eMedicine Specialties > Physical Medicine and Rehabilitation > Therapeutic Modalities

Epidural Steroid Injections

Author: Boqing Chen, MD, PhD, Clinical Assistant Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal/Pain Management Fellowship, New Jersey Medical School
Coauthor(s): Todd P Stitik, MD, Professor, Department of Physical Medicine and Rehabilitation; Director, Outpatient Occupational/Musculoskeletal Medicine, UMDNJ-New Jersey School of Medicine; Patrick M Foye, MD, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School; Christopher P Castro, DO, Associate Physiatrist, Northeastern Rehabilitation Associates, Graduate of Musculoskeletal/Pain Management Fellowship, New Jersey Medical School; Michael J Mehnert, MD, Volunteer Faculty, Department of Physical Medicine & Rehabilitation, Thomas Jefferson Medical School; Associate Physiatrist, Rothman Institute of Orthopedics; Graduate of Musculoskeletal/Pain Management Fellowship, New Jersey Medical School
Contributor Information and Disclosures

Updated: Feb 18, 2009

Introduction

Epidural steroid injections (ESIs) have been endorsed by the North American Spine Society and the Agency for Healthcare Research and Quality (formerly, the Agency for Health Care Policy and Research) of the Department of Health and Human Services as an integral part of nonsurgical management of radicular pain from lumbar spine disorders.

Radicular pain is frequently described as a sharp, lancinating, radiating pain, often shooting from the low back down into the lower limb(s) in a radicular distribution. Radicular pain is the result of a nerve root lesion and/or inflammation. Clinical manifestations of nerve root inflammation include some or all of the following: radicular pain, dermatomal hypesthesia, weakness of muscle groups innervated by the involved nerve root(s), diminished deep tendon reflexes, and positive straight or reverse leg–raising tests. In contrast to oral steroids, ESIs offer the advantage of a more localized medication delivery to the area of affected nerve roots, thereby decreasing the likelihood of potential systemic side effects. Studies have indicated that ESIs are most effective in the presence of acute nerve root inflammation.

The first documented epidural medication injection, which was performed using the caudal approach (see Approaches for Epidural Injections), was performed in 1901, when cocaine was injected to treat lumbago and sciatica (presumably pain referred from lumbar nerve roots).1 According to reports, epidurals from the 1920s-1940s involved using high volumes of normal saline and local anesthetics. Injection of corticosteroids into the epidural space for the management of lumbar radicular pain was first recorded in 1952.

ESIs can provide diagnostic and therapeutic benefits. Diagnostically, ESIs may help to identify the epidural space as the potential pain generator, through pain relief after local anesthetic injection to the site of presumed anatomic pathology. In addition, if the patient receives several weeks or more of pain relief, then it may be reasonable to assume that an element of inflammation was involved in his or her pathophysiology. Since prolonged pain relief is presumed to result from a reduction in an inflammatory process, it is also reasonable to assume that during the period of this analgesia, the afflicted nerve roots were relatively protected from the deleterious effects of inflammation. Chronic inflammation can result in edema, wallerian degeneration, and fibrotic changes to the neural tissues.

In these authors' opinion, ESIs are best performed in combination with a well-designed spinal rehabilitation program. In most cases, epidural injections should be considered as a treatment option after other treatment attempts (eg, physical therapy, including therapeutic exercise, manual therapy, and medications) have failed to improve the patient’s symptoms. However, ESIs may be indicated earlier in the treatment algorithm in some selected patients. Examples might include patients with medical contraindications to certain oral analgesics and patients whose pain severity substantially limits their ability to appropriately engage in therapeutic exercise.

A variety of approaches can be used to inject corticosteroids into the epidural space (see Approaches for Epidural Injections). For purposes of this article, the authors generally refer to all epidural steroid injections as ESIs, only specifying the specific type of approach if needed for a point of distinction or clarification.

Related eMedicine articles:
Corticosteroid Injections of Joints and Soft Tissues
Steroid Injection, Carpal Tunnel
Therapeutic Injections for Pain Management

Mechanisms of Radicular Low Back Pain

As mentioned above, radicular pain often is the result of nerve root inflammation +/- mechanical irritation. Clinical practice and research demonstrate that mechanical compression alone to the nerves causes only motor deficits and altered sensation but does not necessarily cause pain. Inflammation within the epidural space and nerve roots, as can be provoked by a herniated disk, is a significant factor in causing radicular pain.

Historical evidence of nerve root inflammation has been demonstrated during surgery in patients with radicular low back pain (LBP) from lumbar disk herniation. Animal research in dogs and rats also has revealed severe inflammation locally within the epidural space and nerve root after injection of autologous nuclear material into the epidural space. A high level of phospholipase A2 (PLA2), an enzyme that helps to regulate the initial inflammatory cascade, has been demonstrated in herniated disk material from surgical samples in humans. Leukotriene B4, thromboxane B2, and inflammatory products also have been discovered within herniated human disks after surgery. Animal models have demonstrated that injection of PLA2 into the epidural space induces local demyelination of nerve roots, with resultant ectopic discharges (which is considered to be the primary pathophysiologic mechanism for sciatica [radicular pain]).

