Clinical Orthopaedics and Related Research®

, Volume 473, Issue 6, pp 1940–1956 | Cite as

Do Epidural Injections Provide Short- and Long-term Relief for Lumbar Disc Herniation? A Systematic Review

  • Laxmaiah Manchikanti
  • Ramsin M. Benyamin
  • Frank J. E. Falco
  • Alan D. Kaye
  • Joshua A. Hirsch
Symposium: Current Approaches to the Management of Lumbar Disc Herniation



As part of a comprehensive nonsurgical approach, epidural injections often are used in the management of lumbar disc herniation. Recent guidelines and systematic reviews have reached different conclusions about the efficacy of epidural injections in managing lumbar disc herniation.


In this systematic review, we determined the efficacy (pain relief and functional improvement) of the three anatomic approaches (caudal, lumbar interlaminar, and transforaminal) for epidural injections in the treatment of disc herniation.


We performed a literature search from 1966 to June 2013 in PubMed, Cochrane library, US National Guideline Clearinghouse, previous systematic reviews, and cross-references for trials studying all types of epidural injections in managing chronic or chronic and subacute lumbar disc herniation. We wanted only randomized controlled trials (RCTs) (either placebo or active controlled) to be included in our analysis, and 66 studies found in our search fulfilled these criteria. We then assessed the methodologic quality of these 66 studies using the Cochrane review criteria for RCTs. Thirty-nine studies were excluded, leaving 23 RCTs of high and moderate methodologic quality for analysis. Evidence for the efficacy of all three approaches for epidural injection under fluoroscopy was strong for short-term (< 6 months) and moderate for long-term (≥ 6 months) based on the Cochrane rating system with five levels of evidence (best evidence synthesis), with strong evidence denoting consistent findings among multiple high-quality RCTs and moderate evidence denoting consistent findings among multiple low-quality RCTs or one high-quality RCT. The primary outcome measure was pain relief, defined as at least 50% improvement in pain or 3-point improvement in pain scores in at least 50% of the patients. The secondary outcome measure was functional improvement, defined as 50% reduction in disability or 30% reduction in the disability scores.


Based on strong evidence for short-term efficacy from multiple high-quality trials and moderate evidence for long-term efficacy from at least one high quality trial, we found that fluoroscopic caudal, lumbar interlaminar, and transforaminal epidural injections were efficacious at managing lumbar disc herniation in terms of pain relief and functional improvement.


The available evidence suggests that epidural injections performed under fluoroscopy by trained physicians offer improvement in pain and function in well-selected patients with lumbar disc herniation.

Supplementary material

11999_2014_3490_MOESM1_ESM.doc (127 kb)
Supplementary material 1 (DOC 127 kb)


  1. 1.
    Ackerman WE 3rd, Ahmad M. The efficacy of lumbar epidural steroid injections in patients with lumbar disc herniations. Anesth Analg. 2007;104:1217–1222.PubMedGoogle Scholar
  2. 2.
    Ahadian FM, McGreevy K, Schulteis G. Lumbar transforaminal epidural dexamethasone: a prospective, randomized, double-blind, dose-response trial. Reg Anesth Pain Med. 2011;36:572–578.PubMedGoogle Scholar
  3. 3.
    Amr YM. Effect of addition of epidural ketamine to steroid in lumbar radiculitis: one-year follow-up. Pain Physician. 2011;14:475–481.PubMedGoogle Scholar
  4. 4.
    Arden NK, Price C, Reading I, Stubbing J, Hazelgrove J, Dunne C, Michel M, Rogers P, Cooper C; WEST Study Group. A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: The WEST study. Rheumatology (Oxford). 2005;44:1399–1406.Google Scholar
  5. 5.
    Armon C, Argoff CE, Samuels J, Backonja M. Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2007;68:723–729.PubMedGoogle Scholar
  6. 6.
    Arner S, Lindblom U, Meyerson BA, Molander C. Prolonged relief of neuralgia after regional anesthetic block: a call for further experimental and systematic clinical studies. Pain. 1990;43:287–297.PubMedGoogle Scholar
  7. 7.
    Benny B, Azari P. The efficacy of lumbosacral transforaminal epidural steroid injections: a comprehensive literature review. J Back Musculoskelet Rehabil. 2011;24:67–76.PubMedGoogle Scholar
  8. 8.
