Can L5 spinal nerve neuropathic pain respond to an L5 spinal injection with a local anesthetic (e.g. lidocaine or bupivacaine) and corticosteroid (e.g. triamcinolone or methylprednisolone)?

L5 Spinal Nerve Neuropathic Pain Response to Local Anesthetic and Corticosteroid Injection

Spinal injections with local anesthetic and corticosteroid are NOT recommended for L5 neuropathic pain due to lack of evidence for meaningful pain relief and potential risks.

Evidence Against Spinal Injections for Neuropathic Pain

The most recent and highest quality evidence strongly recommends against epidural injections for chronic radicular spine pain. The 2025 BMJ clinical practice guideline issued strong recommendations against epidural injections of local anesthetic, steroids, or their combination for chronic radicular spine pain (≥3 months) 1. This recommendation is based on moderate certainty evidence showing little to no effect on pain relief compared to sham procedures.

Key findings against spinal injections include:

• Epidural injections show little to no difference in pain relief compared to saline epidurals for chronic spine pain 2
• For chronic radicular pain, epidural injections of local anesthetic with steroids show minimal effectiveness for long-term pain management 2
• No high certainty evidence exists for important pain relief for any interventional procedure for either chronic axial or radicular spine pain 2

Risks Associated with Spinal Injections

Spinal injections carry significant risks that must be considered:

• Serious adverse events including death, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, stroke, seizures, and brain edema have been reported with steroid epidurals 2
• Common risks include prolonged pain or stiffness (8.6%), temporary altered level of consciousness (2.1%), dural puncture (1.4%), and deep infection (0.7%) 2
• Steroids can cause secondary adrenal insufficiency and altered immune response, with immune suppression potentially lasting up to 4 weeks after methylprednisolone injection 2

Alternative Approaches for Neuropathic Pain

For neuropathic pain, including L5 radiculopathy, the evidence supports several other treatment options:

1. Adjuvant analgesics are particularly important in treating neuropathic pain 1:

   • Anticonvulsants (pregabalin, gabapentin)
   • Antidepressants (particularly tricyclic antidepressants)
   • Topical treatments (lidocaine 5% patch, capsaicin)

2. Systemic medications with evidence of efficacy in neuropathic pain:

   • Tricyclic antidepressants
   • Gabapentinoids (gabapentin, pregabalin)
   • Certain opioids and tramadol (for severe cases) 3

3. Topical therapies:

   • Lidocaine 5% patch
   • Capsaicin 3

Special Considerations for Cancer-Related Neuropathic Pain

In cases where L5 neuropathic pain is related to cancer, different considerations may apply:

• Corticosteroids have been used to relieve neuropathic pain syndromes, particularly radiculopathies associated with vertebral body compression fractures 1
• For neuropathic pain due to bone metastases, higher dose radiation therapy (20 Gy in five fractions) should be considered instead of epidural injections 2

Conclusion

The current evidence does not support the use of L5 spinal injections with local anesthetic and corticosteroid for neuropathic pain. While some older studies and limited evidence suggest potential short-term benefits in specific scenarios (such as acute radicular pain from disc herniation), the most recent and comprehensive guidelines strongly recommend against this practice for chronic neuropathic pain.

For L5 neuropathic pain, clinicians should instead consider evidence-based alternatives such as anticonvulsants, antidepressants, topical agents, and in selected cases, opioid analgesics.