What is the difference in outcome between saline and steroid epidurals for chronic pain management?

Saline versus Steroid Epidurals for Chronic Pain Management

Based on moderate certainty evidence, epidural injections with steroids show little to no difference in pain relief compared to saline epidurals for chronic spine pain, with both demonstrating minimal effectiveness for long-term pain management. 1

Evidence on Effectiveness

The 2025 BMJ clinical practice guideline on interventional procedures for non-cancer chronic spine pain provides the most recent and highest quality evidence on this topic:

• For chronic axial spine pain, epidural injections of local anesthetic (with or without steroids) show little to no effect on pain relief compared to sham procedures (moderate certainty evidence) 1
• For chronic radicular spine pain, epidural injections of local anesthetic with steroids also show little to no effect on pain relief (moderate certainty evidence) 1
• There is no high certainty evidence of important pain relief for any interventional procedure for either chronic axial or radicular spine pain 1

Comparative Outcomes

When comparing saline and steroid epidurals specifically:

1. Pain Relief:

   • Meta-analysis shows no significant difference between epidural sodium chloride solution and epidural steroids with sodium chloride solution 2
   • Both epidural saline and epidural steroids with saline were effective in reducing pain by 20%, but only reducing disability scores by 10-12% 2
   • This suggests that neither is truly a placebo, and both may have some therapeutic effect

2. Duration of Effect:

   • Some evidence suggests that adding hypertonic saline to conventional transforaminal epidural steroid injections may provide superior and longer-lasting pain relief 3, 4
   • However, this finding is from smaller studies with limitations and doesn't override the higher quality evidence from the BMJ guideline

3. Safety Concerns:

   • Steroid epidurals carry additional risks not present with saline injections
   • Between 1997 and 2014, the FDA reported 90 serious adverse events from epidural corticosteroid injections, including death, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, stroke, seizures, and brain edema 1
   • Steroids can cause secondary adrenal insufficiency and altered immune response, with immune suppression potentially lasting up to 4 weeks after methylprednisolone injection 1

Risk Profile

All epidural injections carry risks, regardless of injectate:

• 8.6% risk of prolonged (>48 hours) pain or stiffness
• 2.1% risk of temporary altered level of consciousness
• 1.4% risk of dural puncture
• 0.7% risk of deep infection
• Very small risk of catastrophic harms such as infection resulting in meningitis, spinal cord injury, and paraplegia 1

Clinical Implications

1. For most chronic pain patients:

   • Neither saline nor steroid epidurals are strongly supported for long-term pain management
   • Both interventions should be considered only after failed conservative management
   • Patients should be informed about the limited evidence for effectiveness and potential risks

2. Special considerations:

   • During periods of immunocompromise (such as during the COVID-19 pandemic), saline may be preferable to steroids due to the potential immunosuppressive effects of steroids 1
   • For neuropathic pain due to bone metastases, higher dose radiation therapy (20 Gy in five fractions) should be considered instead of epidural injections 1

Practical Recommendations

1. Initial approach:

   • Start with conservative management for at least 4-6 weeks before considering any epidural injections 5
   • Ensure proper diagnostic workup with imaging correlation before considering interventional procedures 5

2. If epidural injection is considered:

   • Inform patients that both saline and steroid epidurals show limited long-term effectiveness
   • Consider saline epidural if there are concerns about steroid-related adverse effects
   • Use fluoroscopic guidance to ensure accurate needle placement 5
   • Consider the parasagittal interlaminar approach which shows equivalent effectiveness with potentially better safety profile 5

3. Follow-up and reassessment:

   • Evaluate response after initial injection before considering repeat procedures
   • Document functional improvement and medication reduction to justify any repeat injections 5

Conclusion

The evidence does not support a significant difference in chronic pain outcomes between saline and steroid epidurals, with both showing limited long-term effectiveness. The decision between the two should consider the additional risks associated with steroids, particularly in immunocompromised patients or those with concerns about steroid-related adverse effects.