What is a clinical indication for a fluoroscopically (using fluoroscopy) guided epidural steroid injection?

From the Guidelines

Fluoroscopically guided epidural steroid injections are primarily indicated for patients with radicular pain caused by conditions such as disc herniation, spinal stenosis, or degenerative disc disease that has not responded adequately to conservative treatments. These injections are particularly useful when a patient experiences moderate to severe pain that limits function and quality of life despite having tried oral medications (including NSAIDs, acetaminophen, or short-term opioids), physical therapy, and activity modifications for at least 4-6 weeks. The procedure involves injecting a corticosteroid (such as methylprednisolone 40-80mg, triamcinolone 40-80mg, or dexamethasone 4-10mg) mixed with local anesthetic (like lidocaine 1% or bupivacaine 0.25%) into the epidural space. Fluoroscopic guidance ensures accurate needle placement, reducing the risk of complications and improving efficacy, as recommended by the British Pain Society 1.

Key Points

• The injections are used for radicular pain caused by disc herniation, spinal stenosis, or degenerative disc disease.
• Patients should have tried conservative treatments for at least 4-6 weeks before considering injections.
• Fluoroscopic guidance is the gold standard for targeted interlaminar epidural or transforaminal epidural steroid injections, as stated in the British Journal of Anaesthesia 1.
• The anti-inflammatory effect of steroids helps reduce inflammation around compressed nerve roots, potentially providing pain relief for weeks to months.
• Patients should be aware that these injections are typically limited to 3-4 per year to minimize steroid-related side effects.

Recommendations

• Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with MRI (preferred) or CT only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) 1.
• Fluoroscopically guided epidural steroid injections should be considered for patients who do not improve with self-care options and have suspected radiculopathy, as part of a comprehensive treatment approach 1.

From the Research

Clinical Indications for Fluoroscopically Guided Epidural Steroid Injections

• Chronic low back pain with radiculopathy is a clinical indication for fluoroscopically guided epidural steroid injections, as shown in studies 2, 3, 4
• Degenerative lumbar scoliotic stenosis and radiculopathy is another indication, with fluoroscopic transforaminal epidural steroid injections appearing to be an effective nonsurgical treatment option 3
• Lumbar disc herniation and radiculitis can also be treated with fluoroscopically guided caudal epidural steroid or local anesthetic injections, with significant pain relief improvement observed in patients 4
• Unilateral, single-level lumbar radicular pain due to disk herniation with or without radiculopathy is an indication for two-level transforaminal epidural steroid injections, which have been shown to be effective in decreasing pain and morbidity 5

Key Findings

• Fluoroscopy guidance is considered the gold standard for pain procedures, including epidural steroid injections 2
• The use of fluoroscopically guided epidural steroid injections has been shown to be effective in reducing pain and improving functional status in patients with various conditions, including chronic low back pain, degenerative lumbar scoliotic stenosis, and lumbar disc herniation 2, 3, 4
• The efficacy of two-level transforaminal epidural steroid injections has been demonstrated, particularly in patients with paracentral/subarticular disk herniations 5