Epidural Steroids for Cervical and Lumbar Radicular Pain and Spinal Stenosis Systematic Review Summary
Report of the AAN Guidelines Subcommittee
Abstract
Background and Objectives
This review systematically evaluates and incorporates evidence for the use of epidural steroid injections (ESIs) in cervical and lumbar spinal stenosis and radiculopathies, assessing short-term (≤3 months) and long-term (≥6 months) improvements in pain and disability.
Methods
We searched databases for randomized controlled trials (RCTs) on the efficacy of ESIs published between January 2005 and January 2021. Data analysis was performed by American Academy of Neurology methodologists. A panel of ESI experts was engaged to interpret the evidence in a clinical context. Owing to the great variability in efficacy measures used in the articles, we report differences based on any measure of success: the success rate difference (SRD).
Results
Ninety RCTs met inclusion criteria. In cervical and lumbar radiculopathies, ESIs probably reduce short-term pain (SRD -24.0%, 95% CI −34.9 to −12.6, number needed to treat [NNT] 4) and disability (SRD −16.0%, 95% CI −26.6 to −5, NNT 6) and possibly decrease long-term disability (SRD −11.1%, 95% CI −25.3 to 3.6, NNT 9). There is insufficient evidence to determine whether ESIs reduce long-term pain in radiculopathies (SRD −10.3%, 95% CI −27.8 to 7.6). In lumbar spinal stenosis, ESIs possibly reduce short-term (SRD −26.2%, 95% CI −52.4 to 3.6, NNT 4) and long-term (SRD −11.8%, 95% CI −26.9 to 3.8, NNT 8) disability, but not short-term pain (SRD −3.5%, 95% CI −12.6 to 5.6). In lumbar stenosis, there is insufficient evidence to determine whether ESIs reduce long-term pain (SRD −6.5%, 95% CI −22.5 to 9.8). For cervical spinal stenosis, evidence is insufficient to determine the effectiveness of ESIs.
Discussion
The review affirms limited efficacy of ESIs in reducing pain and disability in cervical and lumbar radiculopathies and possibly in lumbar spinal stenosis, largely in the short term. The heterogeneity of outcome measures reported preclude presenting integrated data regarding effect size. There is controversy regarding the appropriate choice of inactive comparator treatments as a true placebo in clinical trials of ESIs. The panel recommends that future trials of ESIs use minimal meaningful clinical difference as the measure of efficacy and paraspinal muscle injection of saline as an inactive placebo.
Introduction
In 2007, the American Academy of Neurology (AAN) published the technology assessment “Assessment: Use of epidural steroid injections to treat radicular lumbosacral pain.” This report concluded that the use of epidural steroid injections (ESIs) may improve radicular lumbosacral pain between 2 and 6 weeks after the injection but does not improve function or reduce the need for surgery.1 The purpose of this literature review was to systematically evaluate and incorporate new evidence for the use of epidural steroids in cervical and lumbar spinal stenosis and radiculopathies. This review is directed to neurologists, physiatrists, pain management specialists, orthopaedic specialists, neurosurgeons, spine specialists, and primary care clinicians who may refer patients for ESIs or perform ESIs themselves. This article is an executive summary of the complete systematic review (SR). The complete SR is available in eAppendix 1.
Lower back pain is common, experienced by 50%–80% of adults in their lifetime.2,3 In 2013, lower back pain and neck pain were reported to be the third largest category of health care spending at $87.6 billion, after diabetes and ischemic heart disease.4
Radicular pain is defined physiologically as pain evoked by ectopic discharges arising from a dorsal nerve root or dorsal root ganglion. Disk herniation is the most common cause of radicular pain.5 The incidence of lumbar radiculopathies is estimated at 486/100,000 person-years,6 and the incidence of cervical radiculopathies is estimated at 83/100,000 person-years.7 The natural history of radiculopathy is favorable in most patients, but only 33%–50% of patients with spinal stenosis improve over time.8
ESIs are frequently used in the treatment of radicular pain and pain caused by spinal stenosis. The overall utilization of these procedures remains stable, although rates (utilization per 100,000 people in the Medicare population) have declined somewhat owing to the growth of the population.9 Absolute utilization remains high, which is why efficacy of this treatment merits review.
A Cochrane review of ESIs for lumbosacral radicular pain found that ESIs were probably slightly more effective compared with placebo in reducing leg pain at short-term follow-up.10 Other systematic reviews and meta-analyses have come to similar conclusions—benefits of ESIs compared with a control treatment were small and short lived.11,12
Some investigators have postulated that the apparent small effects of epidural steroids in these studies were being masked by a therapeutic effect of the control treatment.13 The control treatment used in most clinical trials of ESIs was epidural injections of saline or a local anesthetic without steroids. Epidural saline injections could, in theory, remove chemical mediators promoting sensitization, thus having a therapeutic effect. Based on this, these investigators concluded that “lidocaine alone or lidocaine in conjunction with steroids were significantly effective.”13 From this perspective, the equivalent or similar effectiveness of local anesthetic or saline with and without steroids has been interpreted to support effectiveness of saline or local anesthetic alone rather than lack of effectiveness of the additional steroids.14-16
This SR addresses the following questions:
1.
In patients with radiculopathy (lumbar, cervical), do epidural corticosteroid injections, compared with placebo or active control, reduce short-term or long-term pain or reduce short-term or long-term disability?
2.
