Epidural Steroid Injections for Chronic Back Pain
Artikel-ID: 7423Minimalinvasive Schmerztherapie lumbar epidural steroid injection x ray in ausgewählten und gut indizierten Fällen zu einer deutlichen Schmerzlinderung und Zunahme der Funktionalität des Patienten führen. Der ary Beitrag gibt einen kursorischen und kritischen Überblick über die Möglichkeiten der minimalinvasiven, interventionellen Schmerztherapie. Anabolika zum spritzen wissen wir, dass bei Schmerzpatienten eine strenge Korrelation von Untersuchungsbefunden 18Anamnese und radiologischen Befunden 23, 25, 42 fehlt. Aus diesem Grund können lumbar epidural steroid injection x ray, minimalinvasive Tests in diagnostisch prognostischer Hinsicht äusserst hilfreich sein. Intraartikuläre Injektionen, Infiltrationen an peripheren oder zentralen Nerven, transforaminale oder interlaminäre Infiltrationen an der Neuraxis können Aufschluss über die mögliche Ätiologie eines Schmerzgeschehens geben Meistens werden deshalb zeitlich verschoben zwei oder mehr Infiltrationen mit einem kurz und einem lang wirkenden Lokalanästhetikum durchgeführt.
Septic and Aseptic Complications of Corticosteroid Injections
Tsen; Epidural Catheter Design: History, Innovations, and Clinical Implications. Epidural catheters have evolved during the past several decades, as clinicians and manufacturers have sought to influence the quality of analgesia and anesthesia and reduce the incidence of catheter-related complications. This evolution has allowed a transformation from single-shot to continuous-infusion techniques and resulted in easier passage into the epidural space, more extensive medication distribution, and ultimately, improved patient satisfaction.
Particular catheter features, including the materials used, tip design, and orifice number and arrangement, have been associated with specific outcomes and provide direction for future development. Modifications in catheter materials, tip design, and orifice number and arrangement have been introduced over the past several decades in an attempt to improve analgesic and anesthetic outcomes.
We have emailed you at with instructions on how to set up a new password. If you do not receive an email in the next 24 hours, or if you misplace your new password, please contact:.
To get started with Anesthesiology, we'll need to send you an email. To add an email address to your ASA account please contact us:. Enter your username and email address. We'll send you a link to reset your password. Enter your email address. We'll send you your username identified by your email account. Login Log in to access full content You must be logged in to access this feature. Submitted for publication July 8, Accepted for publication February 7, Address correspondence to Dr.
Information on purchasing reprints may be found at www. Anesthesiology 07 , Vol. You will receive an email whenever this article is corrected, updated, or cited in the literature. You can manage this and all other alerts in My Account. You must be logged in to access this feature. FROM its origins as a modified ureteral catheter, the epidural catheter has evolved into versions made with silk, rubber, plastic, and coiled stainless steel. These changes resulted from a growing recognition that particular design elements could potentially influence catheter performance.
This article reviews the history of epidural catheter design, focusing on how modifications in the materials used, tip design, and orifice number and arrangement may have affected analgesic and anesthetic outcomes, and provides a summary of the comparative studies that evaluate the clinical performance of distinct epidural catheter design features. The most consistent entry into the epidural space for the administration of anesthesia occurred at the turn of the 20th century when the French physicians Jean A.
In , clinicians at the Louisiana State University Medical Center reported the first application of this technique to the obstetric population. A number of innovations attempted to prolong single-shot epidural procedures. In , Eugen B. Marine Hospital, Stapleton, Staten Island, New York , both affiliated with the United States Public Health Service during the Second World War, pioneered an approach to continuous caudal analgesia for the obstetric population in with the use of a modified Lemmon needle.
The authors reported occasional complications, such as needle breakage, and warned of the theoretical possibility of undetected needle migration into the subarachnoid space. In his early works, he described threading a gradated, round-tipped nylon ureteral catheter through a gauge Barker needle at the level of the lower lumbar vertebrae and connecting a rubber adapter or, alternatively, a gauge needle to the free end for dosing.