The radicular LBP caused by spinal stenosis is probably related to the inhibition of normal nerve root vascular flow with resultant nerve root nutrition, nerve root edema, and nerve root dysfunction. Chronic nerve root compression can induce axon ischemia, impede venous return, promote plasma protein extravasation, and cause local inflammation. If dorsal root ganglia are chronically compressed and irritated, this theoretically can lead to their sensitization and resultant radicular pain. Similar mechanisms of radicular pain are postulated to occur in the thoracic and cervical spine as well.

In summary, clinical practice and animal research suggest that radicular pain is the result of inflammation of the nerve root in the epidural space provoked by leakage of disk material, compression of the nerve root vasculature, and/or irritation of dorsal root ganglia from spinal stenosis.

Related eMedicine topics:
 Cervical Disc Disease
Disk Herniation
Herniated Nucleus Pulposus
Lumbar Disk Problems in the Athlete
Mechanical Low Back Pain
Pathophysiology of Chronic Back Pain

Rationale for Use of Steroids in Back Pain

Since lumbar radicular pain may originate from inflammation of the epidural space and the nerve root, analgesic effects of corticosteroids most likely are related to the following mechanisms:

  • Inhibition of PLA2 and inflammation
  • Inhibition of neural transmission in nociceptive C fibers
  • Reduction of capillary permeability

Indications and Contraindications for Epidural Steroid Injections

Although the primary indication for epidural steroid injection (ESI) is radicular pain associated with a herniated nucleus pulposus, a variety of other indications have been reported in the literature.

Lumbar ESIs may be indicated for lumbar radicular pain associated with any of the following conditions:

  • Lumbosacral disk herniation
  • Spinal stenosis with radicular pain (central canal stenosis, foraminal and lateral recess stenosis)
  • Compression fracture of the lumbar spine with radicular pain
  • Facet or nerve root cyst with radicular pain

Cervical ESIs have been used to treat the following conditions:

Thoracic ESIs have been reported in the medical literature as treatment for pain associated with the following conditions:

Absolute contraindications for ESIs include the following:

  • Systemic infection or local infection at the site of a planned injection
  • Bleeding disorder or fully anticoagulated (for example, on a fully "therapeutic" dose of Coumadin, heparin, etc.)
  • History of significant allergic reactions to injected solutions (eg, contrast, anesthetic, corticosteroid)
  • Acute spinal cord compression 
  • Patient refusal to proceed with the injection procedure

In addition, fluoroscopy should not be used in epidural injections for women who are pregnant, to avoid exposing the fetus to ionizing radiation. Caution should be used when performing injections in patients with poorly controlled diabetes, since the corticosteroid may transiently, but significantly, increase blood glucose levels. Patients with a history of immunosuppression may require additional precautions, such as preprocedure laboratory testing and/or antibiotics. Caution should be exercised when performing injections in individuals who have a history of congestive heart failure because of the potential for steroid-induced fluid retention.

Efficacy of Epidural Injections and Rationale for Fluoroscopy and Contrast

Efficacy of epidural steroid injections (ESIs)

 Although numerous articles have supported the benefit of ESIs for LBP, especially if the pain is caused by radiculopathy, other studies have disputed the efficacy of these procedures. Unfortunately, most of the earlier studies (those that failed to show a benefit from the injection) had significant limitations. Aside from employing a less-than-desirable research methodology, most of these studies did not use fluoroscopy and radiographic contrast to document accurate placement of the injected substance into the epidural space. Many also failed to demonstrate that injection was performed at a presumed level of pathology, which has been shown to be critical to the success of ESIs.

Studies have reported that without fluoroscopy and radiographic contrast confirmation, incorrect injection placement (that is, placement outside the epidural space) occurs in 30% of cases, on average, even when ESI is performed by experienced injectionists. These methodologic problems most likely were the major factors that led to the mixed assessment of ESIs.

When lumbar ESIs are used for radicular pain in a well-selected patient population, studies have demonstrated the positive efficacy of these injections as long as proper placement is confirmed by employing fluoroscopic needle guidance and radiographic confirmation, using a contrast medium. Benefits include relief of radicular pain and LBP (with leg pain generally relieved more than back pain), facilitation of the ability to participate in physical therapy, improvement of quality of life, reduction of analgesic consumption, and improvement in the maintenance of work status.

Patients should be educated that ESI alone may not be the only solution to give them long-term benefits. ESI is just one of several nonoperative methods used to treat LBP and/or radicular symptoms. Other treatments may include short-term bed rest, medications (eg, analgesics, muscle relaxants), a properly designed program of physical therapy, and the management of any psychological, financial, marital, and work-related problems. This combined treatment approach is likely to produce better outcomes for patients with LBP than can any single modality used in isolation. Published research on the outcome of ESIs has supported this notion of multifaceted treatment.

