Epidural Corticosteroid Injections: Conclusion
Technical Considerations: Summary
In summary, if there is evidence to suspect an anterior column pain source (intrinsic disc pain, radiculopathy from disc disease and/or other causes, and extrinsic disc mediated pain without radiculopathy) then choices for typical interventions include inter-laminar and/or transforaminal epidural steroid injections (selective epidural). With multi-level pathology, an interlaminar epidural steroid injection is usually performed. With unilateral, unilevel pathology or with foraminal disease then a selective, transforaminal epidural is usually indicated. If documentation of the pain source is required for medico-legal reasons and/or if it may change subsequent treatment interventions, then nerve root blocks and/or discography can be performed to isolate the pain generators and prove/disprove the presumptive, clinical anatomic diagnosis, provided conservative care, including epidural steroid injections, has failed.
Epidural steroid injections have a role in radicular pain, as proven with some controlled and many uncontrolled studies, including meta-analyses. However there are no well-designed validation studies available to substantiate their use in a number of other spinal pain syndromes. Initially, conservative treatment for lumbar radiculopathy may include bed rest, pain medication, and-inflammatory medication and physical therapy. With persistent pain, early use of epidural steroid injections may provide pain relief, reduction in inflammation, and a means to facilitate physical therapy. The optimal method of delivery is through the use of fluoroscopy and contrast agent, and the transforaminal approach may prove to be more efficacious following completion of current clinical studies. Ideally, anesthetic and corticosteroid should be injected without too much dilutional effect from extra normal saline/carrier agent. Patient evaluation is also essential after each epidural steroid injection and the approach and technique should be justified by patient presentation and ancillary data, such as electrodiagnostics or imaging studies, when available. At the time of this publication, prospective controlled research trials are underway to provide outcome data and validation for the preferred routes of epidural injection, the most efficacious types and dosages of steroid, and even the ideal number of injections for specific spinal diagnoses.