Epidural injections in prevention of surgery for spinal pain: systematic review and meta-analysis of randomized controlled trials

  • Mark C. Bicket
    Corresponding author. Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA. Tel.: (617) 726-8810; fax: (617) 726-3441.
    Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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  • Joshua M. Horowitz
    Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA

    Department of Anesthesiology & Critical Care Medicine, Johns Hopkins School of Medicine, 1800 Orleans Street, Zayed Building Room Rm 6220, Baltimore, MD, USA 21287
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  • Honorio T. Benzon
    Department of Anesthesiology, Northwestern School of Medicine, 675 N. St, Clair Galter 17-200, Chicago, IL 60611, USA
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  • Steven P. Cohen
    Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 550 N. Broadway, Ste 301, Baltimore, MD 21029, USA

    Department of Anesthesiology, Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD 20889, USA
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Published:October 13, 2014DOI:


      Background context

      Low back pain is debilitating and costly, especially for patients not responding to conservative therapy and requiring surgery.


      Our objective was to determine whether epidural steroid injections (ESI) have a surgery-sparing effect in patients with spinal pain.

      Study design/setting

      The study design was based on a systematic review and meta-analysis.


      Databases searched included Cochrane, PubMed, and EMBASE. The primary analysis evaluated randomized controlled trials (RCTs) in which treatment groups received ESI and control groups underwent control injections. Secondary analyses involved RCTs comparing surgery with ESI, and subgroup analyses of trials comparing surgery with conservative treatment in which the operative disposition of subjects who received ESI were evaluated.


      Of the 26 total studies included, only those evaluating the effect of ESI on the need for surgery as a primary outcome examined the same patient cohort, providing moderate evidence that patients who received ESI were less likely to undergo surgery than those who received control treatment. For studies examining surgery as a secondary outcome, ESI demonstrated a trend to reduce the need for surgery for short-term (<1 year) outcomes (risk ratio, 0.68; 95% confidence interval, 0.41–1.13; p=.14) but not long-term (≥1 year) outcomes (0.95, 0.77–1.19, p=.68). Secondary analyses provided low-level evidence suggesting that between one-third and half of patients considering surgery who undergo ESI can avoid surgery.


      Epidural steroid injections may provide a small surgery-sparing effect in the short term compared with control injections and reduce the need for surgery in some patients who would otherwise proceed to surgery.


