Pain reduction after lumbar epidural injections using particulate versus non-particulate steroids: intensity of the baseline pain matters.

OBJECTIVES: To compare pain relief after CT-guided lumbar epidural steroid injections (ESI) using particulate (triamcinolone) and non-particulate (dexamethasone) steroids, and to explore factors affecting the effectiveness of both steroid types. METHODS: This retrospective observational study included 806 patients with lumbar radiculopathy and corresponding MRI or CT abnormalities of the lumbar spine, who were matched using the propensity score method, yielding two cohorts of 209 patients each. Pain intensity was evaluated prior to the procedure using a pain numerical rating scale (NRS) with range 0-10. Reevaluation took place 1 day and 4 weeks post-injection. Logistic regression analysis and cubic splines applied to generalized additive models were implemented to assess the differences in pain reduction after ESI in the analyzed patient groups. RESULTS: Four weeks post-injection, the overall chance of ≥ 50% pain reduction was lower in the dexamethasone group than that in the triamcinolone group (odds ratio [OR] = 0.55; p < 0.012). In the dexamethasone cohort, the intensity of baseline pain and the presence of a herniated intervertebral disc in the infiltrated segment were both significant and independent predictors of ≥ 50% pain relief. Patients with baseline NRS score ≥ 7 points had markedly less chance of ≥ 50% pain relief than patients with NRS score < 7 (OR = 0.53; p < 0.032), whereas disc herniation increased the chances more than twofold (OR = 2.29; p < 0.044). There was no significant correlation between the effectiveness of triamcinolone and any analyzed concomitant variables. CONCLUSIONS: Triamcinolone was superior for lumbar radiculopathy of severe intensity. For mild to moderate pain, no benefit of using triamcinolone over dexamethasone was found. The effectiveness of dexamethasone was lower for stenotic spinal lesions than for disc herniation. KEY POINTS: • Triamcinolone is superior to dexamethasone for epidural treatment of severe lumbar radiculopathy. • For mild to moderate pain, dexamethasone could be equally effective. • Dexamethasone reduces pain caused by disc herniation much better than it does to pain caused by fixed stenotic spinal lesions.

Aortoenteric fistula as a complication of open reconstruction and endovascular repair of abdominal aorta.

The paper intends to present a review of imaging characteristics of secondary aortoenteric fistula (AEF). Mechanical injury, infection, and adherence of a bowel segment to the aorta or aortic graft are major etiologic factors of AEF after open aortic repair. The pathogenesis of AEF formation after endovascular abdominal aortic repair is related to mechanical failure of the stent-graft, to stent graft infection, and to persistent pressurization of the aneurysmal sac. The major clinical manifestations of AEF comprise haematemesis, melaena, abdominal pain, sepsis, and fever. CT is the initial diagnostic modality of choice in a stable patient. However, the majority of reported CT appearances are not specific. In case of equivocal CT scans and clinical suspicion of AEF, scintigraphy, (67)Ga citrate scans or (18)F-FDG PET/CT is useful. Diagnostic accuracy of endoscopy in evaluation of AEF is low; nevertheless it allows to evaluate other than AEF etiologies of gastrointestinal bleeding. Without adequate therapy, AEF is lethal. Conventional surgical treatment is associated with high morbidity and mortality. The endovascular repair may be an option in hemodynamically unstable and high-risk surgical patients. We also illustrate an example of a secondary AEF with highly specific albeit rare radiologic picture from our institution.