In patients with spinal stenosis (lumbar, cervical), do epidural corticosteroid injections, compared with placebo or active control, reduce short-term or long-term pain or reduce short-term or long-term disability?
This SR does not address pain caused by etiologies other than radiculopathy and spinal stenosis.
In addition, because of the controversy around the selection of an inactive control treatment mentioned above, the author panel for this review was asked to recommend an appropriate inactive control intervention for future trials of the efficacy of ESIs.
Description of the Analytic Process
In July 2015, the AAN Guidelines Subcommittee convened a panel of clinicians with expertise in methodology, pain management, anesthesiology, and back pain. A majority (at least 51 percent) of the members (C.A., P.N., S.P., G.G., M.-M.B., J.D., S.A.H., and D.B.S.) of the development panel, including the initial lead developer (P.N.) and the current lead developer (C.A.), are free of conflicts of interest (COI) relevant to the subject matter of this SR. Two panel members (V.L.C. and C.G.) were determined to have relevant COI, but the COI were judged to be not significant enough to preclude them from authorship. These panel members were not permitted to review or rate the evidence. In late 2022, P. Narayanaswami stepped down as project lead because of competing professional priorities and C. Armon stepped into the lead developer role for the remainder of the project. The entire author panel was responsible for decisions concerning the design, analysis, and reporting of the SR.
Medline, Embase, and Cochrane Library databases were searched for relevant articles in all languages published that met inclusion criteria (eAppendix 1). Selected articles were randomized controlled trials (RCTs) relevant to the clinical questions that met the following inclusion criteria: Patients were at least 18 years old and diagnosed with radiculopathy or spinal stenosis; the intervention included was an ESI (transforaminal, interlaminar, or caudal). Articles were excluded for the following reasons: Patients only had axial pain without radiculopathy, intervention was a facet joint injection or medial branch block, or the study type was anything other than an RCT. Each of these articles was independently selected, reviewed, and abstracted by at least 2 individuals.
The initial literature search and article abstraction, covering studies published from 2005 to 2017, was performed by staff at Doctor Evidence with oversight from the author panel. An updated literature search covering studies published from 2017 to February 2021 was completed by the AAN.
The risk of bias including internal (class of evidence) and external (indirectness) validity was assessed using the AAN therapeutic rating scheme.17 Indirectness was judged to be moderate when the primary outcome of the study was not the outcome measure of interest for the SR.
The following rules were decided a priori for data analysis: In defining radiculopathy and spinal stenosis, we used the terminology provided in the original studies. Outcomes at ≤3 months were considered short term, and outcomes ≥6 months were considered long term.
The preferred outcome measures for pain were visual analog scale scores followed by Numerical Rating Scale (NRS) scores. The preferred measures for disability were the Oswestry Disability Index and Neck Disability Index. Because outcome measures for pain and disability were not always measured on the preferred scales, effect sizes were converted to standardized mean differences (SMDs). We pooled effect sizes across studies using inverse-variance, random-effects (RE) meta-analyses with I2 as the measure of heterogeneity. Precision was assessed with 95% CIs. Effect sizes were calculated so that negative SMDs favored ESI. We also identified extreme outliers (>3 interquartile ranges below the 25th percentile or above the 75th percentile).
To improve clinical interpretability, we converted SMDs to success rate differences (SRDs).18 In the current context, the SRD measures the proportion of patients undergoing ESI that have more favorable outcomes compared with patients not receiving an ESI. From the SRD, numbers needed to treat (NNT) for any improvement can be computed. Because of the rarity of adverse events in the reviewed studies, we performed a narrative review of adverse events.
Evidence syntheses were performed using the AAN's modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) process.17 In this executive summary, evidence syntheses for each outcome are presented separately by pathology (radiculopathy and spinal stenosis) combining spinal levels (lumbosacral and cervical). Subsequent analyses separating studies by spinal level (cervical vs lumbosacral) are also presented. Exploratory analyses separated studies according to the use of particulate vs nonparticulate corticosteroid preparations, types of injections (interlaminar, transforaminal, or caudal), and types of control interventions.
Analysis of Evidence—Efficacy
The initial search identified 4,055 citations. Of the reviewed abstracts, 198 were identified as potentially relevant. After full-text review, 82 met the inclusion criteria. The updated literature search identified an additional 1,170 potentially relevant articles published since January 2017. Of those articles identified, 8 met the inclusion criteria.
Short-Term Disability
Lumbar and Cervical Spinal Stenosis and Radiculopathy
Cervical and Lumbar Radiculopathy
Three Class I studies19,22,23 and 6 Class II studies24-28,32 addressed the efficacy of ESIs in patients with radiculopathies. All studies evaluated lumbar radiculopathy except for 1,26 which evaluated cervical radiculopathy. An RE meta-analysis of all 9 studies revealed an SRD of −16.0% (95% CI −26.6 to −5, I2 = 57%, NNT 6), favoring ESIs to reduce short-term disability.
Conclusion
For patients with cervical or lumbar radiculopathy, ESIs probably reduce short-term disability (moderate confidence, anchored by class of studies and indirectness). However, this conclusion is driven by data for lumbar radiculopathy because only 1 Class II study26 evaluated cervical radiculopathy.
Lumbar Spinal Stenosis
Conclusion
For patients with lumbar spinal stenosis, ESIs possibly reduce short-term disability (low confidence, anchored by class of studies and indirectness, confidence downgraded for heterogeneity). There were no studies evaluating ESIs in cervical spinal stenosis.
