View the various routes used in an epidural steroid injection: Transforaminal, Interlaminar and Caudal. Typically, up to 3 injections may be given over a month period. While many studies have documented the short-term benefits of epidural steroid injections, the data on long-term effectiveness are less convincing. Controversy persists regarding their effectiveness in reducing pain and improving the function.
Literature both supporting and opposing them are available. These methodological flaws tend to limit the usefulness of the research. More studies are needed to define the role of epidural steroid injections in lower back pain and sciatica. Most common lower back conditions treated include 1 :.
Less commonly, localized back pain axial back pain and neurogenic claudication back pain and leg pain that occurs while walking may be treated with these injections. Doctors who administer this type of injection include spine and pain management specialists, such as physiatrists, anesthesiologists, radiologists, neurologists, and spine surgeons.
The injection procedure typically takes place in a surgery center, hospital, or a physician's clinic. Epidural steroid injections are considered a relatively safe and minimally invasive. Temporary side effects may occur in some cases and include but are not limited to :. These side effects typically resolve in a few minutes to hours.
In general, epidural injections administered for spinal levels L4 or lower carry a lesser risk of complication s compared to higher levels. The injections are typically not given when certain complicating medical conditions are present, such as infections, tumors, or bleeding disorders.
Additionally, the injections may not be given in case of uncontrolled diabetes mellitus, certain heart conditions, and pregnancy. The treatment area in the lower back is numbed with a local anesthetic injection before the epidural is given, so the epidural injection procedure is usually painless.
An epidural steroid injection procedure may take about 30 minutes to administer. A tingling or mild burning sensation, or the feeling of pressure may be experienced as the medication enters the epidural space. When the injection is completed, the irritation and discomfort usually disappear within a few minutes.
Patients typically return home after a few hours. Specific post-injection precautions are followed over the next few days. Sciatica Treatment. Cervical Epidural Steroid Injection Video. Sciatica Treatment Video. Sacroiliac Joint Block Video.
Epidural Steroid Injections. You are here Treatment Injections. By Richard Staehler, MD. Peer Reviewed. Patel K, Upadhyayula S. In: StatPearls [Internet]. Treatment of chronic low back pain - new approaches on the horizon. Epidural corticosteroid injections place medication directly around a pinched nerve as it exits the spine within the epidural space. The epidural space is between the bones and discs of the spine, and the nerves and spinal cord.
This is the space into which disc tissue can herniate and cause pressure and inflammation around spinal nerves. Epidural steroid injections are commonly used to treat back pain caused by a herniated disc slipped disc , lumbar radiculopathy, spinal stenosis or sciatica.
Corticosteroids are strong anti-inflammatory medications and, when placed into the epidural space, can significantly reduce inflammation around an irritated nerve that is causing back and leg pain and discomfort. An epidural steroid injection may be an effective nonsurgical treatment in itself or may aid in surgical planning. Epidural steroid injections work by delivering a potent anti-inflammatory to the site of nerve impingement in the spine.
Injected medications may include steroids, local anesthetics, and saline, and they can vary in volume and concentration on an individual basis. Your physician will choose which method is right for you based on your diagnosis and if you have had any prior spine surgeries. Epidural steroid injections are recommended to be administered up to three to six times per year.
In the case of a new disc herniation, injections may be only weeks apart with a goal of quick and complete resolution of symptoms. For chronic conditions, three to six months or more between injections is common. Epidural steroid injections can help resolve pain permanently in patients with a new disc herniation who respond favorably.
For patients with chronic pain or recurrent disc herniations, the desired duration of effect is three to six months or more. The risks in any procedure involving a needle include bleeding, infection and nerve damage. When performed properly, the risk of any of these is exceedingly low and usually outweighed by the potential benefit of the procedure.
Some contraindications for performing epidural steroid injections include:.
Therefore, we undertook a systematic review and meta-analysis of all the published literature to evaluate the effectiveness and safety of epidural steroid injection interventions for the treatment of LSS. We conducted this systematic review and meta-analysis according to the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions Version 5.
No restriction to specific languages or years of publication were included. The reference lists of the selected studies were also examined manually to identify relevant studies that were not discovered during the database searches. The corresponding authors were contacted when additional information was needed. We included randomized controlled trials RCTs that evaluated the efficacy and safety of epidural injections of steroids plus local anesthetic versus local anesthetic alone for the treatment of LSS patients.