Factors affecting the efficacy of ESIs
As with other medical procedures, the efficacy of the ESIs is related to many factors. Aside from the clinician's experience and training, other factors that play an important role include patient selection, symptom duration, underlying pathophysiology, ESI approach, the use of fluoroscopy and contrast enhancement, and the vocational status, as well as the socioeconomic and psychological circumstances, associated with the individual patient.

In general, patients who have had symptoms for less than 3 months have response rates of 90%. When patients have had radiculopathy symptoms for less than 6 months, response decreases to approximately 70%. Response decreases to 50% in patients who have had symptoms for over 1 year. Patients with symptoms of shorter duration have more sustained relief than those with chronic pain. Patients with chronic back pain will generally have better response if they develop an acute radiculopathy. Patients with factors favoring the use of ESIs also include those who have not had previous back surgery, who are not on workers’ compensation, who are aged younger than 60 years, and who are nonsmokers.

In a cross-sectional study design at a university spine center, 76 patients with sciatica were followed for a mean of 122 days after receiving transforaminal ESIs. Of these patients, 47% experienced improvement, 28% were unchanged, and 16% worsened. The least favorable outcomes were associated with patients receiving Social Security Disability Insurance (SSDI) or workers’ compensation payments, and with those whose work required heavy lifting.

Patient response to ESIs is also related to underlying pathophysiology. In general, acute radicular pain from lumbar disk herniation responds more favorably than does radicular pain from lumbar spinal stenosis. Patients with radicular pain after lumbar spine surgery frequently receive less benefit from ESIs unless the radicular pain is from a recurrent herniated nucleus pulposus. Still, ESIs are often helpful for radicular pain from stenosis.

Lumbar transforaminal epidural injections

The following research demonstrated the efficacy of lumbar transforaminal epidural injections (see Approaches for Epidural Injections) in patients with persistent sciatica from lumbar disk herniation or spinal stenosis:       

  • In 2002, Lutz and colleagues reported a prospective randomized study comparing transforaminal lumbar epidural injection with lumbar paraspinal trigger-point injection. They randomized 48 patients with sciatica from herniated disk pulposus (confirmed by lumbar spine magnetic resonance imaging [MRI]) into 2 groups. One group received transforaminal lumbar epidural injection, and the other received a lumbar paraspinal intramuscular injection with saline. The average follow-up period was 16 months. The authors used patient satisfaction, the Rolland-Morris scale, and pain reduction extent as indices for efficacy. The success rate in the transforaminal injection group was 84%, compared with 48% in the saline group.
  • Botwin and colleagues demonstrated the efficacy of the transforaminal epidural injection in their retrospective cohort study in patients with sciatica (caused by lumbar spinal stenosis).2 Thirty-four patients who did not respond to nonsteroidal anti-inflammatory agents and oral analgesics received 1.9 injections (average). At 1 year, 75% of the patients had greater than 50% pain reduction, 64% improved their walking duration, and 57% increased their standing tolerance. An additional benefit of ESIs in many patients is that the injections can potentially obviate the need for hospitalization and surgery in many patients.
  • Riew and colleagues reported results from a prospective, randomized, double-blinded, controlled clinical trial on 55 patients with severe sciatica from spinal stenosis or lumbar disk herniations.3 These patients had not responded to 6 weeks of conservative treatment and were considered to be surgical candidates. The patients were divided into 2 groups; 1 group received lumbar epidural injection with bupivacaine and steroid, while the other group received only bupivacaine. Up to 4 lumbar epidural injections were delivered if needed. The follow-up period was 2-3 years. The study demonstrated that only 23% of patients in the group that received lumbar ESIs needed surgery, while 67% of patients in the bupivacaine injection group underwent surgery. The difference was statistically significant.

    A follow-up study at 5 years found that 17 of 21 patients (81%) surveyed still had still not opted for surgery.4 This report demonstrated a benefit from lumbar ESIs in patients who had been diagnosed with lumbar spinal stenosis or herniated nucleus pulposus, with the injections helping to reduce the need for surgery
  • A systematic review on lumbar transforaminal epidural injection confirmed its efficacy.5 Evidence drawn from well-designed controlled trials without randomization indicated that transforaminal ESIs can provide short-term (<6 months) relief of radicular low back pain. Evidence obtained from well-designed cohort or case-control analytic studies also suggested long term (>6 months) benefit.
  • There is more evidence favoring the use of transforaminal ESIs in the lumbar spine, compared with the cervical spine. Although the interlaminar approach (see Approaches for Epidural Injections) may allow the injectate to flow to the site of pathology by migrating around the thecal sac and into the ventral epidural space, the transforaminal route is presumably more reliable for delivering the steroid to the affected area in cases of disk herniation in which the disk comes into contact with the nerve root.

