Epidural Steroids

Abstract

Epidural steroid injections (ESIs) are the most widely utilized pain management procedure in the world, their use supported by more than 45 placebo-controlled studies and dozens of systematic reviews. Despite the extensive literature on the subject, there continues to be considerable controversy surrounding their safety and efficacy. The results of clinical trials and review articles are heavily influenced by specialty, with those done by interventional pain physicians more likely to yield positive findings. Overall, more than half of controlled studies have demonstrated positive findings, suggesting a modest effect size lasting less than 3 months in well-selected individuals. Transforaminal injections are more likely to yield positive results than interlaminar or caudal injections, and subgroup analyses indicate a slightly greater likelihood for a positive response for lumbar herniated disk, compared with spinal stenosis or axial spinal pain. Other factors that may increase the likelihood of a positive outcome in clinical trials include the use of a nonepidural (eg, intramuscular) control group, higher volumes in the treatment group, and the use of depo-steroid. Serious complications are rare following ESIs, provided proper precautions are taken. Although there are no clinical trials comparing different numbers of injections, guidelines suggest that the number of injections should be tailored to individual response, rather than a set series. Most subgroup analyses of controlled studies show no difference in surgical rates between ESI and control patients; however, randomized studies conducted by spine surgeons, in surgically amenable patients with standardized operative criteria, indicate that in some patients the strategic use of ESI may prevent surgery.

Advances in the diagnosis and management of neck pain

“…119 The evidence supporting other treatments for discogenic pain, including epidural and intradiscal injections, and thermal ablation, is weak and inconsistent. [120][121][122][123][124] Neuropathic pain Cervical disc herniation The annual incidence of cervical radiculopathy resulting from disc protrusion or degenerative spondylosis (or both) is estimated at 1-3.5 per 1000 person years, peaking in the sixth decade of life. A population based study reported a 0.055% incidence of radicular pain secondary to a cervical herniated disc, although estimates based on patients seeking medical attention underestimate incidence.…”

“…136 In both the lumbar and cervical regions, it is widely acknowledged that the benefits afforded by ESI for herniated discs are superior to those for spinal stenosis (table 2). 124 Exercise and integrative medicine Exercise is often touted as an effective treatment for chronic pain, although a recent Cochrane review found that the quality of evidence is low. 158 Exercise may be beneficial for neck pain by stimulating endorphin secretion, transforaminal approach reporting a negative outcome.…”

“…124 135 Comparative effectiveness studies by one group showed similar benefit in pain relief, function, and other outcome measures such as opioid consumption and employment for both steroids and local anesthetic in a variety of cervical diseases including disc hernation. [120][121][122][123][124][125][126][127][128][129][130][131][132][133][134][135][136][137][138] Another randomized study in 169 patients with radicular pain found the combination of ESI and conservative treatment consisting of physical therapy and the adjuvants nortriptyline or gabapentin (or both) provided superior relief compared with either treatment alone (mean reduction in pain score of 3.1 in the combination group versus 1.9 in the others at one month; P=0.035). 139 Together, these studies provide limited evidence that ESI is more effective than epidural non-steroid injections but moderate evidence that a series of epidural injections can provide sustained relief.…”

Nerve root block versus surgery (NERVES) for the treatment of radicular pain secondary to a prolapsed intervertebral disc herniation: study protocol for a multi-centre randomised controlled trial

“…Treatment options are largely uproven but include analgesic drugs of various categories including antiepileptics and antidepressants, injections of drug combinations into the spine and surgical techniques to remove the prolapsed disc [1] Recent evidence has suggested that the commonly used neuromodulator drug pregabalin may not have a strong benefit in the treatment of sciatica in the community [5]. Epidural steroid injections (ESI) are another treatment modality for sciatica and involve the administration of a mixture of local anaesthetic and steroid into the spine via one of three main routes; through the base of the spine (caudal epidural), through the back of the spine (inter-laminar) or through the nerve tunnel directly adjacent to the prolapsed disc (transforaminal epidural steroid injection (TFESI) [6]. Randomised controlled trials (RCTs) have looked at ESI for acute sciatica but these have not included comparisons between TFESI and inter-laminar ESI [7–10].…”

“…Randomised controlled trials (RCTs) have looked at ESI for acute sciatica but these have not included comparisons between TFESI and inter-laminar ESI [7–10]. However, prospective and case control studies have compared these and demonstrated a superior efficacy of TFESI [6–9]. One recent study of TFESI ([9]; n  = 238) reported that 65% of injections were effective at follow-up greater than 6 months (based on patient-reported measures) suggesting that the administration of drug closer to the disc prolapse may improve efficacy when compared to other methods of administration.…”