Is a lumbar epidural steroid injection (ESI) at L3-4 indicated for a 45-year-old female with a history of scoliosis, chronic back pain, and lumbar spinal stenosis, who has tried prednisone (corticosteroid), meloxicam (nonsteroidal anti-inflammatory drug), Tylenol (acetaminophen), ibuprofen (nonsteroidal anti-inflammatory drug), and gabapentin (anticonvulsant), with significant relief from prednisone, but no documented radiculopathy or neurogenic claudication?

Denial of L3-4 Midline ESI Request

This request should be DENIED because the patient lacks documented radiculopathy or neurogenic claudication with objective neurological findings required by both the insurance policy and clinical practice guidelines. 1

Critical Missing Documentation

The insurance policy explicitly requires objective neurological examination findings for radiculopathy, including at least one of the following [@POLICY@]:

• Loss of strength (weakness) in specific myotome distributions
• Sensory changes (altered sensation to light touch, pressure, pin prick, or temperature)
• Diminished, absent, or asymmetric reflexes
• Positive straight leg raise test

None of these findings are documented in this patient's examination. The exam notes specifically state "strength 5/5 in the BLE" (normal strength) and "nonantalgic gait" (normal walking pattern), which directly contradicts the presence of radiculopathy [@POLICY@].

Guideline-Based Rationale for Denial

Non-Radicular Pain Pattern

• The American Academy of Neurology explicitly recommends AGAINST epidural steroid injections for non-radicular low back pain, stating the evidence for their use is limited 1
• The 2025 BMJ guideline provides a STRONG recommendation against epidural injections for chronic axial spine pain without radiculopathy, stating "all or nearly all well-informed people would likely not want such interventions" 1
• The American College of Occupational and Environmental Medicine guideline explicitly recommends AGAINST lumbar epidural injections for spinal stenosis in the absence of significant radicular symptoms 1

Axial Pain vs. Radicular Pain Distinction

• The patient's symptoms are described as "back pain that worsens with standing and improves with leaning forward" (classic neurogenic claudication from spinal stenosis), but the assessment incorrectly states "radiculopathy" when the clinical documentation shows no radicular symptoms 2, 1
• True radiculopathy requires pain and/or numbness that radiates below the knee in a dermatomal distribution, which is not documented here 1
• The patient explicitly has "no radicular symptoms reported" per the history [@POLICY@]

Policy-Specific Deficiencies

For Neurogenic Claudication Indication

The policy allows ESI for neurogenic claudication IF [@POLICY@]:

1. Failure of at least 6 weeks noninvasive treatment ✓ (Met - multiple medications tried)
2. Documented goal is short-term relief of debilitating pain ✗ (Not documented)
3. Objective neurological findings ✗ (Absent - normal strength, normal gait)

The patient does not meet criteria #2 and #3 for the neurogenic claudication pathway.

For Radiculopathy Indication

The policy requires BOTH [@POLICY@]:

1. Objective neurological findings on examination ✗ (Absent)
2. Concordant imaging showing nerve root compression ✓ (MRI shows L3-4 stenosis)

The patient fails criterion #1 - no objective neurological deficits are documented.

Clinical Pitfalls in This Case

Misdiagnosis of Radiculopathy

• The assessment states "lumbar spinal stenosis with radiculopathy" but the documentation explicitly notes "no radicular symptoms reported" - this is a contradictory and inaccurate diagnosis [@POLICY@]
• Neurogenic claudication from spinal stenosis is NOT the same as radiculopathy, and ESI has different evidence profiles for these two conditions 2, 1

Prednisone Response Does Not Justify ESI

• While the patient had excellent response to oral prednisone, this does not meet medical necessity criteria for epidural injection in the absence of radiculopathy 1
• The 2023 PM&R guideline synthesis found that high-quality guidelines were either strongly-against or inconclusive regarding ESI for non-radicular chronic low back pain 2

Required Actions Before Resubmission

To meet medical necessity criteria, the following must be documented [1, @POLICY@]:

1. Repeat neurological examination documenting at least one of:

   • Specific muscle weakness in myotomal distribution (e.g., weak ankle dorsiflexion for L4, weak great toe extension for L5)
   • Dermatomal sensory loss below the knee
   • Asymmetric or absent reflexes (ankle jerk for S1, knee jerk for L4)
   • Positive straight leg raise test reproducing leg pain below the knee

2. Clear documentation of radicular pain pattern - pain radiating below the knee in a specific dermatomal distribution (L3, L4, L5, or S1) 1

3. Explicit statement that the goal is short-term pain relief to allow participation in physical therapy or other functional restoration [@POLICY@]

Alternative Treatment Recommendations

For Neurogenic Claudication Without Radiculopathy

• Continue gabapentin optimization - evidence shows gabapentin improves walking distance and pain in lumbar spinal stenosis with neurogenic claudication 3
• Structured physical therapy program focusing on flexion-based exercises (which the patient finds relieving) 4
• Consider duloxetine as second-line pharmacologic treatment for chronic low back pain 4

If True Radiculopathy Develops

• Re-examine for objective neurological deficits before reconsidering ESI 1
• Ensure imaging correlation with clinical level of symptoms 1
• Use fluoroscopic guidance if ESI is ultimately performed 1, 5

Risk-Benefit Consideration

• Epidural steroid injections carry risks including dural puncture, insertion-site infections, sensorimotor deficits, cauda equina syndrome, and rare catastrophic complications including paralysis and death 1
• Exposing this patient to these risks without meeting evidence-based indications is not justified 1