Lumbar caudal epidural injections

Results from studies on caudal epidural injections are as follows:    

  • Barre and colleagues reported that in 35% of patients with symptomatic lumbar spinal stenosis who received caudal ESIs, a visual numeric score improvement of 50% or greater was seen.6  Long-term treatment success was seen in 35% of patients after a mean follow-up of 32 months. 
  • Anwar and coauthors demonstrated that caudal injections could benefit patients with limited straight leg raise and symptoms of radicular pain or spinal stenosis; in this study, 65% of patients were noted to have some improvement at 3 months.
  • A systematic review demonstrated level I evidence for the relief of chronic pain occurring secondary to disk herniation or radiculitis and diskogenic pain without disk herniation or radiculitis. Further, in the management of chronic pain from post – lumbar laminectomy syndrome and spinal stenosis, the evidence is level II-1 or II-2 for caudal epidural injections.7

Lumbar interlaminar epidural injections


A systematic review revealed a paucity of literature, a lack of quality evidence, a lack of fluoroscopic guidance in studies, and a lack of applicable evidence in contemporary interventional pain management strategies. Therefore, the review concluded that the evidence is limited for blind interlaminar epidurals in managing lumbar pain, except for the finding of short-term relief of pain secondary to disk herniation and radiculitis. This evidence is not derived from contemporary interventional pain management practice techniques and therefore may not be extrapolated to fluoroscopically directed lumbar interlaminar epidural injections.8

Comparison of interlaminar vs transforaminal lumbar epidural injections

Rhee and colleagues found a difference in patients undergoing interlaminar and transforaminal ESI.9 Those patients who underwent transforaminal injections had a 46% reduction in their pain score, and 10% went on to need surgery. In contrast, patients who had interlaminar injections had a 19% reduction in pain, and 25% required surgery.

No deleterious effects on diskectomy
Buttermann and colleagues conducted a study involving individuals with a lumbar disk herniation of >25% of the cross-sectional area of the spinal canal; the patients were administered ESIs 1 level above the herniation.10  The patients received up to 3 injections, with 42-56% of these individuals reporting the treatment to be effective. There was a cross-over of patients who first underwent ESIs and then diskectomy. For those who underwent an initial trial of ESIs, the delay in surgical decompression was not found to be detrimental to neurologic recovery at time of follow-up.

Cervical ESIs
No randomized, controlled trials have been performed to date on the efficacy of ESIs for the cervical spine and treatment of upper limb radicular pain. A prospective study by Rowlingson and Kirschenbaum described significant reduction in upper limb pain after cervical ESIs, and other studies (retrospective and prospective) identified radicular pain relief via interlaminar and transforaminal approaches.11  Given the similar mechanisms of radicular pain postulated for the lumbar and cervical regions, compelling evidence regarding the efficacy of lumbar ESIs might be applicable to treatment of upper limb radicular pain, although the authors recognize the need for further research.

In terms of potential efficacy, transforaminal cervical ESIs are preferred over the interlaminar approach by several authors, because the transforaminal cervical injections allow for the delivery of higher concentrations of medications to isolated nerve roots and neuroforamina where stenosis may be present.12

A systematic review of cervical interlaminar epidural injections concluded that such injections are effective for relief of cervical radicular pain in the upper limbs; the report strongly recommended the procedure. However, there were no randomized trials identified in this review.

Rationale for fluoroscopy and contrast

 Reports suggest that injection without fluoroscopic guidance (ie, “blind injection”) results in 30-40% of needle misplacements, such as needle tip placement outside the epidural space (including intravascular injection) and placement not at the presumed level of pathologic process. Therefore, it is recommended that ESIs be performed under fluoroscopic guidance and with radiographic contrast documenting appropriate placement in order to improve the safety, accuracy, and potential efficacy of ESIs.

Fluoroscopy in conjunction with contrast is utilized in practice to not only improve efficacy, but also to minimize potential complications. Furman and coauthors discovered that for lumbar spine ESIs, using flash or positive blood aspirate to predict intravascular injections was 97.9% specific but only 44.7% sensitive.13  This suggests that negative aspiration of blood does not ensure a lack of vascular uptake. Similarly, in the cervical spine, vascular uptake injections occurred at a rate of nearly 20% with the use of fluoroscopy (confirmed by contrast injection), via a transforaminal approach. Again, a visible flash of blood in the needle hub or positive aspiration of blood demonstrated similar specificity and sensitivity to the lumbar injection study.

In a prospective study involving 191 patients who underwent single-level lumbar transforaminal epidural injection, simultaneous epidural and vascular injection was found to be 8.9%. Therefore, live fluoroscopy is recommended during contrast injection for confirmation of lumbosacral transforaminal epidural injections.14

Safety of Epidural Injections

When performed by a skilled, experienced clinician in an appropriate setting and with carefully selected patients, the chance of significant complication from epidural steroid injections (ESIs) is remote. Nonetheless, similar to regional analgesia procedures, there are risks associated with ESIs. The more common risks from lumbar epidural injections are as follows:       

