Management of Lumbar Radiculopathy and Spinal Stenosis with Epidural Injection
Epidural injections are one of the most commonly performed procedures in managing low back and lower extremity pain, specifically for managing radiculopathy secondary to a herniated disc and for spinal stenosis. The prevalence of chronic low back pain and related disability is rapidly increasing as the myriads treatments which includes epidural injections. Even though epidural injections are one of the most commonly performed procedures in managing the low back and extremity pain, starting in 1901 with local anesthetic alone conflicting the recommendations that have been provided.
Various cases have been reported to review the lack of effectiveness of epidural steroid injections in managing lumbar radiculopathy and spinal stenosis. In contrast, many publications have also supported the efficacy and use of epidural injections. To assess the efficacy of 3 categories of epidural injections for lumbar and spinal stenosis: performed with saline with steroids, local anesthetic alone or steroids with local anesthetic and separate facts from opinions. Randomized controlled trials were performed with either placebo or active control of epidural injections for lumbar radiculopathy and spinal stenosis. Data were extracted and quality assessment were performed utilizing Cochrane review methodologic quality assessment and Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB). Evidence was summarized utilizing principles of best evidence synthesis.
In the randomized trial, 39 controlled trials met inclusion criteria. There were 9 placebo-controlled trial evaluating epidural corticosteroid injections, either with sodium chloride solution or bupivacaine, compared to placebo injections. There were 12 studies comparing local anesthetic alone to local anesthetic with steroid. After the meta-analysis of 5 studies utilizing sodium chloride or bupivacaine with steroid showed a lack of efficacy. A comparison of lidocaine to lidocaine with steroids in 7 studies showed significant effectiveness from baselines to long-term follow up periods.
Meta-analysis showed a similar effectiveness for pain and function without non-inferiority of lidocaine compared to lidocaine with steroid at 3 months and 12 months. The review was restricted to the data available with at least 3 months of follow up which was excluded from some studies. Results indicated that the epidural corticosteroid injections for radiculopathy or spinal stenosis with sodium chloride solution or bupivacaine were shown to be ineffective. Lidocaine alone or in combination with steroids were significantly effective.