Is epidural injection helpful for spine arthropathy?

Epidural Injections Are Not Recommended for Spine Arthropathy

Epidural injections are strongly recommended against for chronic spine pain associated with arthropathy, as they do not provide meaningful clinical benefit and carry risks of complications. 1

Evidence Against Epidural Injections for Spine Arthropathy

The most recent and highest quality evidence from the 2025 BMJ clinical practice guideline specifically addresses this question with strong recommendations against epidural injections for chronic spine pain:

• For chronic axial spine pain (≥3 months), there is a strong recommendation against epidural injection of local anesthetic, steroids, or their combination 1
• For chronic radicular spine pain (≥3 months), there is also a strong recommendation against epidural injection of local anesthetic, steroids, or their combination 1

These recommendations specifically apply to spine pain not associated with cancer or inflammatory arthropathy that has persisted for at least 3 months.

Reasons for Recommendation Against Epidural Injections

1. Limited efficacy: Despite their widespread use, the evidence does not support meaningful clinical benefit for chronic spine pain related to arthropathy
2. Risk-benefit profile: The potential risks outweigh the limited benefits
3. Inconsistent evidence: Previous guidelines have provided inconsistent recommendations, but the most recent high-quality evidence does not support their use 1

Common Pitfalls in Clinical Practice

• Overreliance on imaging findings: Advanced imaging often shows incidental findings with low correlation between pathology and symptoms 1
• Procedural inconsistency: Proper technique requires fluoroscopic guidance for accurate needle placement, as "blind" injections should not be performed 1
• Complications: Though rare, serious complications can occur, including:
  • Vascular injury leading to spinal cord infarction 2
  • Dural puncture
  • Infection
  • Bleeding
  • Nerve damage

Historical Context and Practice Patterns

Despite the current evidence against epidural injections, their use has increased dramatically over time:

• Between 1994 and 2001 in the US, there was a 271% increase in lumbar epidural steroid injections 1
• The average billings among physicians working at pain clinics providing nerve blocks in Ontario was C$724,183/year (£405,905/year) 1
• Only 37% of Canadian physicians who performed interventional procedures believed their colleagues practiced in accordance with current best evidence 1

Alternative Approaches for Spine Arthropathy

Since epidural injections are not recommended, management should focus on:

1. Self-management strategies
2. Early assessment using validated tools like the STarT Back Tool to stratify patients and allocate resources 1
3. Biopsychosocial approach to pain management
4. Stepped care approach that empowers patients to make informed choices regarding available treatment options 1

Conclusion

The most recent and highest quality evidence strongly recommends against epidural injections for chronic spine pain related to arthropathy. Despite their historical popularity and continued widespread use, the evidence does not support their efficacy for this condition, and they carry risks of potentially serious complications. Management should instead focus on a biopsychosocial approach with appropriate non-interventional treatments.