Epidural steroid injections are an important therapeutic modality employed by spinal surgeons in the treatment of patients with chronic low back pain with or without lumbar radiculopathy. The caudal epidural is a commonly used and well-established technique; however, little is known about the segmental level of pathology that may be addressed by this intervention. This prospective study of over 50 patients aimed to examine the spreading pattern of this technique using epidurography. The effect of variation in Trendelenburg tilt and the eradication of lumbar lordosis on the cephalic distribution of the injectate were investigated. 52 patients with low back pain and radiculopathy underwent caudal epidural. All had 20 ml volume injected, comprised of 5 ml contrast (Ultravist TM Schering) 2 ml Triamcinolone (Adcortyl TM Squibb) and 13 ml local anaesthetic (1% lignocaine). Patients were randomised to either 0°or 30°of Trendelenburg tilt, as referenced from the lumbar spine. Patients were further randomised to presence or absence of lumbar lordosis, which was eradicated using a flexion device placed beneath the prone patient. A lateral image of each sacrum was obtained, to identify variations in sacral geometry particularly resistant to cephalic spread of injectate. The highest segment reached on fluoroscopy was recorded post injection. Fifty-two patients with a mean age of 50 years underwent caudal epidural. Thirty-one were in 0°head tilt, with 21 in 30°of head tilt. In each of these groups, 50% had their lumbar lordosis flattened prior to caudal injection.The median segmental level reached was L3, with a range from T9 to L5. Eradication of lumbar lordosis did not significantly alter cephalic spread of injectate. There was a trend for 30°tilt to extend the upper level reached by caudal injection (p = 0.08). There were no adverse events in this series. Caudal epidural is a reliable and relatively safe procedure for the treatment of low back pain. Pathology at L3/4 and L4/5 and L5/S1 can be approached by this technique. Although in selected cases thoracic and high lumbar levels can be reached, this is variable. If pathology at levels above L3 needs to be addressed, we propose a 30°head tilt may improve cephalic drug delivery. The caudal route is best reserved for pathology below L3.

Preliminary results from this pilot study do not demonstrate any benefit of viscosupplementation in the management of symptomatic lumbar facet arthropathy.

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Across published in vivo studies related to 20 FDA-approved cancer therapies, drugmodel pairs which achieved a high DELVE score showed greater than or equal to 90% tumor growth inhibition in vivo 78% of the time. Drug-model pairs with low DELVE scores showed less than or equal to 60% tumor growth inhibition in vivo 77% of the time. Across 71 FDA-approved drugs, using chemical structure alone, the platform was able to predict at least one approved solid tumor indication 84% of the time. Random chance indication-therapy pairing was correct only 21% of the time. Across 10 failed therapies, the platform was able to predict failure with 82% accuracy.Conclusions: DELVE is able to predict drug efficacy on cancer models and to correctly select indications for existing therapies, supporting its utility in predicting new indications for cancer therapies. Because the platform can operate on any single transcriptome, it is possible to use this tool to match patients with therapies from which they may benefit without reliance on a previously classified target.Legal entity responsible for the study: Shepherd Therapeutics.