Evidence-based practice of lumbar epidural injections

Epidural administration of corticosteroids is one of the commonly used interventions in managing low back pain with or without radiculopathy. Approaches used to access the lumbar epidural space include the caudal, interlaminar, and transforaminal injections. Reports of effectiveness have varied from 18% to 90%. However, most of the analyses have failed to separate the three approaches, not only mixing the various procedures but also results and outcomes. Recent guidelines by the American Society of Interventional Pain Physicians and others have evaluated effectiveness of caudal epidural steroid injections (ESIs), transforaminal, and interlaminar injections separately. The consensus from these reviews is that caudal ESIs are superior to the interlaminar epidural injections and equal to transforaminal epidural injections. In addition, the response to epidural injections for various pathologic conditions (disc herniation and/or radiculitis, discogenic pain without disc herniation, spinal stenosis, postsurgery syndrome) is variable. The systematic reviews indicated Level I evidence for caudal ESIs in managing disc herniation or radiculitis, and discogenic pain without disc herniation or radiculitis. They also indicated evidence is Level II-1 or II-2 evidence for caudal epidural injections in managing pain of postlumbar surgery syndrome and lumbar spinal stenosis. They also provided strong recommendations of 1B or 1C for caudal ESIs in managing pain secondary to disc herniation and radiculitis, or discogenic pain without disc herniation or radiculitis, postlumbar laminectomy syndrome, and spinal stenosis.