Ultrasound-guided caudal epidural steroid injection versus tramadol-based therapy in borderline surgical lumbar spinal stenosis: A retrospective cohort study

Patients with borderline surgical lumbar spinal stenosis (LSS), defined by significant canal narrowing without absolute surgical indications, present a therapeutic challenge. While caudal epidural steroid injections (ESI) are widely used, direct comparisons with pharmacological therapy remain limited. This study compared ultrasound-guided caudal ESI and tramadol-based therapy on pain, disability, walking capacity, and analgesic use. This single-center retrospective cohort included adults with LSS and dural cross-sectional area 50 to 75 mm². Two contemporaneous cohorts were analyzed: one treated with ultrasound-guided caudal ESI (dexamethasone 12 mg + 0.25% bupivacaine, 8 mL), the other with standardized tramadol/paracetamol (37.5/325 mg TID). Outcomes were Visual Analog Scale (VAS) and Oswestry Disability Index (ODI) at baseline, 1, 3, and 6 months, and 6-minute walk test (6MWT) and daily nonsteroidal anti-inflammatory drug use at baseline and 6 months. Analyses used nonparametric tests and analysis of covariance adjusted for baseline clinical and radiological variables. Fifty-five patients received ESI and 60 tramadol-based therapy. Both cohorts improved significantly (all P < .001). In the ESI group, VAS decreased from 8.85 ± 1.03 to 4.09 ± 0.89 (1M), 3.71 ± 0.83 (3M), and 5.76 ± 0.77 (6M). ODI improved from 56.18 ± 3.04% to 23.80 ± 3.08%, 27.80 ± 2.86%, and 37.78 ± 2.88%. 6MWT rose by ~83 m and nonsteroidal anti-inflammatory drug use decreased ( P < .001). In controls, VAS declined to 5.52 ± 1.30, 5.78 ± 1.22, and 5.92 ± 1.28 at 1, 3, and 6M; ODI to 38.54 ± 11.18%, 40.14 ± 10.44%, and 42.70 ± 7.74%; 6MWT rose by ~50 m (all P < .001). Between-group comparisons showed greater improvement with ESI at 1 to 3M for VAS ( P < .001) and at all time points for ODI ( P < .001), but no difference in VAS at 6M ( P = .568). Analysis of covariance confirmed these results. Higher baseline symptom burden predicted greater 6M improvement. In borderline surgical LSS, ultrasound-guided caudal ESI provides faster and greater pain and functional improvement than tramadol-based therapy. Pain benefit attenuates by 6 months, but functional gains persist. ESI may serve as an effective interim option to enhance mobility and quality of life in carefully selected patients.