Long-Term Disability
Lumbar and Cervical Spinal Stenosis and Radiculopathy
Cervical and Lumbar Radiculopathy
Conclusion
For patients with cervical or lumbar radiculopathy, ESIs possibly decrease long-term disability (low confidence, anchored by imprecision). However, this conclusion is driven mainly by data for lumbar radiculopathy because only 1 Class II study33 evaluated cervical radiculopathy.
Lumbar Spinal Stenosis
Conclusion
For patients with lumbar spinal stenosis, ESIs possibly reduce long-term disability (low confidence, anchored by imprecision). There were no studies evaluating cervical stenosis.
Short-Term Pain
Lumbar and Cervical Spinal Stenosis and Radiculopathy
Cervical and Lumbar Radiculopathy
An RE meta-analysis of 3 Class I studies19,22,23 and 7 Class II studies24-26,28,32,34,35 addressing the efficacy of ESIs in patients with radiculopathies revealed an SRD of −24.0% (95% CI −34.9 to −12.6, I2 = 59%, NNT 4) favoring ESIs to reduce short-term pain. All but 1 study26 addressed lumbar radiculopathy.
Conclusion
For patients with cervical or lumbar radiculopathy, ESIs probably provide short-term pain reduction (moderate confidence, anchored by class of studies and indirectness). However, this conclusion is driven by data for lumbar radiculopathy because only 1 Class II study26 evaluated cervical radiculopathy.
Lumbar Spinal Stenosis
Conclusion
For patients with lumbar spinal stenosis, ESIs probably do not provide short-term pain reduction (moderate confidence, anchored by class of studies, indirectness, and imprecision). No studies were available for cervical stenosis.
Long-Term Pain
Lumbar and Cervical Spinal Stenosis and Radiculopathy
Cervical and Lumbar Radiculopathy
Conclusion
For patients with cervical or lumbar spinal radiculopathy, there is insufficient evidence to determine whether ESIs provide long-term pain reduction (very low confidence, anchored by imprecision). However, this conclusion is driven mainly by data for lumbar radiculopathy because only 1 evaluated cervical radiculopathy.26
Lumbar Spinal Stenosis
Conclusion
For patients with lumbar spinal stenosis, there is insufficient evidence to determine whether ESIs reduce long-term pain (very low confidence, anchored by imprecision). There were no studies evaluating cervical stenosis.
Subgroup Analyses
Efficacy of ESIs by Spinal Level
Pooled results of studies evaluating the efficacy of ESIs for lumbar radiculopathy or stenosis were compared with those of the single study meeting inclusion criteria26 evaluating the efficacy of ESIs for cervical radiculopathy on short-term and long-term disability and short-term and long-term pain. No significant difference by spinal level was noted in any of these analyses (see eAppendix 1).
Conclusion
Epidural steroid injections are possibly equally effective in patients with lumbar and cervical disease (low confidence, anchored by imprecision), considering that there is only 1 RCT meeting inclusion criteria for cervical radiculopathy.
Particulate vs Nonparticulate Corticosteroids
The pooled efficacy results of disability and pain outcomes from studies using particulate steroid preparations were compared with those from studies using nonparticulate preparations. No significant difference by preparation was noted in any of these analyses (see eAppendix 1).
Conclusion
For patients with radiculopathy or stenosis (cervical or lumbar), there is insufficient evidence to determine if particulate ESIs are more effective than nonparticulate steroids (very low confidence, anchored by indirectness and imprecision).
Interlaminar vs Transforaminal vs Caudal ESIs
There is no significant difference between interlaminar, transforaminal, and caudal ESIs in the outcomes of short-term disability or pain or long-term disability or pain (eAppendix 1).
Effect of ESIs on the Subsequent Need for Surgery
One Class I study23 and 2 Class II studies35,36 evaluated the proportion of patients receiving ESIs vs control injections who required surgery on follow-up. An RE meta-analysis of these studies did not demonstrate a significant difference in surgery rates, with a risk difference of 10.5% favoring epidural injections without steroids (95% CI −6.0 to 26.6, I2 = 0%).
Conclusion
There is insufficient evidence to determine whether ESIs compared with epidural injections without steroids change the need for surgery (very low confidence, anchored by imprecision).
Control Interventions
The specific control interventions used in the trials included saline, lidocaine, a surgical intervention, clonidine, and physical therapy. Subgroup analysis comparing saline as control with lidocaine as control showed no differences in our findings.