  • Backache, postural puncture headache (0.5-1% for lumbar interlaminar injections and 0.6% for caudal epidural injections), nausea, vomiting, dizziness, and vasovagal reaction. 
  • Bleeding along the trajectory of the injection, including in proximity to the nerve roots and/or the spinal cord (epidural hematoma), is a rare but potentially serious complication. Epidural hematoma occurs in 0.01-0.02% of procedures.      
  • Infection is more common in immunocompromised patients and can include epidural abscess and meningitis.
  • Nerve root injury has been reported. 
  • Other rare complications include anterior cord syndrome, presumably resulting from the injection of particulate steroid into the artery of Adamkiewicz.
Cervical ESIs carry similar risks, with the apparent caveat that any damage to the spinal cord at the level of the cervical spine will often result in greater impairment than will damage at the lumbar levels and may precipitate respiratory arrest at higher cervical levels. There is the risk of spinal cord trauma if the operator performs direct injection into the spinal cord via an interlaminar approach (a risk that is essentially absent at the lower lumbar spine, since the spinal cord terminates at the level of L2).

Cord trauma can also result from compression of the spinal cord from an epidural abscess or an epidural hematoma. In general, complications can be averted by using fluoroscopic guidance and contrast enhancement to avoid vascular uptake. (Vascular injection of particulate steroid matter is postulated to increase the risk of central nervous system infarct.)

An anatomic study of 95 cervical intervertebral neuroforamina in 10 embalmed cadavers was conducted. Twenty-one arterial branches were found in the posterior aspect of neuroforamina. Seven of them were potential radicular or segmental medullary vessels to the spinal cord. There were variable anastomoses between vertebral arteries and cervical arteries. The study demonstrated that the critical arteries are found in the posterior aspect of the intervertebral neuroforamina and that they may be vulnerable to injection or injury during transforaminal ESI.15 Therefore, aside from the use of live-time fluoroscopy with contrast injection during the cervical transforaminal ESIs to visualize and avoid intravascular injections, the employment of smaller particulate corticosteroid preparations were also recommended to further reduce the risk of central nervous system infarct.

In a randomized study comparing the effectiveness of dexamethasone and triamcinolone used in cervical transforaminal epidural injection, found that at 4 weeks postinjection, both groups exhibited statistically and clinically significant improvement. Although the dexamethasone was slight less effective than triamcinolone, the difference was neither statistically nor clinically significant.16 To date, the authors are unaware of any published literature pertaining to central nervous infarcts secondary to the dexamethasone used in the ESIs.

Some interventionalists have advocated injecting a “test dose” of local anesthetic (nonparticulate medication) after the needle is placed and the correct position is verified with contrast, and then waiting to ensure that the patient does not experience central nervous system side effects. These side effects, including seizures, transient paresis, and respiratory depression, are generally thought of as reversible and an additional indicator of possible vascular uptake. Avoidance of “heavy” sedation during procedures has been recommended to decrease side effects as well.

Despite these risks, most agree that complications are minimal when ESIs are performed by a physician with the proper equipment, training, and technique.

Mild hypothalamic-pituitary-adrenal axis suppression has been reported from 1-3 months after receiving a total of 3 epidural injections (once weekly) with 80 mg of Aristocort in 7 mL of 1% lidocaine.

Safety of the transforaminal approach

There has been increasingly frequent debate in the literature about the safety of continued use of cervical ESIs via a transforaminal approach, given the possibility (although extremely small) of catastrophic complications. Although there is no clear consensus of opinion, alternative approaches, such as using cervical interlaminar injections (or even deferring to thoracic-level interlaminar approaches with the use of a catheter to deliver medication to the cervical levels), have been recommended. However, these alternatives cannot eliminate all possible risk. Regardless of approach, in the opinion of the authors, fluoroscopy and the use of contrast media are clearly necessary for cervical epidural injections.

Timing, Frequency, Dose, and Volume of Epidural Injections

The optimal timing of epidural injection is unknown. Patients with radicular symptoms often undergo a few weeks of treatment, including relative rest or activity modification, medication, physical therapy, and/or manual therapy, prior to undergoing epidural injections. If the patient does not have success with such a program, or if the therapy cannot progress because the patient's pain is too severe (as long as there are no signs of progressive neurologic deficits), epidural injection is indicated for pain control.

In contrast, early use of epidural steroid injections (ESIs) can be considered in patients with severe radicular pain that does not respond even to opioid medication or in whom the pain is severely interfering with sleep habits and daily functioning. Early ESIs also carry the theoretical benefit of controlling inflammation at the early stage and of preventing permanent neural damage, such as nerve fibrosis from the prolonged inflammatory process. Under these circumstances, early administration of ESIs may have a more beneficial effect than would later/delayed use.

The interval between injections varies with the steroid preparation used. Because injected methylprednisolone has been reported to remain in situ for approximately 2 weeks, the clinician should consider waiting approximately 2 weeks after the injection to assess the patient's response and to determine if it would likely be beneficial to administer a repeat injection. However, this 2-week interval may be reduced if a different (short-acting) steroid is used or if the clinical scenario warrants an earlier performance of the repeat epidural. In general, however, routine performance of a predetermined fixed number of epidural injections without a clinical reevaluation in between injection procedures should be discouraged.

