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Do Epidural Steroid Injections Effectively Treat Radicular Pain?

An American Academy of Neurology assessment finds little high-quality evidence, supporting only short-term pain relief of radicular lumbosacral pain.

Back pain is one of the most common disabling conditions in the developed world today. The economic impact of back pain is as important as its clinical impact, contributing by any measure an enormous sum to the total healthcare expenditure in the U.S. In particular, the cost of treating spinal pain is significant and growing yearly. Epidural steroid injections are generally considered to be an important part of the standard conservative therapy for back pain. However, the role and efficacy of epidural steroid injections continues to be debated. Most pain-management physicians who perform these procedures agree that the clinical presentation most likely to respond to these injections is radicular spinal pain.

This assessment covers the literature specific to radicular spinal pain relief from epidural steroid injections. The authors searched Medline in April 2003 and February 2005. (They found no relevant Cochrane systematic reviews.) Of 37 studies, only 4 met very strict inclusion criteria: clear case definitions, clear outcome measures using standardized methodology, either an active or a placebo control group, randomization, and at least a double-blind study design.

The authors conclude that, in general, epidural steroid injection for radicular lumbosacral pain "does not impact average impairment of function, need for surgery, or provide long-term pain relief beyond 3 months." In addition, they found insufficient evidence to recommend either cervical epidural steroid injections or radiographic guidance of injections.

Comment: The authors rightly highlight the paucity of studies that fit their strict inclusion criteria and that can be used to assess efficacy of epidural steroid injections for radicular spinal pain. However, does this mean that epidurals do not work and should not be used, or that the four studies included are the only relevant ones that can be used to assess this question? Is the practice and opinion of pain-management physicians in treating these patients irrelevant? Observational studies and expert opinion have a role in evaluating clinical practice. The authors would have produced a better and well-balanced guideline by including high-quality observational studies, with the appropriate caveats that observational studies with negative results often lack important information, and that a paucity of controlled studies can reflect the difficulty of doing such studies rather than the efficacy of the procedure (J Negat Results Biomed 2002; 1:1). However, the question that these guideline authors attempted to answer is important and clearly must be addressed in further research.

— Edgar Ross, MD

Dr. Ross is Director, Pain Management Center, Brigham and Women’s Hospital, and Assistant Professor of Anesthesia, Harvard Medical School, Boston.

Published in Journal Watch Neurology April 17, 2007

Citation(s):

Armon C et al. 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 Mar 6; 68:723-9.

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• other meds vs. injection
  K. H. Harlow, Cleveland, 11 Sep 2009 3:25 PM EST
  I would like to know whether it is better to have the injection if it allows you to reduce the... [more]