    Benyamin RM, Manchikanti L, Parr AT, Diwan SA, Singh V, Falco FJ, Datta S, Abdi S, Hirsch JA. The effectiveness of lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain. Pain Physician. 2012;15:E363–E404.PubMedGoogle Scholar
  9. 9.
    Bhatia MT, Parikh LC. Epidural saline therapy in lumbo-sciatic syndrome. J Indian Med Assoc. 1966;47:537–542.PubMedGoogle Scholar
  10. 10.
    Bisby MA. Inhibition of axonal transport in nerves chronically treated with local anesthetics. Exp Neurol. 1975;47:481–489.PubMedGoogle Scholar
  11. 11.
    Breivik H, Hesla PE, Molnar I, Lind B. Treatment of chronic low back pain and sciatica: comparison of caudal epidural injections of bupivacaine and methylprednisolone with bupivacaine followed by saline. In: Bonica JJ, Albe-Fesard D, eds. Advances in Pain Research and Therapy. New York, NY: Raven Press; 1976:927–932.Google Scholar
  12. 12.
    Bronfort G, Evans RL, Maiers M, Anderson AV. Spinal manipulation, epidural injections, and self-care for sciatica: a pilot study for a randomized clinical trial. J Manipulative Physiol Ther. 2004;27:503–508.PubMedGoogle Scholar
  13. 13.
    Buchner M, Zeifang F, Brocai DR, Schiltenwolf M. Epidural corticosteroid injection in the conservative management of sciatica. Clin Orthop Relat Res. 2000;375:149–156.PubMedGoogle Scholar
  14. 14.
    Burgher AH, Hoelzer BC, Schroeder DR, Wilson GA, Huntoon MA. Transforaminal epidural clonidine versus corticosteroid for acute lumbosacral radiculopathy due to intervertebral disc herniation. Spine (Phila Pa 1976). 2011;36:E293–E300.Google Scholar
  15. 15.
    Bush K, Hillier S. A controlled study of caudal epidural injections of triamcinolone plus procaine for the management of intractable sciatica. Spine (Phila Pa 1976). 1991;16:572–575.Google Scholar
  16. 16.
    Buttermann GR. Treatment of lumbar disc herniation: epidural steroid injection compared with discectomy: a prospective, randomized study. J Bone Joint Surg Am. 2004;86:670–679.PubMedGoogle Scholar
  17. 17.
    Candido KD, Raghavendra MS, Chinthagada M, Badiee S, Trepashko DW. A prospective evaluation of iodinated contrast flow patterns with fluoroscopically guided lumbar epidural steroid injections: the lateral parasagittal interlaminar epidural approach versus the transforaminal epidural approach. Anesth Analg. 2008;106:638–644.PubMedGoogle Scholar
  18. 18.
    Carette S, Leclaire R, Marcoux S, Morin F, Blaise GA, St-Pierre A, Truchon R, Parent F, Levesque J, Bergeron V, Montminy P, Blanchette C. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med. 1997;336:1634–1640.PubMedGoogle Scholar
  19. 19.
    Cassuto J, Sinclair R, Bonderovic M. Anti-inflammatory properties of local anesthetics and their present and potential clinical implications. Acta Anaesthesiol Scand. 2006;50:265–282.PubMedGoogle Scholar
  20. 20.
    Chou R, Atlas SJ, Loeser JD, Rosenquist RW, Stanos SP. Guideline warfare over interventional therapies for low back pain: can we raise the level of discourse? J Pain. 2011;12:833–839.PubMedGoogle Scholar
  21. 21.
    Chou R, Atlas SJ, Stanos SP, Rosenquist RW. Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976). 2009;34:1078–1093.Google Scholar
  22. 22.
    Chou R, Huffman L. Guideline for the Evaluation and Management of Low Back Pain: Evidence Review. Glenview, IL: American Pain Society, 2009. Available at: Accessed July 26, 2013.
  23. 23.
    Chou R, Loeser JD, Owens DK, Rosenquist RW, Atlas SJ, Baisden J, Carragee EJ, Grabois M, Murphy DR, Resnick DK, Stanos SP, Shaffer WO, Wall EM; American Pain Society Low Back Pain Guideline Panel. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine (Phila Pa 1976). 2009;34:1066–1077.Google Scholar
  24. 24.
