This study is supported by Health Education England and the National Institute for Health and Care Research (HEE/ NIHR ICA Programme Clinical Lectureship, Dr Siobhan Stynes, NIHR300441). The views expressed are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care

To investigate the clinical effectiveness and complications of caudal epidural steroid injections in the treatment of sciatica in patients with an MRI proven sacral tarlov cyst. A Prospective case control study. All patients with corresponding radicular pain received a course of three caudal epidural steroid injections, two weeks apart and patients were reviewed at 3 months, 6 months and 1 year interval in a dedicated epidural follow up clinic. Data including demographics, MRI results, diagnosis and complications were documented. Outcome measures included the Oswestry Disability Questionnaire (ODQ), the visual analogue score (VAS) and the hospital anxiety and depression (HADS) score. Overall patient satisfaction was recorded on a scale of 0-10. 38 patients with a sacral tarlov cyst were compared to a matched control group. In the sacral cyst group, mean VAS for axial pain reduced from 5.859 to 2.59 at three months (p<0.001). VAS for limb pain reduced from 6.23 to 2.53(<0.005). Mean ODI reduced from 45.49 at first visit to 21.98 at 3 months. Mean HADS also improved from 17 to 7. There was no statistical difference between the two groups. BMI did not affect the outcome in either group. Based on our study, we conclude that presence of a sacral tarlov cyst is not a contraindication to caudal epidural steroid injection, as comparable significant improvement in both axial and limb pain in the short and intermediate periods was achieved without any major complications

Aim. Assess efficacy of caudal epidural injection with epidurogram with validated outcome measures. Introduction. The administration of local steroids and other drugs into caudal epidural space has been well established procedure in the management of low back pain with or without leg symptoms. Various studies have been done to assess the efficacy of the different routes of administration of epidural injections. However, only a few published prospective studies have been done on performing caudal epidural injections under fluoroscopic guidance with validated outcome measures. Methods. Between 2007 and 2009, a total of 129 patients underwent caudal epidural injections under image intensifier guidance with epidurogram. The study included 69 males and 60 females ranging from 20 to 80 years of age. They were prospectively followed up using validated outcome measures at 6 weeks, 3 months, 6 months and 12 months. Results. Out of 129 patients 120 patients were followed at one year. There was statistically significant improvement in mean Low Back Outcome Score (LBOS) and Oswestry Disability Index (ODI) Scores in these patients which was maintained at the end of one year. Based on LBOS and ODI scores, 76% of patients at 6 weeks, 68% at 3 months, 55% at 6 months and 49% at 1 year had excellent and good results. Patients with less than two levels of degenerative disc disease, with predominant unilateral leg symptoms and with symptomatic duration of less than 6 months had a better outcome of results when compared with patients with predominant back symptoms, multi-level degenerative disc disease, bilateral involvement and history of previous lumbo-sacral spine surgery. Discussion and Conclusion. Our study on caudal epidural injections done under fluoroscopic guidance indicate improved and predictable outcome in addition to the patient satisfaction

Aims. The aim of this study was to determine whether there is an increased prevalence of scoliosis in patients who have suffered from a haematopoietic malignancy in childhood. Methods. Patients with a history of lymphoma or leukaemia with a current age between 12 and 25 years were identified from the regional paediatric oncology database. The medical records and radiological findings were reviewed, and any spinal deformity identified. The treatment of the malignancy and the spinal deformity, if any, was noted. Results. From a cohort of 346 patients, 19 (5.5%) had radiological evidence of scoliosis, defined as a Cobb angle of > 10°. A total of five patients (1.4% of the total cohort) had a Cobb angle of > 40°, all of whom had corrective surgery. No patient with scoliosis had other pathology as a possible cause of the scoliosis and all had been treated with high doses of steroids for leukaemia, either acute or chronic myeloid, or acute lymphoblastic. Conclusion. There is an increased prevalence of idiopathic-like scoliosis and larger curves (Cobb angle of > 40°) associated with childhood leukaemia, which has not been previously reported in the literature. Causative factors may relate to the underlying disease process and/or its treatment. Cite this article: Bone Joint J 2021;103-B(8):1400–1404

Aims

The aim of this study was to report the long-term prognosis of patients with multiple Langerhans cell histiocytosis (LCH) involving the spine, and to analyze the risk factors for progression-free survival (PFS).

Purpose:. To evaluate if adding clonidine to a standard nerve root block containing local anaesthetic and steroid improved the outcome of patients with severe lumbar nerve root pain secondary to MRI proven lumbar disc prolapse. Methods:. We undertook a single blind, prospective, randomised controlled trial evaluating 100 consecutive patients with nerve root pain secondary to lumbar disc prolapse undergoing trans-foraminal epidural steroid injection either with or without the addition of clonidine. 50 patients were allocated to each arm of the study. The primary outcome measure was the avoidance of a second procedure- repeat injection or micro-discectomy surgery. Secondary outcome measures were also studied: pain scores for leg and back pain using a visual analogue scale (VAS), the Roland Morris Disability Questionnaire (RMDQ) and the Measure Your Own Medical Outcome Profile (MYMOP). Follow up was carried out at 6 weeks, 6 months and 1 year. Results:. No serious complications occurred. Of the 50 patients who received the addition of clonidine, 56% were classified as successful injections, with no further intervention required, as opposed to 40% who received the standard injection. This difference did not reach statistical significance (p=0.109, chi-squared test). All secondary measures showed no statistically significant differences between the groups except curiously, the standard group who had been classified as successful had better leg pain relief than the clonidine group (p=0.026) at 1 year. Conclusions:. This pilot study has shown a 16% treatment effect with adding clonidine to lumbar nerve root blocks and that it is a safe injectate for this purpose

