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Epidural Steroids: A Comprehensive, Evidence-Based Review
  1. Steven P. Cohen, MD*,,
  2. Mark C. Bicket, MD*,
  3. David Jamison, MD,
  4. Indy Wilkinson, MD and
  5. James P. Rathmell, MD§
  1. *Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore; †Pain Management Center, Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD; ‡Department of Anesthesiology, Womack Army Medical Center, Fort Bragg, NC; and §MGH Pain Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
  1. Address correspondence to: Steven P. Cohen, MD, 550 North Broadway, Suite 301, Baltimore, MD 21029 (e-mail: scohen40{at}jhmi.edu).

Abstract

Abstract Epidural steroid injections (ESIs) are the most widely utilized pain management procedure in the world, their use supported by more than 45 placebo-controlled studies and dozens of systematic reviews. Despite the extensive literature on the subject, there continues to be considerable controversy surrounding their safety and efficacy. The results of clinical trials and review articles are heavily influenced by specialty, with those done by interventional pain physicians more likely to yield positive findings. Overall, more than half of controlled studies have demonstrated positive findings, suggesting a modest effect size lasting less than 3 months in well-selected individuals. Transforaminal injections are more likely to yield positive results than interlaminar or caudal injections, and subgroup analyses indicate a slightly greater likelihood for a positive response for lumbar herniated disk, compared with spinal stenosis or axial spinal pain. Other factors that may increase the likelihood of a positive outcome in clinical trials include the use of a nonepidural (eg, intramuscular) control group, higher volumes in the treatment group, and the use of depo-steroid. Serious complications are rare following ESIs, provided proper precautions are taken. Although there are no clinical trials comparing different numbers of injections, guidelines suggest that the number of injections should be tailored to individual response, rather than a set series. Most subgroup analyses of controlled studies show no difference in surgical rates between ESI and control patients; however, randomized studies conducted by spine surgeons, in surgically amenable patients with standardized operative criteria, indicate that in some patients the strategic use of ESI may prevent surgery.

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Footnotes

  • The authors declare no conflict of interest.

    This work was funded in part by the Center for Rehabilitation Sciences Research, US Army (to S.P.C.).

    The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the US Department of the Army or the Department of Defense.

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