    Cohen SP, Bogduk N, Dragovich A, Buckenmaier CC 3rd, Griffith S, Kurihara C, Raymond J, Richter PJ, Williams N, Yaksh TL. Randomized, double-blind, placebo-controlled, dose-response, and preclinical safety study of transforaminal epidural etanercept for the treatment of sciatica. Anesthesiology. 2009;110:1116–1126.PubMedGoogle Scholar
  25. 25.
    Cohen SP, White RL, Kurihara C, Larkin TM, Chang A, Griffith SR, Gilligan C, Larkin R, Morlando B, Pasquina PF, Yaksh TL, Nguyen C. Epidural steroids, etanercept, or saline in subacute sciatica: a multicenter, randomized trial. Ann Intern Med. 2012;156:551–559.PubMedGoogle Scholar
  26. 26.
    Could truly informed consent transform spine care? The Back Letter. 2013;28:61–69.Google Scholar
  27. 27.
    Cuckler JM, Bernini PA, Wiesel SW, Booth RE Jr, Rothman RH, Pickens GT. The use of epidural steroid in the treatment of radicular pain. J Bone Joint Surg. 1985;67:63–66.PubMedGoogle Scholar
  28. 28.
    Czarski Z. [Treatment of sciatica with hydrocortisone and Novocaine injections into the sacral hiatus] [in Polish]. Przegl Lek. 1965;21:511–513.PubMedGoogle Scholar
  29. 29.
    Dashfield A, Taylor M, Cleaver J, Farrow D. Comparison of caudal steroid epidural with targeted steroid placement during spinal endoscopy for chronic sciatica: a prospective, randomized, double-blind trial. Br J Anaesth. 2005;94:514–519.PubMedGoogle Scholar
  30. 30.
    Debi R, Halperin N, Mirovsky Y. Local application of steroids following lumbar discectomy. J Spinal Disord Tech. 2002;15:273–276.PubMedGoogle Scholar
  31. 31.
    DePalma MJ, Bhargava A, Slipman CW. A critical appraisal of the evidence for selective nerve root injection in the treatment of lumbosacral radiculopathy. Arch Phys Med Rehabil. 2005;86:1477–1483.PubMedGoogle Scholar
  32. 32.
    Dilke TF, Burry HC, Grahame R. Extradural corticosteroid injection in the management of lumbar nerve root compression. Br Med J. 1973;2:635–637.PubMedCentralPubMedGoogle Scholar
  33. 33.
    Falco FJ, Manchikanti L, Datta S, Sehgal N, Geffert S, Onyewu O, Zhu J, Coubarous S, Hameed M, Ward SP, Sharma ML, Hameed H, Singh V, Boswell MV. An update of the effectiveness of therapeutic lumbar facet joint interventions. Pain Physician. 2012;15:E909–E953.PubMedGoogle Scholar
  34. 34.
    Freburger JK, Holmes GM, Agans RP, Jackman AM, Darter JD, Wallace AS, Castel LD, Kalsbeek WD, Carey TS. The rising prevalence of chronic low back pain. Arch Intern Med. 2009;169:251–258.PubMedCentralPubMedGoogle Scholar
  35. 35.
    Furlan AD, 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 (Phila Pa 1976). 2009;34:1929–1941.Google Scholar
  36. 36.
    Gallucci M, Limbucci N, Zugaro L, Barile A, Stavroulis E, Ricci A, Galzio R, Masciocchi C. Sciatica: treatment with intradiscal and intraforaminal injections of steroid and oxygen-ozone versus steroid only. Radiology. 2007;242:907–913.PubMedGoogle Scholar
  37. 37.
    Gelalis ID, Arnaoutoglou E, Pakos EE, Politis AN, Rapti M, Xenakis TA, Papadopoulos G. Effect of interlaminar epidural steroid injection in acute and subacute pain due to lumbar disk herniation: a randomized comparison of 2 different protocols. Open Orthop J. 2009;3:121–124.PubMedCentralPubMedGoogle Scholar
  38. 38.