Background. NICE guidance suggests that caudal epidural injections of steroid and local anaesthetic may be considered for acute and severe sciatica, however studies have demonstrated limited long-term benefit and impact on future surgery. This study aimed to investigate the use of caudal epidural injections in a district general hospital setting and the rate of subsequent operation. Methods. All patients undergoing caudal epidural injection between 1. st. January and 30. th. June 2015 were included. Records were reviewed to obtain diagnosis, pre- and post-epidural clinical findings, prior interventions, and subsequent operations. Results. A total of 141 patients underwent a caudal epidural, with a median age of 63 (18 – 90). 37 patients went on to surgical intervention within 3 years, resulting in a conversion rate of 26.1%. Amongst those not requiring surgery, 59 (56.19%) had disc herniation, 42 (40%) stenosis, 4 spondylolisthesis, and 1 a facet cyst. Pre-operatively 63.81% reported back pain and 93.33% sciatica. 39.05% of patients had sensorimotor changes. Post-operatively, 27.62% reported an improvement in their back pain, compared to 62.86% reporting improved leg pain. 36.59% of those with sensorimotor changes reported improvement. 32 later had a further caudal epidural or foraminal block, and 25 had facet and sacroiliac joint injections. Amongst those requiring surgery, 21 (56.76%) had disc herniation, 15 (40.54%) stenosis, and 1 spondylolisthesis (2.7%). Conclusion. In our series, approximately three quarters of patients undergoing caudal epidural injection did not subsequently require surgery. Lumbosacral radicular symptoms improved in two thirds, however the epidural was less effective at treating back pain. No conflicts of interest. No funding obtained

Dysphagia is a common complication of anterior surgery of the cervical spine. The incidence of post-operative dysphagia may be as high as 71% within the first two weeks after surgery, but gradually decreases during the following months. However, 12% to 14% of patients may have some persistent dysphagia one year after the procedure. It has been shown that female gender, advanced age, multilevel surgery, longer operating time and severe pre-operative neck pain may be risk factors. Although the aetiology remains unclear and is probably multifactorial, proposed causes include oesophageal retraction, prominence of the cervical plate and prevertebral swelling. Recently, pre-operative tracheal traction exercises and the use of retropharyngeal steroids have been proposed as methods of reducing post-operative dysphagia. We performed a systematic review to assess the incidence, aetiology, risk factors, methods of assessment and management of dysphagia following anterior cervical spinal surgery. Cite this article: Bone Joint J 2013;95-B:868–73

We determined the frequency, rate and extent of development of scoliosis (coronal plane deformity) in wheelchair-dependent patients with Duchenne muscular dystrophy (DMD) who were not receiving steroid treatment. We also assessed kyphosis and lordosis (sagittal plane deformity). The extent of scoliosis was assessed on sitting anteroposterior (AP) spinal radiographs in 88 consecutive non-ambulatory patients with DMD. Radiographs were studied from the time the patients became wheelchair-dependent until the time of spinal fusion, or the latest assessment if surgery was not undertaken. Progression was estimated using a longitudinal mixed-model regression analysis to handle repeated measurements. Scoliosis ≥ 10° occurred in 85 of 88 patients (97%), ≥ 20° in 78 of 88 (89%) and ≥ 30° in 66 of 88 patients (75%). The fitted longitudinal model revealed that time in a wheelchair was a highly significant predictor of the magnitude of the curve, independent of the age of the patient (p <  0.001). Scoliosis developed in virtually all DMD patients not receiving steroids once they became wheelchair-dependent, and the degree of deformity deteriorated over time. In general, scoliosis increased at a constant rate, beginning at the time of wheelchair-dependency (p < 0.001). In some there was no scoliosis for as long as three years after dependency, but scoliosis then developed and increased at a constant rate. Some patients showed a rapid increase in the rate of progression of the curve after a few years – the clinical phenomenon of a rapidly collapsing curve over a few months. A sagittal plane kyphotic deformity was seen in 37 of 60 patients (62%) with appropriate radiographs, with 23 (38%) showing lumbar lordosis (16 (27%) abnormal and seven (11%) normal). This study provides a baseline to assess the effects of steroids and other forms of treatment on the natural history of scoliosis in patients with DMD, and an approach to assessing spinal deformity in the coronal and sagittal planes in wheelchair-dependent patients with other neuromuscular disorders. Cite this article: Bone Joint J 2014;96-B:100–5

Aims

Symptomatic spinal stenosis is a very common problem, and decompression surgery has been shown to be superior to nonoperative treatment in selected patient groups. However, performing an instrumented fusion in addition to decompression may avoid revision and improve outcomes. The aim of the SpInOuT feasibility study was to establish whether a definitive randomized controlled trial (RCT) that accounted for the spectrum of pathology contributing to spinal stenosis, including pelvic incidence-lumbar lordosis (PI-LL) mismatch and mobile spondylolisthesis, could be conducted.