The ideal number of epidural injections to be administered for a given clinical scenario is often unclear, because there are no clear data in the current literature on the exact number ESIs to be administered and the timing that should be employed. Clinical practice patterns, however, suggest that up to 3-4 injections may be used for acute radicular pain syndromes. Reevaluation by a physician after each injection seems to be indicated to determine the need for additional procedures prior to pursuing a "series" of 3 epidural injections, regardless of clinical response, since there are no medical outcome studies to clearly support such a regimen.

Studies have suggested that, depending on the particular clinical scenario, the total dose of methylprednisolone should probably not exceed approximately 3 mg/kg of body weight, in order to prevent excessive salt and water retention. For interlaminar ESIs, the typical corticosteroid doses are 12-18 mg for betamethasone and 80-120 mg for methylprednisolone. Half of these steroid doses are generally used when performing transforaminal ESIs. The epidural steroid is injected in a diluent, such as lidocaine (1-2%) and/or normal saline.

The volume of the injectate is dictated mainly by the approach used. In cervical and thoracic epidural injections, a total of 3-5 mL may be used for ESIs employing the interlaminar approach. However, in cervical and thoracic transforaminal ESIs, clinicians generally use a total volume of only about 1.5-2 mL. The volume used for lumbar ESIs is slightly greater, generally being 6-10 mL for interlaminar ESIs, up to 20 mL for caudal ESIs, and 3-4 mL for transforaminal ESIs.

Approaches for Epidural Injections

Cervical and thoracic epidural injections can be carried out using interlaminar and transforaminal approaches. Lumbar epidural injections can be performed using 3 approaches: transforaminal, interlaminar, and caudal.

Interlaminar epidural injections

Interlaminar epidural injection refers to injection into the epidural space using an interlaminar approach. The injection can be performed through paramedian or midline approaches. (See image below and Image 2.)

Interlaminar approach at the L5-S1 level on the l...

Interlaminar approach at the L5-S1 level on the left, anteroposterior view.

[ CLOSE WINDOW ]
Interlaminar approach at the L5-S1 level on the l...

Interlaminar approach at the L5-S1 level on the left, anteroposterior view.


The epidural needle penetrates the following (in order, from superficial to deep):
  • Skin
  • Subcutaneous tissue
  • Paraspinal muscles (paramedian approach) or interspinous ligament (midline approach)
  • Ligamentum flavum

Upon contact with the ligamentum flavum, a “loss of resistance” technique is implemented with saline until proper advancement results in penetration into the epidural space.

Botwin and colleagues utilized 5 mL of contrast media via a lumbar interlaminar approach to assess for flow.17  In 36% of the injections, the contrast was noted to spread into the ventral space. Unilateral flow was observed in 84% of the injections. The amounts of cephalad and caudad flow averaged 1.28 and 0.88 levels, respectively.

Transforaminal epidural injections

Transforaminal approach is performed by placing the needle in the neuroforamen, ventral to the nerve root. The needle is directed in an oblique approach towards a target point on the upper margin of an imaginary triangle (the “safe triangle”), formed by a line tangential to the lower margin of the pedicle, a line tangential to the lateral margin of the pedicle, and the hypotenuse passing obliquely inferiorly and laterally from the inferior medial corner of the pedicle. Advancement is made under lateral and anteroposterior views to provide a 3-dimensional spatial representation. (See image below and Image 3.)

Transforaminal approach at the S1 level on the ri...

Transforaminal approach at the S1 level on the right, anteroposterior view.

[ CLOSE WINDOW ]
Transforaminal approach at the S1 level on the ri...

Transforaminal approach at the S1 level on the right, anteroposterior view.


Caudal epidural injections

Caudal lumbar epidural injections may be performed by inserting a needle through the sacral hiatus into epidural space at the sacral canal. Because of the large area in the caudal space and the distance from the nerve roots, larger volumes of injectate are required to deliver drug to the area of the pain generator. (See image below and Image 1.)

Caudal approach, lateral view.

Caudal approach, lateral view.

[ CLOSE WINDOW ]
Caudal approach, lateral view.

Caudal approach, lateral view.


 
Reports suggest that injection without fluoroscopic guidance (that is, blind injection) results in 30-40% of needle misplacement, such as needle tip placement outside the epidural space (including intravascular injection) and not at the presumed level of pathologic process. Therefore, although it is not a standard, it is recommended that epidural steroid injections (ESIs) be performed under fluoroscopic guidance and with radiographic contrast documenting appropriate placement in order to improve the safety, accuracy, and potential efficacy of ESIs.

Medications Used in Epidural Injections

The medication composite for an epidural injection consists of a steroid preparation and, in most cases, an anesthetic. A contrast medium also is generally used, along with fluoroscopic-guided procedures, to verify placement and distribution of the injectate. Newer formulations, labeled as nonionic radiocontrast agents, are commonly used at present for spinal injection procedures. Although these agents do contain iodine atoms, there is minimal free iodine present, allowing for a formulation with a more physiologic osmolality, as well as less free iodine. These media undergo primarily renal excretion with little, if any, metabolism and deiodination.