    Gerszten PC, Smuck M, Rathmell JP, Simopoulos TT, Bhagia SM, Mocek CK, Crabtree T, Bloch DA; SPINE Study Group. Plasma disc decompression compared with fluoroscopy-guided transforaminal epidural steroid injections for symptomatic contained lumbar disc herniation: a prospective, randomized, controlled trial. J Neurosurg Spine. 2010;12:357–371.PubMedGoogle Scholar
  39. 39.
    Ghahreman A, Bogduk N. Predictors of a favorable response to transforaminal injection of steroids in patients with lumbar radicular pain due to disc herniation. Pain Med. 2011;12:871–879.PubMedGoogle Scholar
  40. 40.
    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.PubMedGoogle Scholar
  41. 41.
    Ghai B, Vadaje KS, Wig J, Dhillon MS. Lateral parasagittal versus midline interlaminar lumbar epidural steroid injection for management of low back pain with lumbosacral radicular pain: a double-blind, randomized study. Anesth Analg. 2013;117:219–227.PubMedGoogle Scholar
  42. 42.
    Gharibo C, Varlotta G, Rhame E, Liu EC, Bendo J, Perloff M. Interlaminar versus transforaminal epidural steroids for the treatment of sub-acute lumbar radicular pain: a randomized, blinded, prospective outcome study. Pain Physician. 2011;14:499–511.PubMedGoogle Scholar
  43. 43.
    Gibson JN, Waddell G. Surgical interventions for lumbar disc prolapse. Cochrane Database Syst Rev. 2007;1:CD001350.Google Scholar
  44. 44.
    Gupta AK, Mital VK, Azmi RU. Observations of the management of lumbosciatic syndromes (sciatica) by epidural saline. J Indian Med Assoc. 1970;54:194–196.PubMedGoogle Scholar
  45. 45.
    Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow CD, Teutsch SM, Atkins D; Methods Work Group, Third US Preventive Services Task Force. Current methods of the US Preventive Services Task Force. Am J Prevent Med. 2001;20:21–35.Google Scholar
  46. 46.
    Health and Social Care Information Centre. Hospital Episodes Statistics (HESonline). Available at: Accessed July 26, 2013.
  47. 47.
    Hesla PE, Breivik H. [Epidural analgesia and epidural steroid injection for treatment of chronic low back pain and sciatica] [in Norwegian]. Tidsskr Nor Laegeforen. 1979;99:936–939.PubMedGoogle Scholar
  48. 48.
    Howick J, Bishop FL, Heneghan, Wolstenholme J, Stevens S, Hobbs FD, Lewith G. Placebo use in the United Kingdom: results from a national survey of primary care practitioners. PLOS One. 2013;8:e58247.PubMedCentralPubMedGoogle Scholar
  49. 49.
    Hróbjartsson A, Gøtzsche PC. Placebo interventions for all clinical conditions. Cochrane Database Syst Rev. 2010;1:CD003974.Google Scholar
  50. 50.
    Iversen T, Solberg TK, Romner B, Wilsgaard T, Twisk J, Anke A, Nygaard O, Hasvold T, Ingebrigtsen T. Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial. BMJ. 2011;343:d5278.PubMedCentralPubMedGoogle Scholar
  51. 51.
    Jeong HS, Lee JW, Kim SH, Myung JS, Kim JH, Kang HS. Effectiveness of transforaminal epidural steroid injection by using a preganglionic approach: a prospective randomized controlled study. Radiology. 2007;245:584–590.PubMedGoogle Scholar
  52. 52.
    Jirarattanaphochai K, Jung S, Thienthong S, Krisanaprakornkit W, Sumananont C. Peridural methylprednisolone and wound infiltration with bupivacaine for postoperative pain control after posterior lumbar spine surgery: a randomized double-blinded placebo-controlled trial. Spine (Phila Pa 1976). 2007;32:609–616.Google Scholar
  53. 53.
    Kang SS, Hwang BM, Son HJ, Cheong IY, Lee SJ, Lee SH, Chung TY. The dosages of corticosteroid in transforaminal epidural steroid injections for lumbar radicular pain due to a herniated disc. Pain Physician. 2011;14:361–370.PubMedGoogle Scholar
  54. 54.
    Kaptchuk TJ, Friedlander E, Kelley JM, Sanchez MN, Kokkotou E, Singer JP, Kowalczykowski M, Miller FG, Kirsch I, Lembo AJ. Placebos without deception: a randomized controlled trial in irritable bowel syndrome. PLoS One. 2010;5:e15591.PubMedCentralPubMedGoogle Scholar
  55. 55.