Analysis of Evidence—Safety
With frequent use of ESIs, potential adverse effects are a concern. Overall, the incidence of complications seems to vary widely with reports ranging from 2.4% to 16.8%.37,38 In a retrospective review of 4,265 injections in 1,857 patients over 7 years comprising lumbar injections (transforaminal, interlaminar, and caudal) and cervical interlaminar injections, the incidence of complications was 2.4%. The most commonly reported adverse effects were increased pain, injection site pain, and persistent numbness. No major complications were reported.38 Serious complications after ESI seem to be rare. There are case reports of nerve root injury, pneumocephalus, epidural hematoma, subdural hematoma, Cushing syndrome, hypotension, respiratory insufficiency, transient blindness, epidural abscess, paralysis, cord injury, and death after cervical interlaminar ESI. Cases of transient global amnesia, vertebral artery injury, paralysis, cord infarction, cerebellar infarction, and death have been reported after transforaminal cervical and lumbar ESIs.39,40 The incidence of epidural hematoma has been estimated to be between 1 in 70,000 and 1 in 190,000.41,42 After fungal meningitis complicating the use of contaminated corticosteroids in 2012, the US Food and Drug Administration issued a warning in 2014 that injection of corticosteroids into the epidural space may result in rare but serious adverse events, including loss of vision, stroke, paralysis, and death.43
There are scarce data on the cost-effectiveness of ESIs. In a cost-effectiveness analysis of a Dutch Class III trial of 63 patients with acute lumbar radiculopathy (duration 2–4 weeks), a small reduction in pain and disability was reported in patients receiving a single ESI with usual care compared with usual care alone (−0.24 on an SMD scale). The costs were lower in the ESI group with an incremental cost-effectiveness ratio (ICER) of −$990 (i.e., each point decrease on the NRS for pain would save $990). This ICER was not significant (95% CI −$6,058 to $1,289), but the trend favored ESI. This gain was mainly because of improved productivity in the ESI group (i.e., patients missing less work during the 1–2 weeks following the ESI).44 In an electronic medical record review of 141 patients from a single US center who had lower back pain for greater than 12 weeks, both the ESI treatment group (89 patients) and the standard medical management without ESI group (52 patients) showed small but significant improvements in EuroQol-5 Dimension (ED-5D) scores from baseline to 3 months (0.06 points in the ESI group, 0.07 points in the control group), but there was no difference between groups. No differences in quality-adjusted life year or cost-utility ratios were noted between groups. The study concluded that ESI is not cost-effective at 3 or 6 months, but did not consider opportunity costs (i.e., days lost from work because of disability), although missed work days for the intervention and postprocedure recovery were factored into the indirect costs.45 Two studies were noninformative because of the lack of a control group.46,47 In conclusion, the cost-effectiveness of ESIs remains unclear because of a lack of data.
Discussion
The 2007 AAN technology assessment found that ESIs may help lumbosacral radicular pain compared with controls at 2–6 weeks, but with a small magnitude of effect.17 This updated SR, which included meta-analyses and determination of SRD, produced similar results.
In this SR, we addressed several new questions, such as evidence for efficacy of cervical ESI, different pathophysiologic bases of pain (including spinal stenosis and radiculopathy), different injection approaches, and different formulations. The SR found evidence that ESIs are probably effective in reducing short-term pain and disability caused by radiculopathy and possibly effective in reducing short-term disability, but not pain, in lumbar spinal stenosis. The SR also found insufficient evidence that ESIs provide long-term pain reduction. In addition, the SR found that ESIs possibly reduce long-term disability caused by radiculopathy and lumbar spinal stenosis. Much of this evidence was driven by data for lumbar disease, with only 2 Class II studies33,48 evaluating cervical radiculopathy, and no studies evaluating cervical spinal stenosis. These conclusions are summarized in the Table.
The small number of cervical radiculopathy RCTs and absence of cervical spinal stenosis RCTs are limitations of the data. The studies varied in terms of the type of ESI, type of injection, use or absence of fluoroscopic guidance, and other factors, and this was reflected in the heterogeneity of the meta-analyses. The SMD suggests only a small-to-moderate effect size (Cohen's d 0.2–0.3). The NNT for short-term pain reduction in radiculopathy is 7, meaning that if 7 patients are treated, 1 additional patient will have any degree of pain relief. The CI for the NNT was 4–15, meaning that between 4 and 15 patients might have to be treated for 1 additional patient to derive any pain relief. In radiculopathy, for short-term disability, the NNT is 10 (95% CI 6–32). The small effect size and the modest clinical efficacy for short-term benefit need to be considered when using ESIs for lumbosacral radiculopathy. Factors that may influence the use of ESI include patient demographics and health conditions (e.g., older age, obesity, use of anticoagulation, or inability to do physical therapy because of comorbid conditions such as severe osteoarthritis of the hips), location (cervical vs lumbosacral), and pathophysiology (spinal stenosis vs disk herniation). The SR did not find evidence for the effect of ESI on activities of daily living, quality of life, subsequent surgery, or change in analgesic or opioid use.
| Short-term disability | Long-term disability | Short-term pain | Long-term pain | |
|---|---|---|---|---|
| Radiculopathy, Cervical and Lumbara | ESIs probably reduce | ESIs possibly reduce | ESIs probably reduce | Insufficient Evidence |
| Spinal Stenosis, Lumbarb | ESIs possibly reduce | ESIs possibly reduce | ESIs probably do not reduce | Insufficient Evidence |
Abbreviation: ESI = epidural steroid injection.
a
Driven by lumbar data.
b
Driven by lumbar data, no studies for cervical spinal stenosis.
The SR did not find studies addressing the efficacy of repeated ESIs. However, ESIs are not infrequently used repeatedly every few months in the clinical setting. Repeated ESIs are associated with adverse effects caused by long-term corticosteroid use. These side effects can outlast discontinuation of ESIs.49 Epidural lipomatosis is a known complication of long-term oral corticosteroid use, but it has also been described after repeated ESIs and may worsen spinal stenosis.50 Our SR did not find evidence for or against the use of ESIs in changing the requirement for future surgery. However, repeated ESIs may be of utility in specific clinical situations where continued short-term effectiveness is likely based on the response to previous injections and when alternative interventions are not effective, are contraindicated, or are not aligned with patient preferences. Close monitoring for ongoing effectiveness is necessary to justify continuing treatment.