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        • Woolf A.D.
        • Pfleger B.
        Burden of major musculoskeletal conditions.
        Bull World Health Organ. 2003; 81: 646-656
        • Crow W.T.
        • Willis D.R.
        Estimating cost of care for patients with acute low back pain: a retrospective review of patient records.
        J Am Osteopath Assoc. 2009; 109: 229-233
        • Manchikanti L.
        • Pampati V.
        • Falco F.J.
        • Hirsch J.A.
        Growth of spinal interventional pain management techniques: analysis of utilization trends and Medicare expenditures 2000 to 2008.
        Spine. 2013; 38: 157-168
        • Rajaee S.S.
        • Bae H.W.
        • Kanim L.E.
        • Delamarter R.B.
        Spinal fusion in the United States: analysis of trends from 1998 to 2008.
        Spine. 2012; 37: 67-76
        • Freburger J.K.
        • Holmes G.M.
        • Agans R.P.
        • Jackman A.M.
        • Darter J.D.
        • Wallace A.S.
        • et al.
        The rising prevalence of chronic low back pain.
        Arch Intern Med. 2009; 169: 251-258
        • Social Security Administration Office of Policy
        Annual statistical report on the social security disability insurance program, 2011.
        (SSA Publication No. 13-11827) Social Security Administration, Washington, DC2012
        • Keller R.B.
        • Atlas S.J.
        • Soule D.N.
        • Singer D.E.
        • Deyo R.A.
        Relationship between rates and outcomes of operative treatment for lumbar disc herniation and spinal stenosis.
        J Bone Joint Surg Am. 1999; 81: 752-762
        • Friedly J.
        • Chan L.
        • Deyo R.
        Geographic variation in epidural steroid injection use in Medicare patients.
        J Bone Joint Surg Am. 2008; 90: 1730-1737
        • Price C.
        • Arden N.
        • Coglan L.
        • Rogers P.
        Cost-effectiveness and safety of epidural steroids in the management of sciatica.
        Health Technol Assess. 2005; 9: 1-58
        • Karppinen J.
        • Malmivaara A.
        • Kurunlahti M.
        • Kyllönen E.
        • Pienimäki T.
        • Nieminen P.
        • et al.
        Periradicular infiltration for sciatica: a randomized controlled trial.
        Spine. 2001; 26: 1059-1067
        • Whynes D.K.
        • McCahon R.A.
        • Ravenscroft A.
        • Hardman J.
        Cost effectiveness of epidural steroid injections to manage chronic lower back pain.
        BMC Anesthesiol. 2012; 12: 26
        • Rasmussen S.
        • Krum-Møller D.S.
        • Lauridsen L.R.
        • Jensen S.E.
        • Mandøe H.
        • Gerlif C.
        • et al.
        Epidural steroid following discectomy for herniated lumbar disc reduces neurological impairment and enhances recovery: a randomized study with two-year follow-up.
        Spine. 2008; 33: 2028-2033
        • Juniper M.
        • Le T.K.
        • Mladsi D.
        The epidemiology, economic burden, and pharmacological treatment of chronic low back pain in France, Germany, Italy, Spain and the UK: a literature-based review.
        Expert Opin Pharmacother. 2009; 10: 2581-2592
        • Teasell R.W.
        Compensation and chronic pain.
        Clin J Pain. 2001; 17: S46-S64
        • Dworkin R.H.
        • Turk D.C.
        • Farrar J.T.
        • Haythornthwaite J.A.
        • Jensen M.P.
        • Katz N.P.
        • et al.
        Core outcome measures for chronic pain clinical trials: IMMPACT recommendations.
        Pain. 2005; 113: 9-19
        • Riew K.D.
        • Yin Y.
        • Gilula L.
        • Bridwell K.H.
        • Lenke L.G.
        • Lauryssen C.
        • et al.
        The effect of nerve-root injections on the need for operative treatment of lumbar radicular pain. A prospective, randomized, controlled, double-blind study.
        J Bone Joint Surg Am. 2000; 82-A: 1589-1593
        • Riew K.D.
        • Park J.B.
        • Cho Y.S.
        • Gilula L.
        • Patel A.
        • Lenke L.G.
        • et al.
        Nerve root blocks in the treatment of lumbar radicular pain. A minimum five-year follow-up.
        J Bone Joint Surg Am. 2006; 88: 1722-1725
        • Arden N.K.
        • Price C.
        • Reading I.
        • Stubbing J.
        • Hazelgrove J.
        • Dunne C.C.
        • et al.
        A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: the WEST study.
        Rheumatology (Oxford). 2005; 44: 1399-1406
        • Bush K.
        • Hillier S.
