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Epidural Steroid Injections

Epidural steroid injections (ESIs) are an integral part of nonsurgical management of radicular pain from lumbar spine disorders. Radicular pain is described as sharp and radiating pain, often shooting from the low back down into the lower extremity in a radicular distribution. Radicular pain is the result of a nerve root lesion or inflammation. ESIs have been recommended to deliver steroids in a more localized fashion to the area of affected nerve roots, thereby decreasing the systemic effect of the administered steroid. Studies have indicated that ESIs are most effective in the presence of acute nerve root inflammation.

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 lumbar spine with radicular pain.
  • Facet or nerve root cyst with radicular pain.

Cervical ESIs have been used to treat the following conditions:

  • Pain associated with acute disk herniation and radiculopathy.
  • Postlaminectomy cervical pain.
  • Cervical strain syndromes with associated myofascial pain.
  • Postherpetic neuralgia.

Thoracic ESIs have been used to treat pain associated with the following conditions:

  • Acute thoracic disk pathology.
  • Thoracic radicular pain secondary to disk herniations.
  • Postherpetic neuralgia.
  • Trauma.
  • Diabetic neuropathy.
  • Degenerative scoliosis.
  • Idiopathic thoracic neuralgia.
  • Thoracic compression fracture.

Approximately 60-75% of patients receive some relief after ESIs. Benefits include relief of radicular pain and lower back pain (generally relieving leg pain more than back pain), improvement of quality of life, reduction of analgesic consumption, improved maintenance of work status, and obviating the need for hospitalization and surgery in many patients.

Most patients take several days to respond to ESIs. This is generally due to the delayed effects of the corticosteroid. The commonly used compounds with prominent glucocorticoid action include betamethasone sodium phosphate and betamethasone acetate (Celestone Soluspan), methylprednisolone acetate (Depo-Medrol), and triamcinolone hexacetonide (Aristospan).

In general, patients who have had symptoms fewer than 3 months have response rates of 90%. When patients have radiculopathy symptoms for fewer than 6 months, response decreases to approximately 70%. Response decreases to 50% in patients who have had symptoms for over 1 year.

When performed by a skilled experienced clinician within an appropriate setting and with carefully selected patients, the chance of significant complication from ESIs is small and remote. Studies have demonstrated that patients who did not respond to an initial injection did still show improvement after 1 or 2 more epidural steroid injections. In general, up to 3-4 epidural injections may be performed if clinically indicated.

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