    Karppinen J, Malmivaara A, Kurunlahti M, Kyllönen E, Pienimäki T, Nieminen P, Ohinmaa A, Tervonen O, Vanharanta H. Periradicular infiltration for sciatica: a randomized controlled trial. Spine (Phila Pa 1976). 2001;26:1059–1067.Google Scholar
  56. 56.
    Karppinen J, Ohinmaa A, Malmivaara A, Kurunlahti M, Kyllönen E, Pienimäki T, Nieminen P, Tervonen O, Vanharanta H. Cost effectiveness of periradicular infiltration for sciatica: subgroup analysis of a randomized controlled trial. Spine (Phila Pa 1976). 2001;26:2587–2595.Google Scholar
  57. 57.
    Kim D, Brown J. Efficacy and safety of lumbar epidural dexamethasone versus methylprednisolone in the treatment of lumbar radiculopathy: a comparison of soluble versus particulate steroids. Clin J Pain. 2011;27:518–522.PubMedGoogle Scholar
  58. 58.
    Klenerman L, Greenwood R, Davenport HT, White DC, Peskett S. Lumbar epidural injections in the treatment of sciatica. Br J Rheumatol. 1984;23:35–38.PubMedGoogle Scholar
  59. 59.
    Koes BW, van Tulder MW, Peul WC. Diagnosis and treatment of sciatica. BMJ. 2007;334:1313–1317.PubMedCentralPubMedGoogle Scholar
  60. 60.
    Kraemer J, Ludwig J, Bickert U, Owczarek V, Traupe M. Lumbar epidural perineural injection: a new technique. Eur Spine J. 1997;6:357–361.PubMedCentralPubMedGoogle Scholar
  61. 61.
    Laiq N, Khan MN, Iqbal MJ, Khan S. Comparison of epidural steroid injections with conservative management in patients with lumbar radiculopathy. J Coll Physicians Surg Pak. 2009;19:539–543.PubMedGoogle Scholar
  62. 62.
    Lavoie PA, Khazen T, Filion PR. Mechanisms of the inhibition of fast axonal transport by local anesthetics. Neuropharmacology. 1989;28:175–181.PubMedGoogle Scholar
  63. 63.
    Lee JH, An JH, Lee SH. Comparison of the effectiveness of interlaminar and bilateral transforaminal epidural steroid injections in treatment of patients with lumbosacral disc herniation and spinal stenosis. Clin J Pain. 2009;25:206–210.PubMedGoogle Scholar
  64. 64.
    Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D. 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.PubMedGoogle Scholar
  65. 65.
    Macedo LG, Elkins MR, Maher CG, Moseley AM, Herbert RD, Sherrington C. There was evidence of convergent and construct validity of Physiotherapy Evidence Database quality scale for physiotherapy trials. J Clin Epidemiol. 2010;63:920–925.PubMedGoogle Scholar
  66. 66.
    MacVicar J, King W, Landers MH, 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.PubMedGoogle Scholar
  67. 67.
    Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83:713–721.PubMedGoogle Scholar
  68. 68.
    Makki D, Nawabi DH, Francis R, Hamed AR, Hussein AA. Is the outcome of caudal epidural injections affected by patient positioning? Spine (Phila Pa 1976). 2010;35:E687–E690.Google Scholar
  69. 69.
    Manchikanti L, Abdi S, Atluri S, Benyamin RM, Boswell MV, Buenaventura RM, Bryce DA, Burks PA, Caraway DL, Calodney AK, Christo PJ, Cohen SP, Colson J, Conn A, Cordner HJ, Coubarous S, Datta S, Deer TR, Diwan SA, Falco FJ, Fellows B, Geffert SC, Grider JS, Gupta S, Hameed H, Hameed M, Hansen H, Helm S 2nd, Janata JW, Justiz R, Kaye AD, Lee M, Manchikanti KN, McManus CD, Onyewu O, Parr AT, Patel V, Racz GB, Sehgal N, Sharma M, Simopoulos TT, Singh V, Smith HS, Snook LT, Swicegood J, Vallejo R, Ward SP, Wargo BW, Zhu J, Hirsch JA. An update of comprehensive evidence-based guidelines for interventional techniques of chronic spinal pain. Part II. Guidance and recommendations. Pain Physician. 2013;16:S49–S283.Google Scholar
  70. 70.
