title: The role of adding hyaluronidase to fluoroscopically guided caudal steroid and hypertonic saline injection in patients with failed back surgery syndrome: a prospective, double-blinded, randomized study.
abstract: BACKGROUND
  Failed back surgery syndrome (FBSS) has been reported to account for up to 40% of patients with chronic low back pain. Epidural fibrosis may be responsible for up to 30% of all cases of FBSS. Perineural fibrosis can interfere with cerebrospinal fluid-mediated nutrition, rendering the nerve root hyperesthetic and hypersensitive to compression. Traditionally, steroid injection has been used to treat low back pain and radiculopathy. The addition of hyaluronidase to the injectate has been reported to reduce the degree of fibrosis.
  
  
  OBJECTIVE
  To evaluate the role of hyaluronidase when added to fluoroscopically guided caudal steroid and hypertonic saline in patients with FBSS.
  
  
  METHODS
  Thirty-eight patients with back pain because of FBSS were studied. Twenty patients received fluoroscopically guided caudal epidural steroid, local anesthetic, and hypertonic saline in combination (group 1), and 18 patients received fluoroscopically guided caudal epidural steroid, hypertonic saline, local anesthetic, and hyaluronidase (group 2). Patients were asked to rate their pain using a verbal scale of 0 to 4 (0 = none, 1 = mild, 2 = moderate, 3 = severe, and 4 = extremely severe). Lumbar spine range of motion and opioid intake were measured.
  
  
  RESULTS
  Significant improvement in short-term pain relief was noted in both groups, while significant long-term pain relief was only achieved in group 2 patients.
  
  
  CONCLUSIONS
  The addition of hyaluronidase to fluoroscopically guided caudal epidural steroid and hypertonic saline combination improved long-term pain relief in patients with FBSS.
authors.affiliation: Department of Anesthesia, Faculty of Medicine, Tanta University, Tanta, Egypt. ayman.yousef@rocketmail.com
authors.forename: Ayman Abd Al-Maksoud
authors.initials: AA
authors.lastname: Yousef
authors.forename: Ali Seif
authors.initials: AS
authors.lastname: EL-Deen
authors.forename: Ali Ead
authors.initials: AE
authors.lastname: Al-Deeb
mesh_terms: D004311:Double-Blind Method; D004359:Drug Therapy, Combination; D005471:Fluoroscopy / Q000379:methods; D005500:Follow-Up Studies; D006801:Humans; D006821:Hyaluronoglucosaminidase / Q000627:therapeutic use*; D007268:Injections, Epidural / Q000379:methods; D017116:Low Back Pain / Q000188:drug therapy*; D010147:Pain Measurement; D011183:Postoperative Complications / Q000188:drug therapy*; D011446:Prospective Studies; D012462:Saline Solution, Hypertonic / Q000627:therapeutic use*; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D013256:Steroids / Q000627:therapeutic use*; D013997:Time Factors
chemical_list: D012462:Saline Solution, Hypertonic; D013256:Steroids; D006821:Hyaluronoglucosaminidase