Epidural Steroid Injections for Radiculopathy

Indications and Contraindications

The Spine Intervention Society's appropriate use criteria explicitly state that repeat injection with steroid is appropriate only if there was at least 50% relief for at least 2 months after the first injection 1
The American Society of Anesthesiologists requires additional therapeutic injections should only be performed if the initial injection resulted in at least 50% pain relief for at least 2 weeks 1
The American Academy of Neurology explicitly recommends against epidural steroid injections for non-radicular low back pain 1

The American College of Physicians defines radicular pain as pain and/or numbness that radiates below the knee, which this patient demonstrates 1
Clinical signs of radiculopathy including decreased sensation in the lower extremities support the diagnosis 1
MRI demonstrates multilevel lumbar spondylosis, disc protrusion, and lumbar stenosis providing the required anatomic substrate for intervention 1

The American Society of Anesthesiologists strongly recommends epidural steroid injections with or without local anesthetics for patients with radicular pain or radiculopathy as part of a multimodal treatment regimen 1
Epidural steroid injections should be provided as part of a comprehensive pain management program that includes physical therapy, patient education, psychosocial support, and oral medications 1
The American College of Physicians strongly recommends MRI evidence of pathology such as nerve root compression to be considered for lumbar epidural steroid injection 1

Fluoroscopic guidance must be used for epidural injections to ensure proper needle placement and reduce risk of complications 1
The American Society of Anesthesiologists strongly agrees that image guidance (fluoroscopy) should be used for both interlaminar and transforaminal epidural injections 1
The patient must be counseled about potential complications including dural puncture, insertion-site infections, sensorimotor deficits, cauda equina syndrome, discitis, epidural granuloma, and retinal complications 1

Epidural injections are not recommended for long-term maintenance treatment of chronic low-back pain without clear radiculopathy 2
The use of lumbar epidural injections is recommended as a treatment option to provide temporary, symptomatic relief in selected patients 2