    Manchikanti L, Benyamin RM, Falco FJ, Caraway DL, Datta S, Hirsch JA. Guidelines warfare over interventional techniques: is there a lack of discourse or straw man? Pain Physician. 2012;15:E1–E26.PubMedGoogle Scholar
  71. 71.
    Manchikanti L, Buenaventura RM, Manchikanti KN, Ruan X, Gupta S, Smith HS, Christo PJ, Ward SP. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician. 2012;15:E199–E245.PubMedGoogle Scholar
  72. 72.
    Manchikanti L, Cash KA, McManus CD, Damron KS, Pampati V, Falco FJ. Lumbar interlaminar epidural injections in central spinal stenosis: preliminary results of a randomized, double-blind, active control trial. Pain Physician. 2012;15:51–63.PubMedGoogle Scholar
  73. 73.
    Manchikanti L, Cash KA, McManus CD, Pampati V. Fluoroscopic caudal epidural injections in managing chronic axial low back pain without disc herniation, radiculitis or facet joint pain. J Pain Res. 2012;5:381–390.PubMedCentralPubMedGoogle Scholar
  74. 74.
    Manchikanti L, Cash KA, McManus CD, Pampati V, Benyamin R. Fluoroscopic lumbar interlaminar epidural injections in managing chronic lumbar axial or discogenic pain. J Pain Res. 2012;5:301–311.PubMedCentralPubMedGoogle Scholar
  75. 75.
    Manchikanti L, Cash KA, McManus CD, Pampati V, Fellows B. Results of 2-year follow-up of a randomized, double-blind, controlled trial of fluoroscopic caudal epidural injections in central spinal stenosis. Pain Physician. 2012;15:371–384.PubMedGoogle Scholar
  76. 76.
    Manchikanti L, Datta S, Gupta S, Munglani R, Bryce DA, Ward SP, Benyamin RM, Sharma ML, Helm S 2nd, Fellows B, Hirsch JA. A critical review of the American Pain Society clinical practice guidelines for interventional techniques. Part 2. Therapeutic interventions. Pain Physician. 2010;13:E215–E264.PubMedGoogle Scholar
  77. 77.
    Manchikanti L, Falco FJ, Benyamin RM, Helm S 2nd, Singh V, Hirsch JA. Value-based interventional pain management: a review of Medicare national and local coverage determination policies. Pain Physician. 2013;16:E145–E180.PubMedGoogle Scholar
  78. 78.
    Manchikanti L, Falco FJ, Hirsch JA. Epidural corticosteroid injections in the management of sciatica. Ann Intern Med. 2012;157:865–877; online comment posted March 29, 2013.Google Scholar
  79. 79.
    Manchikanti L, Falco FJ, Pampati V, Cash KA, Benyamin RM, Hirsch JA. Cost utility analysis of caudal epidural injections in the treatment of lumbar disc herniation, central spinal stenosis, post lumbar surgery syndrome, and axial or discogenic low back pain. Pain Physician. 2013;16:E129–E143.PubMedGoogle Scholar
  80. 80.
    Manchikanti L, Falco FJ, Singh V, Benyamin RM, Racz GB, Helm II S, Caraway DL, Calodney AK, Snook LT, Smith HS, Gupta S, Ward SP, Grider JS, Hirsch JA. An update of comprehensive evidence-based guidelines for interventional techniques of chronic spinal pain. Part I. Introduction and general considerations. Pain Physician. 2013;16:S1–S48.PubMedGoogle Scholar
  81. 81.
    Manchikanti L, Falco FJ, Singh V, Pampati V, Parr AT, Benyamin RM, Fellows B, Hirsch JA. Utilization of interventional techniques in managing chronic pain in the Medicare population: analysis of growth patterns from 2000 to 2011. Pain Physician. 2012;15:E969–E982.PubMedGoogle Scholar
  82. 82.
    Manchikanti L, Giordano J, Fellows B, Hirsch JA. Placebo and nocebo in interventional pain management: a friend or a foe—or simply foes? Pain Physician. 2011;14:E157–E175.PubMedGoogle Scholar
  83. 83.
