When are epidural steroid injections (ESI) indicated for spinal conditions?

Indications for Epidural Steroid Injections of the Spine

Epidural steroid injections (ESIs) are strongly recommended for chronic spine pain associated with disc herniation, and moderately to strongly recommended for spinal stenosis, axial discogenic pain, and post-surgery syndrome. 1

Primary Indications for ESI

ESIs are indicated in the following conditions:

Strong Evidence for Use

• Disc herniation with radiculopathy (nerve root compression causing radiating pain) 1
  • Particularly when symptoms persist despite 4 weeks of conservative therapy 1
  • For patients with persistent radicular symptoms who may be candidates for surgery 1

Moderate to Strong Evidence for Use

• Spinal stenosis with radicular symptoms 1
• Axial discogenic pain (pain originating from the disc itself) 1
• Post-surgery syndrome (persistent pain following spine surgery) 1

Patient Selection Criteria

ESIs should be considered when:

1. Radicular symptoms are present - Characterized by radiating pain along a nerve distribution, altered sensation, and possibly diminished reflexes in the affected distribution 2

2. Imaging correlates with symptoms - MRI (preferred) or CT showing nerve compression that matches clinical presentation 1

3. Patient is a potential candidate for surgery or has failed conservative management 1

4. Moderate to severe pain affecting quality of life despite conservative measures 1

Contraindications and Cautions

• NOT recommended for nonspecific low back pain without radicular symptoms 1
• NOT recommended as first-line treatment before trying conservative measures 1
• Use caution in patients with:
  • Coagulopathy
  • Infection
  • Significant comorbidities increasing procedural risk
  • Pregnancy

Technical Considerations

• Image guidance is essential - Fluoroscopic guidance ensures accurate needle placement 2
• Non-particulate corticosteroids are preferred for cervical ESIs to minimize neurological complications 2
• Strict aseptic technique is mandatory to minimize infection risk 2
• Approach selection:
  • Transforaminal: More targeted delivery to affected nerve root
  • Interlaminar: More diffuse spread of medication
  • Caudal: Useful for lower lumbar and sacral pathology

Efficacy and Outcomes

• ESIs typically provide short-term pain relief (immediate to 2 months) rather than long-term solutions 3
• Approximately 32% of patients report >2 months of pain relief 4
• 53% report improved functional abilities following ESI 4
• For lumbar spinal stenosis, ESIs may help avoid surgery in up to 68% of patients at 2-year follow-up 5
• Lower doses of corticosteroid (40mg methylprednisolone) may be as effective as higher doses (80mg) with fewer potential side effects 6

Common Pitfalls to Avoid

1. Overuse in nonspecific back pain - ESIs are not indicated for axial back pain without radicular symptoms 1

2. Performing without proper imaging - MRI or CT is necessary to confirm pathology before intervention 1

3. Multiple repeat injections without reassessment - Diminishing returns with repeated injections

4. Unrealistic expectations - Patients should understand ESIs typically provide temporary rather than permanent relief 3

5. Ignoring red flags - ESIs should not delay appropriate workup for serious conditions like cancer, infection, or cauda equina syndrome 1

ESIs should be part of a comprehensive treatment approach, with careful patient selection being the key to successful outcomes. The strongest evidence supports their use for radicular pain from disc herniation, with moderate evidence for spinal stenosis, axial discogenic pain, and post-surgery syndrome.