In this pragmatic study, ESIs offered transient benefit in symptoms at 3 weeks in patients with sciatica, but no sustained benefits in terms of pain, function or need for surgery. Sciatica is a chronic condition requiring a multidisciplinary approach. To fully investigate the value of ESIs, they need to be evaluated as part of a multidisciplinary approach.

Background-Severe chest pain is common in mesothelioma. Percutaneous cervical cordotomy, which interrupts the spinothalamic tract at the C1/C2 level causing contralateral loss of pain sensation, is particularly appropriate in mesothelioma as the tumour is unilateral and systemic analgesia may be ineVective and is limited by harmful side eVects. Method-A retrospective review was performed to determine the eVectiveness and complication rate of this procedure. Results-Fifty two patients were using opioids prior to cordotomy. The median daily dose of morphine before and after cordotomy was 100 mg (range 0-1000 mg) and 20 mg (range 0-520 mg), respectively (p<0.001). Forty three patients (83%) had a reduction in pain such that their dose of opioid could be at least halved. Twenty patients (38%) were able to stop completely. Recurrence of pain requiring an increase in opioid medication was recorded in 18 patients at a median time of nine weeks (range 0.7-26 weeks). Four patients developed mild weakness, two had troublesome dysaesthesia. The median time from cordotomy to death was 13 weeks (range 0.3-52 weeks). Six early deaths within two weeks of cordotomy occurred early in the series and reflect postoperative chest infection and poor selection as the patients were in the terminal stages of mesothelioma. Conclusions-Percutaneous cervical cordotomy is successful in treating pain from mesothelioma. There was a low complication rate in this series. Referral to a unit experienced in cordotomy is recommended as soon as pain from chest wall invasion is suspected.

Objectives-To investigate the accuracy of placement of epidural injections using the lumbar and caudal approaches. To identify which factors, if any, predicted successful placement. Methods-200 consecutive patients referred to a pain clinic for an epidural injection of steroid were randomly allocated to one of two groups. Group L had a lumbar approach to the epidural space and group C a caudal approach to the epidural space. Both groups then had epidurography performed using Omnipaque and an image intensifier to determine the position of the needle. Results-Body mass index (BMI), grade of operator, and route of injection were predictors of a successful placement. 93% of lumbar and 64% of caudal epidural injections were correctly placed (p< 0.001). 97% of lumbar and 85% of caudal epidural injections clinically thought to be correctly placed were confirmed radiographically. For epidural injections where the clinical impression was "maybe", 91% of lumbar injections, but only 45% of caudal injections were correctly placed. Obesity was associated with a reduced chance of successful placement (odds ratio (OR) 0.34 (95% confidence interval (CI) 0.17 to 0.72) BMI >30 v BMI <30). A more senior grade of operator was associated with a reduced chance of successful placement (OR 0.16 (95% CI 0.03 to 0.89) consultant v other). However, small numbers may have accounted for the latter result. Conclusions-The weight of the patient and intended approach need to be considered when deciding the method used to enter the epidural space. In the non-obese patient, lumbar epidural injections can be accurately placed without x ray screening, but caudal epidural injections, to be placed accurately, require x ray screening no matter what the weight of the patient. (Ann Rheum Dis 2000;59:879-882) Epidural steroids have been used for many years in the management of various rheumatological spinal conditions, including spinal stenosis and sciatica. The mechanisms of action are thought to include an antiinflammatory eVect of the corticosteroid, which reduces the inflammatory mediators around the nerve roots and reduces adhesions owing to the volume eVect of the injection. Correct placement of the injection into the epidural space is therefore essential. Both lumbar and caudal (through the sacral hiatus) approaches to the epidural space are regularly used, but little is known of their relative eYcacy. One of the main determinants of the relative eYcacy of the two approaches will be the accuracy of their placement. The accuracy of placement of the injection has not been extensively studied, but has been reported to be 60-75% for both approaches, whereas clinical practice would suggest that the figure for the lumbar approach is much higher. This randomised study aimed at examining the accuracy of placement of lumbar and caudal epidural injections by experienced operators, and identifying other factors that may aVect the accuracy of placement of epidural injections. Methods STUDY DESIGNThis was a single centre, randomised trial. Local re...

Chronic widespread pain (CWP), including fibromyalgia, is a highly prevalent condition with a range of disabling symptoms, both physical and psychological. The British Pain Society (BPS) is supporting the treatment of this group of patients through a care pathway and this article describes the rationale and discussion points relevant to the CWP and fibromyalgia pathway. There are several aims in producing this pathway: to reduce variation in the standards of care, to reduce delays at all stages of care, and in particular, to enable clinicians to help patients accept a diagnosis of CWP. This diagnosis should be based on the presence and distribution of symptoms in the absence of another defined pathological process: the features in the history or clinical examination are generally more important than laboratory investigations. There is an emphasis on addressing all aspects of symptomatology (physical, psychological, social, and personal needs) without an overemphasis on any one treatment modality. The pathway has focused on the potential pitfalls in the use of long-term opioids and the rationale is provided why these are not recommended. Patients with CWP value explanation and education and although clinicians may be unfamiliar with the condition, the majority of clinicians have generic skills in managing long-term conditions which can be supplemented by the interventions and actions detailed in this pathway.

These consensus guidelines aim to provide an overview of best practice for managing chronic spinal pain reflecting the heterogeneity of low back pain. Most guidelines have covered only one aspect of spinal care and thus have been divisive and potentially worsened the quality of care. Additionally, some of the evidence base is subjective and of poor quality. The British Pain Society low back pain pathway has reached across all disciplines and involved input from patients. It is recognized, however, that there is an urgent need for further good-quality clinical research in this area to underpin future guidelines. Considerable work is still needed to clarify the evidence; however, foundations have been laid with this pathway. Key features include: risk stratification; clarification of intensity of psychological interventions; a logical progression for the management of sciatica; and decision points for considering structural interventions such as spinal injections and surgery.