The inclusion criteria for the systematic review and meta-analysis were as follows: 1 randomized controlled trials in adults with LSS with epidural injection treatment; 2 clinical or radiological diagnosis of LSS; 3 describe neurogenic claudication with back leg pain and gait assessment; 4 provide the dosage and route of epidural steroid injection administration; and 5 outcomes measured, such as walking ability, pain intensity, quality of life, and global improvement.
Studies evaluating radiculopathy caused by disc lesions were excluded. Studies with mixed populations were only included if the data for neurogenic claudication due to lumbar spinal stenosis were provided. All of the eligible studies were reviewed for baseline data such as age and sex , intervention such as epidural injection administration method, dose and duration and outcome measures.
Both subjective and objective functional outcome measurements were used to evaluate the data. However, the primary key polled outcomes were the pain scale such as visual analog scale [VAS] and walking ability. Adverse effects of epidural steroid injections were also examined. The quality of eligible studies was also assessed according to the Cochrane Handbook for Systematic Reviews of Interventions 5.
The titles and abstracts of the publications were reviewed using the previously mentioned selection criteria by two readers KL and PCL. The data extraction of all of the variables and outcomes of interest and assessment of the methodological quality were performed independently by two investigators. Any disagreement was resolved by discussion and consensus.
The methodological quality of the trials was assessed using the Cochrane Handbook for Systematic Reviews of Interventions 5. Statistical analysis was performed by Review Manager 5. Statistical heterogeneity among studies was evaluated by Q-statistic and quantified by the I 2 statistic.
If the Q or I 2 statistic was significant, a random-effects model was used. Otherwise, a fixed-effects model was used. The initial literature search retrieved relevant articles, and duplicates were discarded. After a careful screen of the titles, 84 articles were excluded as they did not cover the topic of interest. After reviewing the abstracts, seven more articles were excluded one editorial and six reviews , leaving ten studies for further full publication review. Therefore, ten studies matched the selection criteria and were suitable for meta-analysis, 14 — 23 and all of them were prospective randomized control trials Figure 1.
A total of 1, patients who received epidural steroid injection and who received epidural local anesthetic injection were enrolled in the studies. The key characteristics of the included studies are summarized in Table 1. All the studies involved patients with LSS and a follow-up of at least 6 weeks. Ten level I—II studies from to that compared epidural steroid injection with epidural local anesthetic injection for the treatment of LSS prospectively and randomly were identified.
Figure 2 summarizes the methodological quality of the studies. All of the studies were RCTs with a high level of methodological quality. Thus, the methodological bias of this study was low. Table 2 summarizes the outcomes of this meta-analysis. Because no significant heterogeneity was observed for the above comparisons, the fixed-effects model was subsequently used, as no significant clinical heterogeneity was found between the studies.
Note: The bold numbers mean that the effect estimate values for the contrast models are significant. Because no significant heterogeneity was observed for the change from the BP and PF subscale scores, the fixed-effects model was subsequently used, as no significant clinical heterogeneity was found between the studies.
We did not draw funnel plots because the trials for each comparison were less than ten. LSS is a significant problem that affects many elderly adults annually. Walking limitation due to neurogenic claudication of LSS is thought to be the hallmark of disability. This systematic review and meta-analysis of RCTs summarizes all of the available studies on the use of epidural steroid injection for LSS patients. We were only able to identify ten randomized, double-blind, controlled trials involving a total of 1, patients.
Overall, the evidence described that epidural steroid injections offered minimal or no effective analgesic and do not significantly improve walking ability in LSS patients, regardless of the method of epidural injection. Overall, epidural steroid injection treatment seems to be quite safe. While there were very few adverse effects reported in these RCTs, the safety of epidural steroid injections needs to be further evaluated.
Due to the lack of significant adverse effects, epidural steroid injections are thought to be a safe treatment for future clinical research. Now it was hard to address through meta-analysis due to the heterogeneity and diversity of the criteria in patient selection, different epidural injection approaches, doses, follow-up lengths, and differences in sample sizes.
Another weakness was the different outcome measurements, such as pain and walking ability assessments, which were measured in different ways. They found evidence supporting the recommendation of epidural steroid injection therapy, elaborating a B recommendation in favor of it use. However, this systematic review was based on only four 14 , 16 , 19 , 31 trials. The limitations of this meta-analysis were as follows.