The effect sizes reported in this review assume that the comparator intervention was inactive. If the comparator interventions are active, the effect sizes reported here may be inaccurate. We point out that the efficacy of epidural saline and a local anesthetic alone has not been established by controlled clinical trials, and thus, it is complete conjecture whether they have therapeutic benefit.
Suggestions for Future Research
There was no evidence for the effect of ESIs on other relevant outcomes such as activities of daily living, self-management, independence, quality of life, functional status, and return to work. No studies were available addressing the effect of ESIs on subsequent surgery or reduced analgesic or opioid use. Studies of ESIs in cervical radiculopathy and cervical stenosis are limited. Future studies should address these gaps and should use clinically meaningful improvement in pain and function as outcome measures.
To address the possibility that the available trials of the efficacy of ESIs have used control interventions with a therapeutic effect, the authors propose the following as true placebo controls: The parallel control group would receive an IM saline injection to a lumbar paraspinal muscle with a saline volume of 0.5–1.0 mL. These would have to be naïve patients because experienced patients might be able to know whether what was happening was similar to or different from their previous injections. This approach would simulate an epidural procedure while avoiding the potential effect of fluid volume in the epidural space to dilute local inflammatory cytokines.35
A final area for future qualitative research is understanding the reasons for the gap between the National Institute for Health and Care Excellence (NICE) indications for ESI (acute radicular pain) and those of the US Centers for Medicare & Medicaid Services. Under the NICE paradigm, ESIs seem to be used for their short-term effect—to limit inactivity due to pain to permit initiation of additional treatments (such as physical therapy, learning proper back use strategies)—but not as part of the armamentarium for managing pain in the long term. Qualitative research may help capture the reasons why ESIs continue to be used in the management of chronic pain in the United States.
Disclaimer
Clinical practice guidelines, practice advisories, systematic reviews, Evidence in Focus articles, and other guidance published by the AAN and its affiliates are assessments of current scientific and clinical information provided as an educational service. The information (1) should not be considered inclusive of all proper treatments or methods of care, or as a statement of the standard of care; (2) is not continually updated and may not reflect the most recent evidence (new evidence may emerge between the time information is developed and when it is published or read); (3) addresses only the question(s) specifically identified; (4) does not mandate any particular course of medical care; (5) represents the medical/scientific opinion of the author panel based on an analysis of then-current clinical data, literature, and public comment (where applicable); and (6) is not intended to substitute for the independent professional judgment of the treating provider, as the information does not account for individual variation among patients. In all cases, the selected course of action should be considered by the treating provider in the context of treating the individual patient. Use of the information is voluntary. The AAN provides this information on an as-is basis and makes no warranty, expressed or implied, regarding the information. The AAN specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. The AAN assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.
Conflict of Interest
The AAN is committed to producing independent, critical, and trustworthy clinical practice guidelines and evidence-based documents. Significant efforts are made to minimize the potential for conflicts of interest to influence the recommendations of this evidence-based document. Management and disclosure of document developer relationships is conducted in compliance with the 2017 AAN process manual section titled, “Implementing the AAN Conflict of Interest Policy for Guidelines and Case Definitions,” which can be viewed at aan.com.
Glossary
- AAN
- American Academy of Neurology
- AHRQ
- Agency for Healthcare Research and Quality
- BIDMC
- Beth Israel Deaconess Medical Center
- COI
- conflicts of interest
- ESI
- epidural steroid injection
- ICER
- incremental cost-effectiveness ratio
- NICE
- National Institute for Health and Care Excellence
- NNT
- number needed to treat
- NRS
- Numerical Rating Scale
- PCORI
- Patient-Centered Outcomes Research Institute
- RCT
- randomized controlled trial
- RE
- random effect
- SMD
- standardized mean difference
- SR
- systematic review
- SRD
- success rate difference
Acknowledgment
The authors thank Shaheen Lakhan, MD, PhD, MEd, and Christine Peeters-Asdourian, MD, for their contributions to this systematic review.
Supplementary Materials
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References
1.
Armon C, Argoff CE, Samuels J, Backonja MM, Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2007;68(10):723-729.
2.
Rubin DI. Epidemiology and risk factors for spine pain. Neurol Clin. 2007;25(2):353-371.
3.
Volinn E. The epidemiology of low back pain in the rest of the world. A review of surveys in low- and middle-income countries. Spine (Phila Pa 1976). 1997;22(15):1747-1754.
4.
Dieleman JL, Baral R, Birger M, et al. US spending on personal health care and public health, 1996-2013. JAMA. 2016;316(24):2627-2646.
5.
Bogduk N. On the definitions and physiology of back pain, referred pain, and radicular pain. Pain. 2009;147(1-3):17-19.
6.
Schoenfeld AJ, Laughlin M, Bader JO, Bono CM. Characterization of the incidence and risk factors for the development of lumbar radiculopathy. J Spinal Disord Tech. 2012;25:163-167.
7.
Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain. 1994;117(2):325-335.
8.
Kreiner DSSW, Baisden J, Gilbert T, et al. Diagnosis and Treatment of Degenerative Lumbar Spinal Stenosis. North American Spine Society. 2011. Accessed July 1, 2024. spine.org/Portals/0/assets/downloads/ResearchClinicalCare/Guidelines/LumbarStenosis.pdf
9.