        A controlled study of caudal epidural injections of triamcinolone plus procaine for the management of intractable sciatica.
        Spine. 1991; 16: 572-575
        • Carette S.
        • Leclaire R.
        • Marcoux S.
        • Morin F.
        • Blaise G.A.
        • St-Pierre A.
        • et al.
        Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus.
        N Engl J Med. 1997; 336: 1634-1640
        • Cohen S.P.
        • White R.L.
        • Kurihara C.
        • Larkin T.M.
        • Chang A.
        • Griffith S.R.
        • et al.
        Epidural steroids, etanercept, or saline in subacute sciatica: a multicenter, randomized trial.
        Ann Intern Med. 2012; 156: 551-559
        • Cuckler J.M.
        • Bernini P.A.
        • Wiesel S.W.
        • Booth Jr., R.E.
        • Rothman R.H.
        • Pickens G.T.
        The use of epidural steroids in the treatment of lumbar radicular pain. A prospective, randomized, double-blind study.
        J Bone Joint Surg Am. 1985; 67: 63-66
        • Dilke T.F.
        • Burry H.C.
        • Grahame R.
        Extradural corticosteroid injection in management of lumbar nerve root compression.
        Br Med J. 1973; 2: 635-637
        • Ghahreman A.
        • Ferch R.
        • Bogduk N.
        The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain.
        Pain Med. 2010; 11: 1149-1168
        • Hegihara Y.
        • Ogata S.
        • Hirayama H.
        • Koyama T.
        • Watanabe E.
        Why use steroids in lumbar selective nerve root block? A randomized control study.
        Chiba Med J. 2009; 85: 71-76
        • Klenerman L.
        • Greenwood R.
        • Davenport H.T.
        • White D.C.
        • Peskett S.
        Lumbar epidural injections in the treatment of sciatica.
        Br J Rheumatol. 1984; 23: 35-38
        • Kraemer J.
        • Ludwig J.
        • Bickert U.
        • Owczarek V.
        • Traupe M.
        Lumbar epidural perineural injection: a new technique.
        Eur Spine J. 1997; 6: 357-361
        • Mathews J.A.
        • Mills S.B.
        • Jenkins V.M.
        • Grimes S.M.
        • Morkel M.J.
        • Mathews W.
        • et al.
        Back pain and sciatica: controlled trials of manipulation, traction, sclerosant and epidural injections.
        Br J Rheumatol. 1987; 26: 416-423
        • Snoek W.
        • Weber H.
        • Jørgensen B.
        Double blind evaluation of extradural methyl prednisolone for herniated lumbar discs.
        Acta Orthop Scand. 1977; 48: 635-641
        • Tafazal S.
        • Ng L.
        • Chaudhary N.
        • Sell P.
        Corticosteroids in peri-radicular infiltration for radicular pain: a randomised double blind controlled trial. One year results and subgroup analysis.
        Eur Spine J. 2009; 18: 1220-1225
        • Valat J.P.
        • Giraudeau B.
        • Rozenberg S.
        • Goupille P.
        • Bourgeois P.
        • Micheau-Beaugendre V.
        • et al.
        Epidural corticosteroid injections for sciatica: a randomised, double blind, controlled clinical trial.
        Ann Rheum Dis. 2003; 6: 639-643
        • Wilson-MacDonald J.
        • Burt G.
        • Griffin D.
        • Glynn C.
        Epidural steroid injection for nerve root compression. A randomised, controlled trial.
        J Bone Joint Surg Br. 2005; 87: 352-355
        • Iversen T.
        • Solberg T.K.
        • Romner B.
        • Wilsgaard T.
        • Twisk J.
        • Anke A.
        • et al.
        Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial.
        BMJ. 2011; 343: d5278
        • Sayegh F.E.
        • Kenanidis E.I.
        • Papavasiliou K.A.
        • Potoupnis M.E.
        • Kirkos J.M.
        • Kapetanos G.A.
        Efficacy of steroid and nonsteroid caudal epidural injections for low back pain and sciatica: a prospective, randomized, double-blind clinical trial.
        Spine. 2009; 34: 1441-1447
        • Furlan A.D.
        • Pennick V.
        • Bombardier C.
        • van Tulder M.
        • Editorial Board, Cochrane Back Review Group
        2009 Updated method guidelines for systematic reviews in the Cochrane Back Review Group.
        Spine. 2009; 34: 1929-1941
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • Mulrow C.
        • Gøtzsche P.C.
        • Ioannidis J.P.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
        Ann Intern Med. 2009; 151: W65-W94
        • Aronsohn J.
        • Chapman K.
        • Soliman M.
        • Shah T.
        • Costandi S.
        • Michael R.
        • et al.
