Cervical and Lumbar Epidural Injections

Epidural injection involves the placement of a therapeutic substance immediately outside the outermost and thickest protective covering of the spinal cord and the fluid in which it resides. It is a standard part of the practice of anesthesia and has, for instance, revolutionized the provision of pain relief in childbirth. The use of epidural steroid injections for low back and leg pain dates back many decades. There are a number of anecdotal reports of efficacy and a number of uncontrolled studies, which at best provide conflicting evidence.

In a literature review, completed in 1995, of randomized trials of epidural steroid injections in the treatment of low back pain and/or sciatica [3] twelve trials were identified, all with flaws in their study design. Six studies showed benefit and six showed either no benefit or worse outcomes after epidural steroid injection. The best quality studies showed inconsistent results and any benefits appeared to be only short term. Therefore the efficacy of epidural steroids was not established. A significant number of side effects and complications, including headache, backache, water retention, fever, bacterial meningitis and epidural abscess, were noted.

In 2003 a randomized double blind study concluded that there was no difference between epidural steroid or saline injections for sciatica [4] and in 2005 a review of various treatments [5] concluded that the use of epidural steroid injections could be an effective treatment modality but this statement was qualified noting the lack of current evidence.

An editorial in the British Medical Journal [6] concluded that in spite of the lack of good evidence from clinical trials, clinical experience suggests that there was still a place for epidural steroid injections. However, another review suggested that the benefits of epidural steroid injections for sciatica are transient and not cost effective [7].

Yet another review noted there was a trend towards a positive benefit [8] but no clear evidence. The authors outlined the possible reasons for the lack of clear evidence including small sample size, variations in patient groups, and variation in procedure.

The evidence for cervical epidural steroid injections is even less clear than for lumbar epidural injections. There are few published data. In two studies the data presented were on small numbers of patients (17 and 27 per group) and neither study included a control group. The initial outcomes seemed promising, particularly for radicular symptoms (attributable to a nerve root) rather than central spinal pain, but the potential adverse consequences can be catastrophic and even fatal [9, 10].

A further issue is that successful placement of a needle into the epidural space can be challenging, even with the use of X-ray guidance [5, 11, 12] and there are a number of serious published complications [13], some of which are life threatening. Overall side effects and complication rates are high (0.5% to 2.5%). Most of these are minor and self-limiting, such as, headache but some are life threatening,

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such as meningitis. Excessive or frequent steroid administration, by any route, can cause many side effects although the long-term effects of frequent repeated epidural steroid injections are unknown.

In summary, the weight of evidence does not support the use of epidural steroid injections for chronic pain. However, our clinical experience suggests that selected patients with primarily radicular pain can benefit from epidural injections as a part of a multidisciplinary multimodal treatment plan. Patients should be made aware of the very rare but potentially catastrophic complications that may occur.

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