Manchikanti L, Pampati V, Soin A, Sanapati MR, Kaye AD, Hirsch JA. Declining utilization and inflation-adjusted expenditures for epidural procedures in chronic spinal pain in the medicare population. Pain Physician. 2021;24:1-15.
10.
Oliveira CB, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database Syst Rev. 2020;4:CD013577.
11.
Pinto RZ, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Ann Intern Med. 2012;157(12):865-877.
12.
Chou R, Hashimoto R, Friedly J, et al. Epidural corticosteroid injections for radiculopathy and spinal stenosis: a systematic review and meta-analysis. Ann Intern Med. 2015;163(5):373-381.
13.
Manchikanti L, Knezevic NN, Boswell MV, Kaye AD, Hirsch JA. Epidural injections for lumbar radiculopathy and spinal stenosis: a comparative systematic review and meta-analysis. Pain Physician. 2016;19(3):E365-E410.
14.
Knezevic NN, Manchikanti L, Urits I, et al. Lack of superiority of epidural injections with lidocaine with steroids compared to without steroids in spinal pain: a systematic review and meta-analysis. Pain Physician. 2020;23(4S):S239-S270.
15.
Manchikanti L, Knezevic NN, Parr A, Kaye AD, Sanapati M, Hirsch JA. Does epidural bupivacaine with or without steroids provide long-term relief? A systematic review and meta-analysis. Curr Pain Headache Rep. 2020;24(6):26.
16.
Manchikanti L, Knezevic NN, Sanapati J, Kaye AD, Sanapati MR, Hirsch JA. Is epidural injection of sodium chloride solution a true placebo or an active control agent? A systematic review and meta-analysis. Pain Physician. 2021;24(1):41-59.
17.
American Academy of Neurology. Clinical Practice Guideline Process Manual. 2011.
18.
Kraemer HC, Kupfer DJ. Size of treatment effects and their importance to clinical research and practice. Biol Psychiatry. 2006;59(11):990-996.
19.
Carette S, Leclaire R, Marcoux S, et al. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med. 1997;336(23):1634-1640.
20.
Cohen SP, Gupta A, Strassels SA, et al. Effect of MRI on treatment results or decision making in patients with lumbosacral radiculopathy referred for epidural steroid injections: a multicenter, randomized controlled trial. Arch Intern Med. 2012;172(2):134-142.
21.
Friedly JL, Comstock BA, Turner JA, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med. 2014;371(1):11-21.
22.
Ghai B, Kumar K, Bansal D, Dhatt SS, Kanukula R, Batra YK. Effectiveness of parasagittal interlaminar epidural local anesthetic with or without steroid in chronic lumbosacral pain: a randomized, double-blind clinical trial. Pain Physician. 2015;18(3):237-248.
23.
Karppinen J, Malmivaara A, Kurunlahti M, et al. Periradicular infiltration for sciatica: a randomized controlled trial. Spine (Phila Pa 1976). 2001;26(9):1059-1067.
24.
Iversen T, Solberg TK, Romner B, et al. Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial. BMJ. 2011;343:d5278.
25.
Manchikanti L, Singh V, Cash KA, Pampati V, Damron KS, Boswell MV. A randomized, controlled, double-blind trial of fluoroscopic caudal epidural injections in the treatment of lumbar disc herniation and radiculitis. Spine (Phila Pa 1976). 2011;36(23):1897-1905.
26.
Manchikanti L, Cash KA, Pampati V, Wargo BW, Malla Y. A randomized, double-blind, active control trial of fluoroscopic cervical interlaminar epidural injections in chronic pain of cervical disc herniation: results of a 2-year follow-up. Pain Physician. 2013;16(5):465-478.
27.
Ng L, Chaudhary N, Sell P. The efficacy of corticosteroids in periradicular infiltration for chronic radicular pain: a randomized, double-blind, controlled trial. Spine (Phila Pa 1976). 2005;30(8):857-862.
28.
Nandi J, Chowdhery A. A randomized controlled clinical trial to determine the effectiveness of caudal epidural steroid injection in lumbosacral sciatica. J Clin Diagn Res. 2017;11(2):RC04-RC08.
29.
Wei P, Xu Y, Yao Q, Wang L. Randomized trial of 3-drug combination for lumbar nerve root epidural injections with a TNF-α inhibitor in treatment of lumbar stenosis. Br J Neurosurg. 2020;34(2):168-171.
30.
Tafazal S, Ng L, Chaudhary N, Sell P. Corticosteroids in peri-radicular infiltration for radicular pain: a randomised double blind controlled trial. One year results and subgroup analysis. Eur Spine J. 2009;18(8):1220-1225.
31.
Manchikanti L, Singh V, Cash KA, Pampati V, Datta S. Fluoroscopic caudal epidural injections in managing post lumbar surgery syndrome: two-year results of a randomized, double-blind, active-control trial. Int J Med Sci. 2012;9(7):582-591.
32.
Manchikanti L, Cash KA, Pampati V, Falco FJ. Transforaminal epidural injections in chronic lumbar disc herniation: a randomized, double-blind, active-control trial. Pain Physician. 2014;17(4):E489-E501.
33.
Manchikanti L, Cash KA, Pampati V, Malla Y. Fluoroscopic cervical epidural injections in chronic axial or disc-related neck pain without disc herniation, facet joint pain, or radiculitis. J Pain Res. 2012;5:227-236.
