What is the efficacy of lumbar transforaminal epidural steroid injections?

Efficacy of Lumbar Transforaminal Epidural Steroid Injections

Lumbar transforaminal epidural steroid injections (TFESI) show good evidence of efficacy for radicular pain due to disc herniation but are not recommended for non-radicular chronic low back pain. 1

Efficacy Based on Clinical Indication

Radicular Pain from Disc Herniation

• TFESI demonstrates Level 1 evidence (highest quality) for treating radicular pain due to disc herniation, with statistically significant improvements in both pain and function at 3 and 6 months 1
• Meta-analyses show that TFESI with local anesthetic and steroids provides good pain relief for radiculopathy secondary to disc herniation 2
• TFESI can be considered part of a multimodal treatment approach for patients with clear radicular symptoms 3

Spinal Stenosis

• For radicular pain from spinal stenosis, the evidence is fair (Level IV) for TFESI with local anesthetic and steroids 1
• Observational data suggests that TFESI may help patients with symptomatic lumbar spinal stenosis avoid surgery, with one study showing only 32% of patients requiring surgery at 2-year follow-up 4
• TFESI has shown effectiveness in patients with degenerative lumbar scoliotic stenosis and radiculopathy, with 37.2% of patients reporting successful outcomes at one year post-injection 5

Non-Radicular Low Back Pain

• TFESI is not recommended for non-radicular low back pain, as evidence for this indication is poor, limited, or unavailable 6, 2
• The American Academy of Neurology specifically recommends against offering spinal epidural steroid injections for non-radicular low back pain 3
• For axial low back pain, the evidence is Level V (opinion-based/consensus), which is the lowest level of evidence 1

Failed Back Surgery Syndrome

• For radicular pain caused by failed back surgery syndrome, there is only Level IV evidence (limited) supporting the use of TFESI 1

Duration of Efficacy

• Most studies show diminishing benefits over time:
  • Short-term relief (up to 6 months) is more consistently demonstrated than long-term relief 2
  • In patients with degenerative lumbar scoliotic stenosis, successful outcomes decreased from 59.6% at one week to 27.3% at two years post-injection 5
• Meta-analyses indicate that TFESI may improve pain but not necessarily disability 7

Medical Necessity Criteria

• TFESI should be considered only when:
  • There is MRI evidence of pathology such as nerve root compression or moderate to severe disc herniation 3
  • The patient has clear radicular pain that radiates below the knee 3
  • The patient has failed at least 4 weeks of conservative treatment including physical therapy 3
  • Clinical examination shows signs of radiculopathy (decreased sensation, positive straight leg raise) 3

Common Pitfalls and Caveats

• TFESI should not be used as a long-term treatment for chronic low back pain without radiculopathy 6
• Image guidance (fluoroscopy) should always be used to ensure proper needle placement and reduce complications 3
• Potential complications include dural puncture, insertion-site infections, sensorimotor deficits, and rare but serious neurologic complications related to cord infarct 3, 1
• The infraneural approach and use of blunt needles appear to offer the greatest patient safety 1
• No specific injectate (particulate vs. non-particulate steroids) has been proven superior, though safety concerns exist with particulate steroids 1

Summary of Recommendations

• TFESI is recommended for radicular pain due to disc herniation (strongest evidence) 2, 1
• TFESI may be considered for radicular pain due to spinal stenosis (fair evidence) 2, 1
• TFESI is not recommended for non-radicular chronic low back pain 6, 3
• TFESI should be part of a comprehensive pain management approach that includes physical therapy, patient education, and other conservative measures 3