Pain

tens of thousands annually. There is remarkably little useful literature on the subject, given the numbers performed. There have been a number of reviews of the available information and even these fail to reach consensus. It can be said that although epidural steroid injections give modest help to acute sciatica, long-term benefit is not apparent. What, therefore, is their place? It is reasonable to offer patients with short-term sciatica (of, say, less than 1 year) an epidural that can be repeated once or twice if benefit accrues, but does not last. It is also the authors' practice to offer epidurals to all patients on the waiting list for surgery for decompression of nerve roots (discogenic or spondylotic). Long waiting lists are a particular peculiarity of UK healthcare [17,18].

Lumbar Steroid Epidural Injections

Epidural injection techniques vary widely; there is no evidence in favor of any method over another, provided both are properly practiced. The authors use the lumbar rather than the caudal route, trying to place the steroid-anesthetic mixture as close to the affected level as possible. Once the epidural space is located, the chosen mixture of steroid, with or without local anesthetic, is injected. It is the authors' practice to use 5-10 ml (depending on age, infirmity, etc.) of 0.375% plain bupivacaine plus 80 mg Depomedrone (methylprednisolone). The choice of local anesthetic or saline, methyl-prednisolone or triamcinolone, volume of injec-tate and route (caudal or lumbar) is operator dependent. There is no helpful scientific evidence. Neither steroid compound has a license for epidural use in the UK.

Despite the widespread use of epidural steroids, controversy still exists as to their mechanism of action and potential beneficial effects. Possible mechanisms of action include inhibition of phospholipase A2 (phospholipase A2 activity increases in the area of disc hernia-tion, causing release of arachidonic acids from cell membranes, from which inflammatory mediators are then manufactured), blockade of C-fiber transmission, mast cell stabilization and changes in capillary permeability. There are a few contraindications to the procedure, including sepsis close to the injection site, allergy to the planned drugs and bleeding diathesis of whatever cause. Problems that may occur when using epidural steroids include arachnoiditis, if accidental sub-arachnoid injection occurs, and systemic effects - worsening diabetes, Cushing's syndrome and later adrenal suppression if large and repeated doses are used. Menstrual irregularity has been reported. Serious side effects are rare and include infection (the incidence of this is unknown) and reports in the literature are sporadic. Accidental dural puncture, which occurs in 1% of cases, is a nuisance rather than a serious event. Management is bed rest and copious fluids by mouth for 24 hours. Rarely, epidural blood patch will be needed to cope with a persistent CSF leak headache [17,18].

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