        Percutaneous microdiscectomy versus epidural injection for management of chronic spinal pain.
        Proc West Pharmacol Soc. 2010; 53: 16-19
        • Brown L.L.
        A double-blind, randomized, prospective study of epidural steroid injection vs. the mild® procedure in patients with symptomatic lumbar spinal stenosis.
        Pain Pract. 2012; 12: 333-341
        • Reeves B.C.
        • Deeks J.J.
        • Higgins J.P.T.
        • Wells G.A.
        Including non-randomized studies.
        in: Higgins J.P.T. Green S. Cochrane handbook for systematic reviews of interventions. John Wiley & Sons, Chichester, UK2008: 391-432
        • Higgins J.P.T.
        • Altman D.G.
        • Sterne J.A.C.
        Assessing risk of bias in included studies.
        in: Higgins J.P.T. Green S. Cochrane handbook for systematic reviews of interventions. John Wiley & Sons, Chichester, UK2008: 187-241
        • Bicket M.B.
        • Gupta A.
        • Brown C.H.
        • Cohen S.P.
        Epidural injections for spinal pain: a systematic review and meta-analysis evaluating the “control” injections in randomized controlled trials.
        Anesthesiology. 2013; 119: 907-931
        • Atkins D.
        • Best D.
        • Briss P.A.
        • Eccles M.
        • Falck-Ytter Y.
        • Flottorp S.
        • et al.
        Grading quality of evidence and strength of recommendations.
        BMJ. 2004; 328: 1490
        • Henschke N.
        • Ostelo R.W.
        • van Tulder M.W.
        • Vlaeyen J.W.
        • Morley S.
        • Assendelft W.J.
        • et al.
        Behavioural treatment for chronic low-back pain.
        Cochrane Database Syst Rev. 2010; : CD002014
        • Guyatt G.H.
        • Oxman A.D.
        • Vist G.E.
        • Kunz R.
        • Falck-Ytter Y.
        • Alonso-Coello P.
        • et al.
        GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
        BMJ. 2008; 336: 924-926
        • Hopwood M.
        • Abram S.
        Factors associated with failure of lumbar steroids.
        Reg Anesth. 1993; 18: 238-243
        • Manchikanti L.
        • Buenaventura R.
        • Manhcikanti K.N.
        • Ruan X.
        • Gupta S.
        • Smith H.S.
        • et al.
        Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain.
        Pain Physician. 2012; 15: E199-E245
        • Stout A.
        Epidural steroid injections for low back pain.
        Phys Med Rehabil Clin N Am. 2010; 21: 825-834
        • Airaksinen O.
        • Brox J.
        • Cedraschi C.
        • Hildebrandt J.
        • Klaber-Moffett J.
        • Kovacs F.
        • et al.
        European guidelines for the management of chronic nonspecific low back pain.
        Eur Spine J. 2006; 15: S192-S300
        • Ferrante F.
        • Wilson S.
        • Iacobo C.
        • Orav E.J.
        • Rocco A.G.
        • Lipson S.
        Clinical classification as a predictor of therapeutic outcome after cervical epidural steroid injection.
        Spine. 1993; 18: 730-736
        • Benyamin R.
        • Manchikanti L.
        • Parr A.T.
        • Diwan S.
        • Singh V.
        • Falco F.J.
        • et al.
        The effectiveness of lumbar interlaminar epidural injections in the managing chronic low back and lower extremity pain.
        Pain Physician. 2012; 15: E363-E404
        • Jacobs W.C.
        • van Tulder M.
        • Arts M.
        • Rubinstein S.M.
        • van Middelkoop M.
        • Ostelo R.
        • et al.
        Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review.
        Eur Spine J. 2011; 20: 513-522
        • May S.
        • Comer C.
        Is surgery more effective than non-surgical treatment for spinal stenosis, and which non-surgical treatment is more effective? A systematic review.
        Physiotherapy. 2013; 99: 12-20
        • Bono C.M.
        • Ghiselli G.
        • Gilbert T.J.
        • Kreiner D.S.
        • Reitman C.
        • Summers J.T.
        • et al.
        An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders.
        Spine J. 2011; 11: 64-72
        • Chou R.
        • Baisden J.
        • Carragee E.J.
        • Resnick D.K.
        • Shaffer W.O.
        • Loeser J.D.
        Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline.
        Spine. 2009; 34: 1094-1109
        • Cohen S.P.
        • Bicket M.C.
        • Jamison D.
        • Wilkinson I.
        • Rathmell J.P.
        Epidural steroids: a comprehensive, evidence-based review.
        Reg Anesth Pain Med. 2013; 38: 175-200
        • Ackerman III, W.E.
        • Ahmad M.