Purposes of the study and background. Pain of lumbar facet-joint origin is a common cause of low back pain in adults, and may lead to chronic pain and disability. At present, there is no definitive research to support the use of targeted lumbar facet-joint injections to manage this pain. The study's objective was to assess the feasibility of carrying out a definitive study to evaluate the clinical- and cost-effectiveness of lumbar facet-joint injections compared to a sham procedure. Summary of methods and results. This was a blinded parallel two-arm pilot randomised controlled trial. Adult patients referred to the pain and orthopaedic clinics at Barts Health NHS Trust with non-specific low back pain of at least three months' duration were considered for inclusion. Participants who had a positive result following diagnostic single medial branch nerve blocks were randomised to receive either intra-articular lumbar facet-joint injections with steroid or a sham procedure. All participants were invited to attend a combined physical and psychological programme. Questionnaires were used to assess a range of pain and disability-related issues. Healthcare utilisation and cost data were also assessed. Of 628 participants screened for eligibility, 9 were randomised to receive the study intervention and 8 participants completed the study. Conclusions. Due to the small numbers of participants recruited to the study, we were unable to draw any conclusions on the effectiveness of intra-articular lumbar facet-joint injections in the management of non-specific low back pain. We however demonstrated our ability to develop a robust study protocol and deliver the intended interventions safely, thus addressing many of the feasibility objectives. Stronger collaborations with primary care may improve the recruitment of patients earlier in their pain trajectory, suitable for inclusion in a future trial. Conflicts of interest: None. Sources of funding: National Institute for Health Research Health Technology Assessment programme grant (reference number 11/31/02)

Between 1986 and 1995, we treated with foraminal injection of local anaesthetic and steroids 30 patients with severe lumbar radiculopathy secondary to foraminal and extraforaminal disc herniation which had not resolved with rest and non-steroidal anti-inflammatory agents. They were assessed prospectively using standardised forms as well as the Low Back Outcome Score, and were reviewed at an average of 3.4 years (1 to 10) after injection by an independent observer (BKW). Relief of symptoms was obtained in 27 immediately after injection. Three subsequently relapsed, requiring operation, and two were lost to long-term follow-up. Thus 22 of the 28 patients available for long-term follow-up had considerable and sustained relief from their symptoms. Before the onset of symptoms 17 were in employment and, after injection, 13 resumed work, all but two in the same job. The average score before injection was 25 out of a possible 75 points. At follow-up, the overall average score was 54, and in those who had obtained relief of symptoms it had improved to a mean of 61. Based on these findings we recommend foraminal injection of local anaesthetic and steroids as the primary treatment for patients with severe radiculopathy secondary to foraminal or extraforaminal herniation of a lumbar disc

Aims

To develop and internally validate a preoperative clinical prediction model for acute adjacent vertebral fracture (AVF) after vertebral augmentation to support preoperative decision-making, named the after vertebral augmentation (AVA) score.

Thoracic back pain caused by osteoarthritis of a single costovertebral joint is a poorly recognised condition. We report a series of five patients who were successfully treated by resection arthroplasty of this joint. Each had received a preliminary image-guided injection of local anaesthetic and steroid into the joint to confirm it as the source of pain. The surgical technique is described. There were no complications. The pain improved from a mean of 7.0 (6 to 8) on a visual analogue scale to 2.0 (0 to 4) post-operatively. The final post-operative Oswestry disability index was a mean of 19.4 (9 to 38). Isolated osteoarthritis of a costovertebral joint is a rare but treatable cause of thoracic back pain. It is possible to obtain excellent short- and intermediate-term relief from pain with resection arthroplasty in appropriately selected patients

This review provides a concise outline of the advances made in the care of patients and to the quality of life after a traumatic spinal cord injury (SCI) over the last century. Despite these improvements reversal of the neurological injury is not yet possible. Instead, current treatment is limited to providing symptomatic relief, avoiding secondary insults and preventing additional sequelae. However, with an ever-advancing technology and deeper understanding of the damaged spinal cord, this appears increasingly conceivable. A brief synopsis of the most prominent challenges facing both clinicians and research scientists in developing functional treatments for a progressively complex injury are presented. Moreover, the multiple mechanisms by which damage propagates many months after the original injury requires a multifaceted approach to ameliorate the human spinal cord. We discuss potential methods to protect the spinal cord from damage, and to manipulate the inherent inhibition of the spinal cord to regeneration and repair. Although acute and chronic SCI share common final pathways resulting in cell death and neurological deficits, the underlying putative mechanisms of chronic SCI and the treatments are not covered in this review.

Aims

The aim of this study was to identify factors associated with poor outcome following coccygectomy on patients with chronic coccydynia and instability of the coccyx.