34.
Bush K, Hillier S. A controlled study of caudal epidural injections of triamcinolone plus procaine for the management of intractable sciatica. Spine (Phila Pa 1976). 1991;16(5):572-575.
35.
Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med. 2010;11(8):1149-1168.
36.
Cohen SP, Hayek S, Semenov Y, et al. Epidural steroid injections, conservative treatment, or combination treatment for cervical radicular pain: a multicenter, randomized, comparative-effectiveness study. Anesthesiology. 2014;121(5):1045-1055.
37.
Botwin KP, Castellanos R, Rao S, et al. Complications of fluoroscopically guided interlaminar cervical epidural injections. Arch Phys Med Rehabil. 2003;84(5):627-633.
38.
McGrath JM, Schaefer MP, Malkamaki DM. Incidence and characteristics of complications from epidural steroid injections. Pain Med. 2011;12(5):726-731.
39.
Huston CW. Cervical epidural steroid injections in the management of cervical radiculitis: interlaminar versus transforaminal. A review. Curr Rev Musculoskelet Med. 2009;2(1):30-42.
40.
Plastaras C, McCormick ZL, Garvan C, et al. Adverse events associated with fluoroscopically guided lumbosacral transforaminal epidural steroid injections. Spine J. 2015;15(10):2157-2165.
41.
Abram SE, O’Connor TC. Complications associated with epidural steroid injections. Reg Anesth. 1996;21(2):149-162.
42.
Wulf H. Epidural anaesthesia and spinal haematoma. Can J Anaesth. 1996;43(12): 1260-1271.
43.
FDA Drug Safety Communication: FDA Requires Label Changes to Warn of Rare But Serious Neurologic Problems After Epidural Corticosteroid Injections for Pain. Accessed October 2, 2024. fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-requireslabel-changes-warn-rare-serious-neurologic-problems-after#:;:text=%5B04%2D23%2D2014%5D,stroke%2C%20paralysis%2C%20and%20death
44.
Spijker-Huiges A, Vermeulen K, Winters JC, van Wijhe M, van der Meer K. Costs and cost-effectiveness of epidural steroids for acute lumbosacral radicular syndrome in general practice: an economic evaluation alongside a pragmatic randomized control trial. Spine (Phila Pa 1976). 2014;39(24):2007-2012.
45.
Pennington Z, Swanson MA, Lubelski D, et al. Comparing the short-term costeffectiveness of epidural steroid injections and medical management alone for discogenic lumbar radiculopathy. Clin Neurol Neurosurg. 2020;191:105675.
46.
Whynes DK, McCahon RA, Ravenscroft A, Hardman J. Cost effectiveness of epidural steroid injections to manage chronic lower back pain. BMC Anesthesiol. 2012;12:26.
47.
Carreon LY, Bratcher KR, Ammous F, Glassman SD. Cost-effectiveness of lumbar epidural steroid injections. Spine (Phila Pa 1976). 2018;43(1):35-40.
48.
Manchikanti L, Cash KA, Pampati V, Wargo BW, Malla Y. The effectiveness of fluoroscopic cervical interlminar epidural injections in managing chronic cervical disc herniation and radiculitis: preliminary results of a randomized, double-blind, controlled trial. Pain Physician. 2010;13(3):223-236.
49.
Tuel SM, Meythaler JM, Cross LL. Cushing's syndrome from epidural methylprednisolone. Pain. 1990;40(1):81-84.
50.
Sandberg DI, Lavyne MH. Symptomatic spinal epidural lipomatosis after local epidural corticosteroid injections: case report. Neurosurgery. 1999;45(1):162-165.
Letters to the Editor
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© 2025 American Academy of Neurology.
Publication History
Received: August 15, 2024
Accepted: December 24, 2024
Published online: February 12, 2025
Published in issue: March 11, 2025
Disclosure
C. Armon serves on the editorial boards of Neurology® and Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration; has served on the editorial board of Annals of Neurology; received personal compensation in the range of $5,000–$9,999 for serving as a consultant for Inbal Insurance Company; has received personal compensation in the range of $5,000–$9,999 for serving as an editor, associate editor, or Editorial Advisory Board member for the Journal of Neurological Sciences; has received personal compensation in the range of $10,000–$49,999 for serving as an expert witness for individual attorney offices, or as a court-appointed expert; and has received publishing royalties from a publication relating to health care. P. Narayanaswami has received grant support from the Agency for Healthcare Research and Quality (AHRQ), the Patient-Centered Outcomes Research Institute (PCORI), and Momenta Pharmaceuticals; serves on the editorial boards of Neurology®, the Journal of Clinical Neuromuscular Disease, and Annals of Neurology; serves as an associate editor for Muscle and Nerve; has received personal compensation in the range of $500–$4,999 for serving as a consultant for Momenta and Novartis; has received personal compensation in the range of $5,000–$9,999 for serving on a scientific advisory or data safety monitoring board for Alexion/AstraZeneca Rare Disease; has received personal compensation in the range of $5,000–$9,999 for serving on a scientific advisory or data safety monitoring board for ARGENX US Inc.; has received personal compensation in the range of $10,000–$49,999 for serving as a consultant to UCB Pharmaceuticals; has received personal compensation in the range of $500–$4,999 for serving on a scientific advisory or data safety monitoring board for Sanofi; has received personal compensation in the range of $5,000–$9,999 for serving on a scientific advisory or data safety monitoring board for Janssen; has received personal compensation for serving as a consultant or member of an advisory board for Amgen, CVS, Dianthus, and UCB; has received personal compensation below $500 for serving as a consultant for Sarepta Pharmaceuticals; has received personal compensation in the range of $500–$4,999 for serving as an editor, associate editor, or editorial advisory board member for Muscle and