Several other investigators introduced the catheter as an alternative to an indwelling needle for continuous caudal anesthesia. Catheter curling, tearing, cracking, and improper sterilization were among the complications associated with this technique. With the collaboration of the surgeon James L. However, a high incidence of paresthesias, inadequate analgesia, unilateral blockade, and intravascular cannulation forced the collaborators to devise a new approach.
Familiar with the work by Francis R. Innovations in spinal and epidural catheterization, however, soon superseded this technique. They threaded plastic tubing in lieu of a ureteral catheter through a blunt-tipped gauge Tuohy needle at the level of the second lumbar interspace to provide analgesia or anesthesia for vaginal or cesarean delivery.
In the late s, John G. The caudal catheter, autoclaved in the straightened position to prevent kinking or curling, was placed at the same time as the lumbar catheter but was activated only when the parturient reached the second stage of labor.
By the second half of the 20th century, the practice of epidural analgesia had gained popularity in North America. In , Oral B. Obstetric anesthesia also gained momentum as epidural techniques became more widespread. The acceptance and proliferation of analgesic and anesthetic applications for the epidural catheter prompted further innovations in catheter materials and designs.
Catheter Design Innovations and Clinical Implications. During the past few decades, a number of innovations in the design and manufacture of epidural catheters have been made, including changes in the materials used, tip design, and orifice location and number.
Comparative studies that evaluate the clinical performance of these distinct epidural catheter design features have been performed; however, a number of factors should be acknowledged when interpreting their results. As a consequence, robust, blinded assessments of the altered epidural catheter design feature likely did not occur during the approval process, with claims regarding the efficacy of a design modification being the result of internal, manufacturer-conducted investigations.
Second, many of the published investigations were nonrandomized, open-labeled trials performed at a time when industry support and relevant conflicts of interest were not routinely disclosed.
It is possible that bias in conducting the research, interpreting the findings, or publishing the results may have occurred. Finally, some of the studies evaluating epidural catheter modifications were small in number and did not disclose whether anatomic approaches to the epidural space e. With an appreciation of these potential study limitations, the epidural catheter design features may be reviewed.
These properties, in turn, may influence clinical outcomes, such as analgesic spread, paresthesias, intravascular cannulation, kinking, breakage, and migration. During the past several decades, materials have evolved to improve the flexibility and reduce the complications associated with catheters.
Ureteral catheters used initially for cerebrospinal fluid drainage and then adapted for continuous spinal and epidural techniques were made of various materials.
In the s, woven natural silk catheters with gum elastic interior walls were widely available. Early prototypes were flexible at body temperature, required cold sterilization, and were equipped with red rubber adapters to connect with syringes.
By , autoclavable silk and nylon catheters impregnated with a woven gum coating for improved longevity and elasticity replaced previously imported products. Lacquered nylon number 3. Advances in the plastics industry eventually led to the development of catheters that better withstood the sterilization process. Polyethylene, a widely available plastic, is easily deformed during the autoclaving process and at body temperature. Polyvinylchloride catheters, available in bulk in the s, proved more resistant to kinking and easier to place than polyethylene versions; however, the intrinsic stiffness of polyvinylchloride may have contributed to a higher incidence of tissue trauma, intravascular cannulation, and dural punctures.
Polyvinylchloride tubing was cut, marked with centimeter gradations, and sterilized by autoclaving by individual anesthesia providers.
Nylon, a polyamide, largely replaced polyvinylchloride because of its improved tissue inertness, transparency, and tensile strength. The high melting point of nylon confers an ability to withstand the sterilization process and retain its shape at body temperature.
Nylon is sufficiently flexible to stretch rather than buckle or break, yet rigid enough to thread easily. Many currently available catheters are nylon blends. Polytetrafluoroethylene has an extremely low coefficient of friction that facilitates catheter placement, a high melting point, which minimizes thermolability, and greater tensile strength than polyvinylchloride or polyethylene.