For patients with a suspected allergy to contrast medium, consideration should be given to pretreatment orally with antihistamines and corticosteroids prior to the procedure. Acute allergic reactions will generally occur in the first few minutes after injection. Ideally, therefore, patients should be observed for at least a few minutes after the procedure.

Local anesthetics bind with intracellular sodium channels to prevent sodium influx, which occurs during depolarization of the neural membrane. The nerve impulse fails to propagate if sufficient sodium channels are blocked. When local anesthetics are used to minimize pain during an epidural procedure, the medication is acting on closed sodium channels. In this case, the duration of the local anesthetic is shorter than it is when pain is present and the sodium channels are open.
 
A local anesthetic's time to onset of action can be decreased by: (1) "buffering" the anesthetic by adding a base (such as bicarbonate) and (2) increasing its concentration. Typically, 1% lidocaine is used as a skin anesthesia for epidural steroid injections (ESIs).
 
Anesthetics are classified as amides or esters. Esters, such as procaine, are metabolized by plasma cholinesterase and are then excreted by the kidney. Amides, such as lidocaine and bupivacaine, are metabolized by the liver and then in the kidney. Because amides are metabolized more slowly than esters, they have a longer duration of action.
 
It is the primary author's experience that when cervical ESIs are performed, a test dose, with a small quantity of anesthetic, should be administered after placement of the contrast medium, to confirm lack of vascular uptake. Should the patient complain of any symptoms indicating side effects of the anesthetic, this could suggest local vascular uptake. Such symptoms could indicate a need to change the spinal needle position, to prevent intravascular corticosteroid injection. 
 
Different steroid preparations are utilized for ESIs. Examples include dexamethasone (Decadron), triamcinolone (Kenalog), betamethasone (Celestone), and methylprednisolone (Solu-Medrol).
 
The fact that corticosteroids differ significantly in microscopic size has become an important consideration because of an awareness that the larger a particle is, the greater are its chances of occluding a blood vessel should the compound be inadvertently injected intravascularly. A study that analyzed the microscopic size of the aforementioned corticosteroids found the following:

  • Dexamethasone - Particles were 5-10 times smaller than red blood cells, contained few particles, and showed no aggregation.
  • Triamcinolone - Particles varied greatly in size, were densely packed, and formed extensive aggregations.
  • Betamethasone - Particles varied greatly in size, were densely packed, and formed extensive aggregations.
  • Methylprednisolone - Particles were relatively uniform in size, smaller than red blood cells, and densely packed and did not form very many aggregations.

Most patients take several days to respond to ESIs. Celestone Soluspan provides an extended anti-inflammatory effect, whereas Depo-Medrol and Kenalog provide a more rapid anti-inflammatory effect that is of shorter total duration.

Multidose vials of Depo-Medrol contain benzyl alcohol, which is potentially toxic when administered locally to neural tissue and may increase the risk of arachnoiditis or meningitis. Thus, for epidural injections, many physicians prefer to use steroid preparations without such preservatives. One option is to use only single-dose vials of the corticosteroids, because these generally do not contain benzyl alcohol. However, for some steroid products, even the single-dose vials may contain at least some preservatives or antimicrobial additives, so physicians should be aware of all of these factors when deciding on the steroid to be used for the injection.

Further Investigations on Radicular Pain Management

Becker and colleagues studied the use of autologous conditioned serum containing enriched IL-1 antagonist, during lumbar transforaminal epidural injections for radiculopathy. In comparison with triamcinolone 10 mg, the autologous conditioned serum injection had the same efficacy at 22-week follow-up with respect to pain reduction. The injection with autologous conditioned serum was more effective than triamcinolone 5 mg. This was an encouraging result, because autologous blood has no known side effects per se, in contrast to corticosteroids, and therefore can theoretically be used more frequently than can corticosteroid injection. Further studies are needed to confirm these findings.18

The anti-tumor necrotic factor agents were also investigated in treating lumbar radicular pain. Open-label results from animal studies revealed the positive effect of anti – tumor necrosis factor alpha (anti – TNF-alpha) therapy in reducing the abnormal nociresponse and the neurotoxic effects induced by the nucleus pulposus on the neuronal tissues.19

Human clinical trials include 2 open-label studies — one of which used intravenous infliximab, a monoclonal antibody against TNF-alpha, and the other of which employed the soluble TNF-alpha receptor antagonist etanercept — in patients with sciatica from disk herniation. These studies demonstrated significant efficacy with respect to pain reduction.20,21,22

However, long-term findings were disappointing with regard to the efficacy of an anti – TNF-alpha treatment, when compared with that of a placebo injection, in disk herniation – induced sciatica, as derived from research in a randomized, controlled setting. The 3-month results showed no difference in patient-reported symptoms or in more objective outcomes (SLR, days on sick leave, diskectomies) between intravenous infliximab 5 mg/kg and placebo.22 The 1-year results indicated that infliximab cannot be recommended for herniation-induced sciatica.23 Clearly, further studies using multiple intravenous infusion of the anti – TNF-alpha agents or epidural injection of similar substances are necessary to clarify the efficacy of anti