Nerve; holds stock in Moderna, Pfizer, Viatris, Dr. Reddys laboratories, and Doximity; has received personal compensation in the range of $500–$4,999 for serving as a member on the Pharmacy and Therapeutics Committee with Blue Cross Blue Shield of MA; has a noncompensated relationship as a member on the Medical and Scientific Advisory Board with Myasthenia Gravis Foundation of America; has a noncompensated relationship as a Member, Board of Directors, with the American Association of Neuromuscular and Electrodiagnostic Medicine; and has received royalties from Springer Nature for a publication related to health care. The institution of P. Narayanaswami has received research support from AHRQ, PCORI, Alexion/AstraZeneca Rare Disease, Ra/UCB, and Momenta/Janssen. S. Potrebic has received funding for travel from the AAN to attend Guidelines International Network meetings; has received honoraria and a subscription to Continuum from the AAN for her work on the AAN Residency In-service Training Examination (RITE) exam work group; and has received personal compensation in the range of $500–$4,999 for serving as a consultant for the Center for Diagnostic Imaging Quality Institute. G. Gronseth has received travel funding from the AAN to attend Guidelines Subcommittee meetings; serves as an associate editor for Neurology®; has received personal compensation in the range of $0-$499 for serving as an editor, associate editor, or Editorial Advisory Board member for Brain & Life; and has received personal compensation in the range of $0–$499 for serving as an evidence-based medicine consultant for the AAN Guidelines Subcommittee. M.-M. Bačkonja has served on the editorial boards of the Clinical Journal of Pain, the European Journal of Pain, Journal of Pain, and Pain; and is currently employed by PRA Health Sciences. V.L. Cai held stock in Nevro Corp (spinal cord stimulators) while a pain fellow and relinquished stocks in June 2018 while serving as an attending physician at Beth Israel Deaconess Medical Center (BIDMC); served as a subinvestigator for the Sollis Therapeutics trial on epidural depot clonidine for lumbar radiculopathy, and serves as a subinvestigator for the Boston Scientific Corporation RELIEF study, which focuses on spinal cord stimulation; has an academic appointment at Harvard Medical School under BIDMC; and receives travel stipends from BIDMC to attend conferences; serves as a practicing pain physician. Dr. Cai's spouse holds patents in the fecal microbiota private sector. J. Dorman's spouse, Dr. Josune Iglesias, participated in a “vaccine hesitancy” panel as a representative of the American College of Physicians and received travel expenses of $6,000 from Merck pharmaceuticals. The institution of Dr. Dorman has received research support from NIH. C. Gilligan has served on scientific advisory boards for Eli Lilly, Medtronic, Abbott, Saluda, Cubist Pharmaceuticals, Mainstay Medical, Spine Biopharma, Persica, and Medasense; has had research support paid directly to his department from Mainstay Medical and Sollis Therapeutics; has received honoraria from the American Society of Regional Anesthesia and from the Principles and Practice of Pain Medicine Course at Harvard Medical School; performs ESIs as 15% of his clinical effort in his practice, which overlaps with the content of this evidence-based study; receives financial research support from the NIH; has served as an expert witness for the US Attorney and Federal Bureau of Investigation and for 3 malpractice cases; and serves as Editor-in-Chief of Pain Practice. S.A. Heller reports no relevant disclosures. H.M. Silsbee is an employee of the AAN. D.B. Smith is a paid evidence-based medicine consultant for the AAN. Go to Neurology.org/N for full disclosures.
Study Funding
This systematic review was developed with financial support from the American Academy of Neurology (AAN). Authors who have served as AAN subcommittee members (P.N., S.P., G.G., J.D., and S.A.H.), methodologists (D.S.), or staff (H.S.) may have been reimbursed by the AAN for expenses related to travel to subcommittee meetings where drafts of manuscripts were reviewed.
Authors
Author Contributions
C. Armon: drafting/revision of the manuscript for content, including medical writing for content; study concept or design; analysis or interpretation of data. P. Narayanaswami: drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; study concept or design; analysis or interpretation of data. S. Potrebic: drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; study concept or design; analysis or interpretation of data. G. Gronseth: drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; study concept or design; analysis or interpretation of data. M.-M. Bačkonja: drafting/revision of the manuscript for content, including medical writing for content; study concept or design; analysis or interpretation of data. V.L. Cai: drafting/revision of the manuscript for content, including medical writing for content; study concept or design; analysis or interpretation of data. J. Dorman: drafting/revision of the manuscript for content, including medical writing for content; study concept or design; analysis or interpretation of data. C. Gilligan: Drafting/revision of the manuscript for content, including medical writing for content; study concept or design; analysis or interpretation of data. S.A. Heller: drafting/revision of the manuscript for content, including medical writing for content; analysis or interpretation of data. H.M. Silsbee: drafting/revision of the manuscript for content, including medical writing for content. D.B. Smith: drafting/revision of the manuscript for content, including medical writing for content; study concept or design; analysis or interpretation of data.
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