Caudal Epidural/Epidurogram
Lumbar Epidural - lateral view
Lumbar Epidural - AP view (bird’s eye view)
The following is a case discussion carried out on pain caused by disc problems.
Case discussion
A male patient, 76 years old, consulted me a couple of weeks ago, in my clinic in Colombo, presenting with lower back pain despite a surgery performed on his lower back. He had undergone surgery on two occasions, by spinal surgeons. Despite the operations the back pain persists, he said.
This is not uncommon. He has had relief from surgery for about three months, especially the leg pain (sciatic pain). Spinal surgery helps the sciatic leg pain, but not the back pain in the Lumbo Sacral region.
Therefore, localised lower back pain is not an indication for surgery. The term, failed back surgical syndrome (FBSS) is used in this cohort of patients. It’s a straightforward diagnosis.
Despite the surgery there are disc bulges in 4-5 spaces (L2-S1). This was found on a fresh MRI scan that I carried out two weeks ago. Some of the disc bulges were old and some were of recent origin.
I came to this conclusion by comparing the old scans with the latest one. I did carry out two epidurals, one from the caudal end and the other from the mid lumbar region.
It is a good practice to carry out a fresh MRI scan to see the success of surgery. But costs are involved.
Information seen on the AP view cannot be demonstrated even with an MRI or CT scan. The spread of the dye gives a clue.
Note the absence of the dye on the right side which shows obstruction to the exiting nerve roots.
Outcome of the procedure
The patient is doing well after the procedure and having 90 percent pain relief after a week.
How long will the pain relief last? This is to be seen from the feedback from the patient.
Physiotherapy, walking, simple analgesics is the way forward.
If these measures do not help his long term pain the last resort is to insert a ‘spinal cord stimulator’.
This is an implantable device. This is very expensive, and not within the reach of many people including patients living in the west. The NHS will fund a limited number.
But we need to consider his age and assess the pros and cons. Does he need the hassle of going through a major procedure at his age?
Spinal Cord Stimulator
A right L4 root block done on 2/12/20 on a 49-year-old patient with an L4/5 disc bulge with pressure on the exiting right L4 root.
Dr Senasinghe MBBS, Dip in Pain Med, FFARCS, FFPMCA, CCST(U.K) is a consultant in pain medicine (United Kingdom and Sri Lanka) at the London Pain Management Centre, 31, Horton Place, Colombo 7, Sri Lanka and The Chaucer BMI private hospital in Canterbury, Kent, UK.
(To be continued next week)