        The efficacy of lumbar epidural steroid injections in patients with lumbar disc herniations.
        Anesth Analg. 2007; 104: 1217-1222
        • Kolsi I.
        • Delecrin J.
        • Berthelot J.M.
        • Thomas L.
        • Prost A.
        • Maugars Y.
        Efficacy of nerve root versus interspinous injections of glucocorticoids in the treatment of disk-related sciatica. A pilot, prospective, randomized, double-blind study.
        Joint Bone Spine. 2000; 67: 113-118
        • Lee J.H.
        • Moon J.
        • Lee S.H.
        Comparison of effectiveness according to different approaches of epidural steroid injection in lumbosacral herniated disk and spinal stenosis.
        J Back Musculoskelet Rehabil. 2009; 22: 83-89
        • Laiq N.
        • Khan M.N.
        • Iqbal M.J.
        • Khan S.
        Comparison of epidural steroid injections with conservative management in patients with lumbar radiculopathy.
        J Coll Physicians Surg Pak. 2009; 19: 539-543
        • Radcliff K.
        • Hilibrand A.
        • Lurie J.D.
        • Tosteson T.D.
        • Delasotta L.
        • Rihn J.
        • et al.
        The impact of epidural steroid injections on the outcomes of patients treated for lumbar disc herniation: a subgroup analysis of the SPORT trial.
        J Bone Joint Surg Am. 2012; 94: 1353-1358
        • Radcliff K.
        • Kepler C.
        • Hilibrand A.
        • Rihn J.
        • Zhao W.
        • Lurie J.
        • et al.
        Epidural steroid injections are associated with less improvement in patients with lumbar spinal stenosis: a subgroup analysis of the spine patient outcomes research trial.
        Spine. 2013; 38: 279-291
        • Weinstein J.N.
        • Tosteson T.D.
        • Lurie J.D.
        • Tosteson A.N.
        • Hanscom B.
        • Skinner J.S.
        • et al.
        Surgical vs. nonoperative treatment for lumbar disk herniation: the spine patient outcomes research trial (SPORT): a randomized trial.
        JAMA. 2006; 296: 2441-2450
        • Weinstein J.N.
        • Tosteson T.D.
        • Lurie J.D.
        • Tosteson A.N.
        • Blood E.
        • Hanscom B.
        • et al.
        Surgical versus nonsurgical therapy for lumbar spinal stenosis.
        N Engl J Med. 2008; 358: 794-810
        • Buttermann G.R.
        Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy. A prospective, randomized study.
        J Bone Joint Surg Am. 2004; 86-A: 670-679
        • Gerszten P.C.
        • Smuck M.
        • Rathmell J.P.
        • Simopoulos T.T
        • Bhagia S.M.
        • Mocek C.K.
        • et al.
        Plasma disc decompression compared with fluoroscopy-guided transforaminal epidural steroid injections for symptomatic contained lumbar disc herniation: a prospective, randomized, controlled trial.
        J Neurosurg. 2010; 12: 357-371
        • Roberts S.T.
        • Willick S.E.
        • Rho M.E.
        • Rittenberg J.D.
        Efficacy of lumbosacral transforaminal epidural steroid injections: a systematic review.
        PM R. 2009; 1: 657-668
        • MacVicar J.
        • King W.
        • Landers M.H.
        • Bogduk N.
        The effectiveness of lumbar transforaminal injection of steroids: a comprehensive review with systematic analysis of the published data.
        Pain Med. 2013; 14: 14-28
        • Pinto R.Z.
        • Maher C.G.
        • Ferreira M.L.
        • Hancock M.
        • Oliveira V.C.
        • McLachlan A.J.
        • et al.
        Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis.
        Ann Intern Med. 2012; 157: 865-877
        • Kerkering T.M.
        • Grifasi M.L.
        • Baffoe-Bonnie A.W.
        • Bansal E.
        • Garner D.C.
        • Smith J.A.
        • et al.
        Early clinical observations in prospectively followed patients with fungal meningitis related to contaminated epidural steroid injections.
        Ann Intern Med. 2013; 158: 154-161
        • Lewis R.
        • Williams N.
        • Matar H.E.
        • Din N.
        • Fitzsimmons D.
        • Phillips C.
        • et al.
        The clinical effectiveness and cost-effectiveness of management strategies for sciatica: systematic review and economic model.
        Health Technol Assess. 2011; 15: 1-578
        • Fitzgibbon D.R.
        • Posner K.L.
        • Domino K.B.
        • Caplan R.A.
        • Lee L.A.
        • Cheney F.W.
        Chronic pain management: American Society of Anesthesiologists Closed Claims Project.
        Anesthesiology. 2004; 100: 98-105