First, the epidural injection approaches, doses, frequencies, and duration in each trial were not exactly the same, which may have influenced the outcomes of interest. Second, some parameters of interest demonstrated a large degree of heterogeneity. The heterogeneity of change from back pain VAS score may be the result of bias from the different assessment methods used in the various trials. Last but not least, meta-analyses require greater patient numbers, and insufficient patients were included in this study.
As such, larger high level studies are required to show the superiority of epidural steroid injection therapy for treating neurogenic claudication due to LSS. On the basis of the reviewed trials, when compared with local anesthetic, we found no evidence that epidural steroid injection therapy provides a statistically significant improvement in pain symptoms or walking ability in LSS patients.
Moreover, local anesthetic appears to play an unusual role in its efficacy for pain control. Additional better and rigorous studies with long-term observation are required to elucidate the effectiveness of epidural steroid injection treatment for LSS.
We would like to thank Run Liu for his assistance in developing the search strategy and retrieving relevant articles. National Center for Biotechnology Information , U. Drug Des Devel Ther. Published online Jan Author information Copyright and License information Disclaimer. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.
This article has been cited by other articles in PMC. Abstract Purpose To investigate the effectiveness and safety of epidural steroid injections in patients with lumbar spinal stenosis LSS. Results We accepted ten studies with 1, participants. Conclusions This meta-analysis suggests that epidural steroid injections provide limited improvement in short-term and long-term benefits in LSS patients. Keywords: lumbar spinal stenosis, epidural injection, steroid, local anesthetic, chronic pain.
Introduction Lumbar spinal stenosis LSS is a degenerative disease that affects the lumbar spine. Materials and methods We conducted this systematic review and meta-analysis according to the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions Version 5.
Study selection We included randomized controlled trials RCTs that evaluated the efficacy and safety of epidural injections of steroids plus local anesthetic versus local anesthetic alone for the treatment of LSS patients. Outcome measures All of the eligible studies were reviewed for baseline data such as age and sex , intervention such as epidural injection administration method, dose and duration and outcome measures. Quality assessment The titles and abstracts of the publications were reviewed using the previously mentioned selection criteria by two readers KL and PCL.
Statistical methods Statistical analysis was performed by Review Manager 5. Results Literature search The initial literature search retrieved relevant articles, and duplicates were discarded. Open in a separate window. Figure 1. Table 1 Transforaminal epidural steroid injections either with placebo or active control.
Experimental group average Steroid group averaged And failed conservative management but not limited to, physical therapy, chiropractic manipulation, exercises, drug therapy, and bed rest Received lumbar interlaminar injections containing a local anesthetic lidocaine 0. The patients received one or two injections before the primary outcome evaluation, performed 6 weeks after randomization and the first injection Receive epidural injections of glucocorticoids plus lidocaine.
The glucocorticoid injectable solution consisted of 1 to 3 mL of 0. Figure 2. Main analysis Table 2 summarizes the outcomes of this meta-analysis. Table 2 Meta-analysis of the outcomes of interest. Publication bias We did not draw funnel plots because the trials for each comparison were less than ten. Discussion LSS is a significant problem that affects many elderly adults annually. Conclusion On the basis of the reviewed trials, when compared with local anesthetic, we found no evidence that epidural steroid injection therapy provides a statistically significant improvement in pain symptoms or walking ability in LSS patients.
Acknowledgments We would like to thank Run Liu for his assistance in developing the search strategy and retrieving relevant articles. Footnotes Disclosure The authors report no conflicts of interest in this work. References 1. The efficiency of gabapentin therapy in patients with lumbar spinal stenosis.
Spine Phila Pa ; 32 9 — Does this older adult with lower extremity pain have the clinical syndrome of lumbar spinal stenosis? Clinical practice. Lumbar spinal stenosis. N Engl J Med. One day, 2 weeks, 3 months, 6 months, and 1 year after the procedure, we will assess the condition of these patients again with the NRS and ODI.
Registered on 8 December Keywords: Caudal epidural steroid injections; Lumbar spinal stenosis; Randomized controlled trial; Selective nerve root blocks. Abstract Background: Lumbar spinal stenosis LSS is a common degenerative condition associated with old age. Publication types Clinical Trial Protocol. Substances Steroids.