Outcome of caudal epidural steroid injection in chronic low back pain

Caudal epidural injection can be considered in persistent low back or sciatic pain not responding to conservative measures. There has been dramatic increase in the use of epidural steroid injection. They are now one of the most commonly performed procedures in the United States for the management of low back pain. Experimental study. The study was conducted at Liaquat university Hospital and a private practice setup during the period from may 2009 to December 2011. Numeric rating scale [NRS] was used to document the intensity of pain. [0 no pain, 1-3 mild pain, 4-6 moderate pain, and 7-10 sever pain.] Inclusion criteria were adult patients between the ages of 18 to 60 years. History of moderate to severe lower back for a minimum period of 8 weeks. Exclusion criteria History of trauma, tuberculosis, and tumor related to the spine. Previous history of spine surgery. Uncontrolled medical illness, pregnancy. Sensitivity to injection drugs. A mixture of 9 ml of 1% lidocaine and 1ml [40 mg] of methyl prednisolone was taken in a 10 cc syringe. Anatomical landmarks were palpated and a 20 gage spinal needle was passed in sacral hiatus without fluoroscopic control. Hoosh test was performed and the mixture was injected. The injection was repeated a total of three times in non responders. Second injection was given after 48 to 72 hours and third after 2 weeks of second injection. The results were assessed soon after first injection, after two week, six weeks, three months and six months. Pain relief was taken as significant when 50% or more of reduction was seen in NRS. A total of 50 patients were included in the study. Mean NRS at base line was 6.8. Thirty two out of 50 patients show significant pain relief [50% or more reduction in NRS from base line] after single injection and were pain free at 6 months. Eighteen out of 50 patients show no relief soon after injection. The procedure was repeated in these patients and a total of three injections were given. Among these patients only 8 responded with significant pain relief which was sustained for 6 months. The remaining 10 [20%] patients did not responded and had no pain relief after third injection. These patients were referred to specialized centers. Mean NRS in 50 patients soon after injection was 3.86, after two weeks it was 3.56, after 6 weeks 2.64. Ten non responding patients were referred to specialized centers at this stage and in the remaining 40 [80%] patients became totally pain free at 3 and 6 months after injection. Caudal epidural steroid injection is effective in patients with chronic low back pain. In majority of patients good long term pain relief is achieved. The procedure is easy to perform and has low complication rate. Failure rate may be high if the injection is performed without fluoroscopic control

Tennis elbow: role of local steroid injection

Tennis elbow is a condition, characterised by pain and tenderness over the lateral epicondyle of the humerus, and pain on resisted dorsiflexion of the wrist, middle finger, or both. The aim of this randomised controlled trial was to investigate the short term efficacy of local steroid injection compared with oral and topical NSAIDs. Sixty patients [45 male and 15 female] were included in the study. The mean age was 42 years for men and 40 years for women. They were placed in group A and B [30 cases each]. Group A received local steroid injection [triamcinolone 20 mg mixed with lignocaine 2% 1 cc] and topical NSAID cream application [diclofenac diethylammonium] twice a day, tab. diclofenac sodium 50 mg twice a day for 3 weeks. Group B received tab diclofenac 50 mg twice a day and, topical NSAID cream application twice a day for 3 weeks. Assessment of patients was made 3 times; first at the start of the study, 2[nd] time after 6 weeks, and 3[rd] time after 12 weeks. A blinded assessor rated the elbow complaints of the patients at resisted dorsiflexion of wrist using VAS [0=no severity, 1-3 mild, 4-6 moderate, 7-9 sever, 10=maximum severity]. At six weeks, 22 [73.33%] patient in group A had no pain as compared to 7 [23.33%] patients in group B who were pain free [p<0.0001, chi-square=38.75]. At 12 weeks 27 [90%] patients in group A were pain free compared to group B in which 7 [23.33%] patients were pain free [p<0.0001, chi-square=27.56]. In patients with tennis elbow, the use of local steroid injection in combination with topical and oral NSAIDs is superior to the use of combination of topical and oral NSAIDs. Better results with combination therapy using local steroid injection may be limited to the short term.

Chronic carpal tunnel syndrome: results of carbal tunnel release

Carpal tunnel syndrome [CTS] is the commonest entrapment neuropathy for which several conservative and surgical treatment options are available. In majority of cases the cause of CTS is unknown [idiopathic CTS], however, there are numerous medical conditions associated with CTS. Surgery for CTS is one of the most often performed procedures. The purpose of this study was to evaluate the clinical outcome of surgical treatment of chronic carpal tunnel syndrome. Thirty patients with chronic CTS were selected for open carpal tunnel release. Twenty patients had bilateral disease. Thirty hands had thenar muscle atrophy. Fifty hands of thirty patients were operated from May 1997 to December 2002. Sensation improved within three months in all patients. Nocturnal pain disappeared within first week after surgery. Grip strength improved gradually even up to two years after surgery. All of thirty hands with thenar muscle atrophy showed symptomatic relief, but recovery of the wasted muscle in term of regaining bulk was very slow in most of cases. Only ten hands showed complete recovery of bulk of thenar muscles in three years time. Surgery is an excellent treatment option in chronic CTS in terms of symptomatic relief. Wasted thenar muscles recover slowly in fraction of cases

Flexor carpi ulnaris transfer to improve function and cosmesis of hand in patients with cerebral palsy

Function and appearance of the involved hand in patients with cerebral palsy can be improved by orthopedic surgery especially in spastic hamiplegia. Flexor carpi unlnaris transfer to extensor carpi radialis longus or bravis is a procedure commonly used for correction of flexion pronation deformity of hand in patients with cerebral palsy. Twenty patients with the mean age 7.5 years were selected for the procedure. Eight patients were in Zancolli class I, and 12 were in Zancolli class II. Green and Banks technique was used. Seventeen out of twenty patients had good functional improvement and cosmetic appearance. There parents were satisfied with the results. In three patients functional improvement and cosmetic appearance was fair but parents were not satisfied with the results. Green and Banks procedure is good for cerebral palsy patients with moderate flexion pronation deformity at wrist. Functional and cosmetic appearance of hand improves considerably with this procedure