Adult versions are gauge in diameter designed for use with a gauge epidural needle and are available in either single end-hole i. The materials used in the manufacture of catheters have been observed to have some effect on clinical performance, including ease of placement and removal and the incidence of paresthesias and intravascular cannulations.
Many commercially available catheters are made of nylon blends with intermediate bending stiffness, which facilitates threading and increases the likelihood of successful insertion.
The rigidity of catheter materials also seems to influence the incidence of paresthesias. Soft-tipped, flexible catheters are believed to result in fewer paresthesias because they curl up or change course as they brush against nerve roots or other obstacles in the epidural space.
A number of studies demonstrate a significantly lower incidence of paresthesias with springwound polyurethane versus non— wire-reinforced catheters table 2. In a study of attempts at epidural placement in parturients randomized to receive continuous epidural analgesia, Banwell et al. Slight modifications in the materials of non— wire-reinforced catheters by a single manufacturer seem to have a negligible impact on the incidence of paresthesias.
In a prospective cohort-controlled study of patients receiving either a gauge polyamide or a gauge polyurethane—polyamide catheter, Bouman et al.
Overall, evidence suggests that paresthesias occur less frequently with springwound polyurethane catheters compared with non—wire-reinforced nylon and polyamide—polyurethane blend catheters.
Studies comparing springwound catheters from different manufacturers, each of which has a different material surrounding the inner wire coil, are currently lacking. Catheter materials can also influence the incidence of intravascular cannulation. Collectively, softer, single end-hole catheters and, specifically, flexible wire-reinforced polyurethane catheters have been observed to have a lower incidence of intravascular cannulation compared with conventional catheters table 3.
In a study, Banwell et al. As in the case of paresthesias, slight changes in the materials of non—wire-reinforced catheters by a single manufacturer seem to have a negligible impact on the incidence of epidural vein cannulation. Catheter breakage also seems to be related to the mechanical properties of materials used.
However, comparative studies on the tensile strength of wire-reinforced versus non—wire-reinforced catheters have resulted in conflicting findings.
When stretched with a rubber-sleeved hemostat, catheters made of polyurethane demonstrated the greatest tensile strength. One nylon catheter demonstrated slightly less tensile strength, with another nylon catheter demonstrating significantly less. Interestingly, all catheters demonstrated less tensile strength under traction from a steel hemostat, with polyurethane and polyethylene catheters exhibiting the least.
These findings suggest that the use of a stainless steel hemostat or similar instruments should not be used to extract epidural catheters that are difficult to remove. Of note, some clinicians have characterized the elasticity associated with the wire-reinforced polyurethane catheter as a disadvantage; the distal tip may remain immobile and allow the proximal portion to stretch until breaking. Other investigators have observed diminished tensile strength of wire-reinforced versus non—wire-reinforced catheters and of springwound polyurethane catheters exposed to higher temperatures.
They concluded that these catheters were therefore unlikely to fracture under normal clinical circumstances. Paul, MN catheters were associated with a globally reported high incidence of occluded catheters.
Limiting the amount of catheter threaded into the epidural space may reduce the risk of this complication. Reports regarding neurologic sequelae from retained portions of broken catheters have been uncommon, suggesting that surgical removal is likely not warranted in the asymptomatic patient. Limited data preclude a robust assessment of whether the position and number of catheter ports significantly affect the spread of analgesia, incidence of paresthesias and intravascular cannulation, and potential for a multicompartmental blockade.
Some studies suggest that single-orifice, open-end catheters reliably detect intravascular and subarachnoid placements and limit infusions to one anatomic site.
Microtherapy - Zentrum für Wirbelsäulenchirurgie und Neurotraumatologie
There are two types of spinal stenosis: lumbar stenosis and cervical stenosis, in the Neck: Diagnosing Cervical Spondylosis with Flexibility Tests and X-Rays. The physician uses a fluoroscope (a type of x-ray device) to confirm that the tip of A lumbar epidural steroid injection is a method of treating lower back pain. Discitis after Lumbar Epidural Corticosteroid Injection: A Case Report and Analysis of the after total knee arthroplasty: early assessment by dual energy X -ray.