OBJECTIVE: To discuss the combined use of selective epidural steroid injection (ESI) and spinal manipulative therapy (SMT) in treating recalcitrant lumbar radiculopathy.

CLINICAL FEATURES: In a first case, a patient suffered from numbness and pain in an S1 dermatome distribution 6 months after undergoing lumbar discectomy. Clinical correlation with advanced imaging led to the diagnosis of L5 intervertebral disc (IVD) syndrome with peridural scar formation. In a second case, a patient suffered from low-back and right-leg pain of 9 months' duration. Various forms of conservative treatment were not effective. A diagnosis of L4 IVD syndrome with radiculopathy was made.

INTERVENTION AND OUTCOME: The first patient received conventional treatments, including physical therapy, SMT, fluoroscopically guided ESI and oral medications, with consistent but short-lived response. A team consisting of an anesthesiologist (dedicated spinal injectionist) and chiropractor performed manipulation under epidural anesthesia (MUEA) with corticosteroid injection. Follow-up at 60 days showed marked improvement in visual analogue scale, pain drawing and Oswestry pain and disability index. The second patient received all of the same conventional care except ESI before the combined procedure. The patient underwent MUEA, followed up with eight sessions of stretching and manipulation over the ensuing 3 wk. At 45 days after the combined procedure, the patient had a negative SLR (previously positive at 70 degrees), no leg pain and a marked reduction in back pain.

CONCLUSION: This article discusses an integrated procedure that combines two standard treatments that may act synergistically. Our positive results are consistent with other reports, both published and anecdotal. The technique of MUEA warrants further investigation by the health care industry.

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