Conclusions

Research has supported the use of lumbar epidural injections in selected patients with significant radicular pain. A review of prospective studies in treating lumbosacral radiculopathy with transforaminal epidural steroid injections (ESIs) or selective nerve root blocks demonstrated that the evidence for transforaminal ESIs was level III (moderate) in support of these minimally invasive and safe procedures in treating painful radicular symptoms. However, conclusive evidence (level I) is lacking.24

A systematic review concluded that there is moderate evidence for long-term relief from interlaminar epidurals in the cervical spine and that there is limited evidence for long-term relief from such injections in the lumbar spine. The evidence for cervical and lumbar transforaminal ESIs is moderate for long-term improvement in managing nerve root pain. The evidence for caudal epidural steroid injections is moderate for long-term relief in managing nerve root pain and chronic low back pain.25

The judicial use of ESIs in conjunction with a properly designed rehabilitation program may play a very important role in the conservative management of patients with severe radicular pain, improving their quality of life and function.

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Caudal approach, lateral view.
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Caudal approach, lateral view.

Caudal approach, lateral view.

Interlaminar approach at the L5-S1 level on the l...
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Media file 2: Interlaminar approach at the L5-S1 level on the left, anteroposterior view.
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Interlaminar approach at the L5-S1 level on the left, anteroposterior view.

Transforaminal approach at the S1 level on the ri...
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Media file 3: Transforaminal approach at the S1 level on the right, anteroposterior view.
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Transforaminal approach at the S1 level on the right, anteroposterior view.

Keywords

epidural steroid injection, steroids, low back pain, herniated disc, herniated disk, radiculopathy, herniated discs, herniated disks, corticosteroids, corticosteroid, epidural steroid, epidural injection, epidural injections, epidural steroid injections, steroid injection, lumbar epidural injection, radicular pain, transforaminal injection, transforaminal epidural, lumbar steroid injection, cervical epidural injection, epidural corticosteroid injections, lumbar epidural steroid injection, nonsurgical management of radicular pain, nerve root inflammation

 


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References
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Further Reading

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Keywords

epidural steroid injection, steroids, low back pain, herniated disc, herniated disk, radiculopathy, herniated discs, herniated disks, corticosteroids, corticosteroid, epidural steroid, epidural injection, epidural injections, epidural steroid injections, steroid injection, lumbar epidural injection, radicular pain, transforaminal injection, transforaminal epidural, lumbar steroid injection, cervical epidural injection, epidural corticosteroid injections, lumbar epidural steroid injection, nonsurgical management of radicular pain, nerve root inflammation

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Contributor Information and Disclosures

Author

Boqing Chen, MD, PhD, Clinical Assistant Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal/Pain Management Fellowship, New Jersey Medical School
Boqing Chen, MD, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Society of Interventional Pain Physicians, and International Spine Intervention Society
Disclosure: Nothing to disclose.

Coauthor(s)

Todd P Stitik, MD, Professor, Department of Physical Medicine and Rehabilitation; Director, Outpatient Occupational/Musculoskeletal Medicine, UMDNJ-New Jersey School of Medicine
Todd P Stitik, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, Phi Beta Kappa, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Patrick M Foye, MD, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Disclosure: Nothing to disclose.

Christopher P Castro, DO, Associate Physiatrist, Northeastern Rehabilitation Associates, Graduate of Musculoskeletal/Pain Management Fellowship, New Jersey Medical School
Christopher P Castro, DO is a member of the following medical societies: American Academy of Pediatrics, American Academy of Physical Medicine and Rehabilitation, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Michael J Mehnert, MD, Volunteer Faculty, Department of Physical Medicine & Rehabilitation, Thomas Jefferson Medical School; Associate Physiatrist, Rothman Institute of Orthopedics; Graduate of Musculoskeletal/Pain Management Fellowship, New Jersey Medical School
Michael J Mehnert, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Medical Association, International Spine Intervention Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Medical Editor

Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM, President and Director, Georgia Pain Physicians, PC; Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Emory University School of Medicine
Robert E Windsor, MD, FAAPMR, FAAEM, FAAPM is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, American Medical Association, International Association for the Study of Pain, Physiatric Association of Spine, Sports and Occupational Rehabilitation, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Jay M Meythaler, MD, Program Director, Director of Brain Injury Services, Director of the Traumatic Brain Injury Care System, Professor, Department of Physical Medicine and Rehabilitation, Spain Rehabilitation Center, University of Alabama at Birmingham
Jay M Meythaler, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Congress of Rehabilitation Medicine, American Medical Association, American Paraplegia Society, American Spinal Injury Association, and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Rene Cailliet, MD, Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center
Rene Cailliet, MD is a member of the following medical societies: American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Pain Society, Association of American Medical Colleges, International Association for the Study of Pain, and Pan American Medical Association
Disclosure: Nothing to disclose.

 
 
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