Lumbar Epidural Injections: Review of Efficacy and Discussion of Practice Options

Abstract

Background: In the United States, low back pain remains a common problem and a number one reason to see a physician in the outpatient setting. Etiology is complex and likely multifactorial and includes; degenerative disc disease, zygapophysial joint arthritis, vertebral misalignment, muscle strain, ligament sprain, myofascial pain, among others. Based on evidence of increased inflammatory response in disc herniation and degenerative discs, epidural steroid injections (ESI) have been used to treat lumbosacral radicular pain. Objective:To focus on the appropriate use of lumbar ESI in treating lumbosacral radicular pain in the United States, comparing and contrasting transforaminal, interlaminar, and caudal approaches for steroid delivery, as well as a comparison of commonly used steroid preparations.Methods: PubMED, MEDLINE, and OVID databases were reviewed utilizing the following subject headings: low back pain, epidural steroid injections, transforaminal epidural steroid injections (TFESI), interlaminar epidural steroid injections (ILESI), and caudal epidural steroid injections (CESI) dated from 2000 to 2014. The bibliographies of major articles and reviews were also cross-referenced for additional sources.Results: A number of articles that included randomized control trials, comprehensive and systematic reviews, and meta-analyses were found. These provided a broad, detailed overview of the subject, that we used to explore the data surrounding use of ESI for treatment of lumbosacral radicular pain. Conclusions:Most agree that the evidence for epidural steroid injection efficacy is strongest for short term relief of lumbosacral radicular pain. Most of the systemic reviews have agreed that the strongest evidence for TFESI use is for relief of unilateral lumbosacral radicular pain. The evidence suggests using ILESI in patients with bilateral and/ or multi-level lumbosacral radicular pain. The data correlates efficacy of CESI in low level bilateral or multilevel lumbosacral radicular pain as well as in patients with history of lumbar surgery. Introduction EpidemiologyIn the United States, low back pain remains common. Approximately two-thirds of the population has low back pain at some time in their lives and approximately 26% of adults surveyed admit to having low back pain within the last three months [1]. Back pain is the fifth most common reason for all physician visits [2] and the second most common symptom-related reason for clinician visits [3,4]. The 2010 Global Burden of Disease (GBD) results showed that there is a very high prevalence and burden from low back pain throughout the world [5]. Low back pain was found to have the sixth highest burden of the 291 conditions studied, and caused more disability than any other condition. It is well known that back pain accounts for a large proportion of health care expenditures and that these expenditures have been increasing substantially [6]. In fact, these expenditures have been increasing more rapidly than overall health expenditures [6]. Taken together ...