Is LESI (Lumbar Epidural Steroid Injection) the best first-line interventional option for lumbar disc protrusion with annular fissure and symptoms of pain with bending, lifting, and prolonged standing?

LESI is NOT the Best First-Line Interventional Option for Lumbar Disc Protrusion with Annular Fissure

For lumbar disc protrusion with annular fissure causing axial low back pain (pain with bending, lifting, prolonged standing), lumbar epidural steroid injections (LESI) are not recommended as first-line interventional therapy because the evidence supports their use specifically for radicular pain, not axial back pain alone. 1, 2

Understanding the Clinical Presentation

Your patient's symptoms—pain with bending, lifting, and prolonged standing—represent axial (mechanical) low back pain rather than radicular pain. This distinction is critical:

• Radicular pain radiates below the knee with dermatomal distribution, indicating nerve root involvement 2
• Axial pain from disc protrusion with annular fissure is mechanical, worsened by loading and flexion activities 3
• The absence of leg pain below the knee excludes this patient from evidence-based indications for epidural steroid injections 2

Why LESI is Not Appropriate Here

Guideline-Based Contraindications

• The American College of Physicians explicitly states that epidural steroid injections should only be considered for patients with persistent low back pain AND signs/symptoms of radiculopathy 1
• The American Academy of Neurology confirms that epidural injections are not recommended for non-radicular low back pain 2
• Authorization criteria require pain radiating below the knee to justify TFESI 2

Evidence Quality for Axial Pain

• Studies evaluating ESIs for chronic low back pain without radiculopathy provide only Level III evidence with minimal support beyond short-term relief (<2 weeks) 1
• A 2004 study by Buttermann showed no clinically relevant improvement in validated outcome measures (VAS, ODI) for patients with degenerative disc disease receiving ESIs, despite some patient satisfaction 1
• The study had severe methodological flaws with 51-60% dropout rates at final follow-up 1

Recommended First-Line Approach

Conservative Management (4-6 Weeks Minimum)

Initial treatment should consist of:

• Activity modification while remaining active—bed rest is contraindicated 1
• Patient education about the favorable natural history of disc-related pain, with most patients improving within the first month 1
• Physical therapy with exercises incorporating individual tailoring, supervision, stretching, and strengthening 1
• Pharmacotherapy starting with NSAIDs and acetaminophen; avoid strong opioids except at lowest doses for shortest duration 1

When to Consider Interventions

Imaging is not indicated initially unless red flags are present (progressive neurologic deficits, cauda equina syndrome, infection, malignancy) 1

After 4-6 weeks of failed conservative management, consider:

• MRI evaluation only if interventional procedures or surgery are being contemplated 1
• Note that disc protrusions and annular fissures are common in asymptomatic patients (29-43% prevalence) and may not correlate with symptoms 1

Alternative Interventional Options for Axial Pain

If conservative management fails after adequate trial:

More Appropriate Interventions

• Trigger point injections may provide short-term benefit for selected patients with identifiable trigger points, though evidence is Class III 1
• Facet joint injections can be considered if facet-mediated pain is suspected, though physical findings don't reliably predict response 1
• Intensive interdisciplinary rehabilitation with cognitive-behavioral components shows moderate effectiveness for chronic low back pain 1

Surgical Consideration

• Intradiscal procedures or fusion would only be considered after comprehensive conservative management failure and specialist evaluation 1
• The relationship between diagnostic facet blocks and surgical outcomes remains problematic 1

Critical Pitfalls to Avoid

Do not order LESI based solely on MRI findings of disc protrusion with annular fissure without radicular symptoms—this represents non-adherence to guidelines and increases healthcare utilization without improving outcomes 1

Avoid early imaging (within 4 weeks) as it leads to increased likelihood of unnecessary injections and surgery without benefit 1

Recognize that annular fissures on MRI are common incidental findings that may not be the pain generator 1, 4

When LESI Would Be Appropriate

LESI becomes a reasonable option only if the patient develops:

• True radicular pain extending below the knee 2
• MRI-confirmed nerve root compression correlating with clinical findings 2, 5
• Failed conservative management for at least 4 weeks 2
• Notably, LESI works best with low-grade nerve root compression (75% success rate) versus high-grade compression (26% success rate) 5