    Manchikanti L, Pampati V, Falco FJ, Hirsch JA. A critical analysis of the growth of epidural injections in the Medicare population from 2000 to 2011. Pain Physician. 2013;16:E349–E364.PubMedGoogle Scholar
  84. 84.
    Manchikanti L, Pampati V, Falco FJ, Hirsch JA. Growth of spinal interventional pain management techniques: analysis of utilization trends and Medicare expenditures 2000 to 2008. Spine (Phila Pa 1976). 2013;38:157–168.Google Scholar
  85. 85.
    Manchikanti L, Singh V, Cash KA, Pampati V, Damron KS, Boswell MV. A randomized, controlled, double-blind trial of fluoroscopic caudal epidural injections in the treatment of lumbar disc herniation and radiculitis. Spine (Phila Pa 1976). 2011;36:1897–1905.Google Scholar
  86. 86.
    Manchikanti L, Singh V, Cash KA, Pampati V, Damron KS, Boswell MV. Effect of fluoroscopically guided caudal epidural steroid or local anesthetic injections in the treatment of lumbar disc herniation and radiculitis: a randomized, controlled, double blind trial with a two-year follow-up. Pain Physician. 2012;15:273–286.PubMedGoogle Scholar
  87. 87.
    Manchikanti L, Singh V, Cash KA, Pampati V, Datta S. Assessment of effectiveness of percutaneous adhesiolysis and caudal epidural injections in managing lumbar post surgery syndrome: a 2-year follow-up of randomized, controlled trial. J Pain Res. 2012;5:597–608.PubMedCentralPubMedGoogle Scholar
  88. 88.
    Manchikanti L, Singh V, Cash KA, Pampati V, Datta S. Fluoroscopic caudal epidural injections in managing post lumbar surgery syndrome: two-year results of a randomized, double-blind, active-control trial. Int J Med Sci. 2012;9:582–591.PubMedCentralPubMedGoogle Scholar
  89. 89.
    Manchikanti L, Singh V, Cash KA, Pampati V, Falco FJ. The role of fluoroscopic interlaminar epidural injections in managing chronic pain of lumbar disc herniation or radiculitis: a randomized, double-blind trial. Pain Pract. 2013;13:547–558.PubMedGoogle Scholar
  90. 90.
    Manchikanti L, Singh V, Falco FJ, Cash KA, Pampati V. Evaluation of lumbar facet joint nerve blocks in managing chronic low back pain: a randomized, double-blind, controlled trial with a 2-year follow-up. Int J Med Sci. 2010;7:124–135.PubMedCentralPubMedGoogle Scholar
  91. 91.
    Manchikanti L, Singh V, Falco FJ, Cash KA, Pampati V. Evaluation of the effectiveness of lumbar interlaminar epidural injections in managing chronic pain of lumbar disc herniation or radiculitis: a randomized, double-blind, controlled trial. Pain Physician. 2010;13:343–355.PubMedGoogle Scholar
  92. 92.
    Mathews JA, Mills SB, Jenkins VM, Grimes SM, Morkel MJ, Mathews W, Scott CM, Sittampalam Y. Back pain and sciatica: controlled trials of manipulation, traction, sclerosant and epidural injection. Br J Rheumatol. 1987;26:416–423.PubMedGoogle Scholar
  93. 93.
    McCahon RA, Ravenscroft A, Hodgkinson V, Evley R, Hardman J. A pilot study of the dose-response of caudal methylprednisolone with levobupivacaine in chronic lower back pain. Anaesthesia. 2011;66:595–603.PubMedGoogle Scholar
  94. 94.
    McGregor AH, Anjarwalla NK, Stambach T. Does the method of injection alter the outcome of epidural injections? J Spinal Disord. 2001;14:507–510.PubMedGoogle Scholar
  95. 95.
    Murakibhavi VG, Khemka AG. Caudal epidural steroid injection: a randomized controlled trial. Evid Based Spine Care J. 2011;2:19–26.PubMedCentralPubMedGoogle Scholar
  96. 96.
    Ng L, Chaudhary N, Sell P. The efficacy of corticosteroids in periradicular infiltration for chronic radicular pain: a randomized, double-blind, controlled trial. Spine (Phila Pa 1976). 2005;30:857–862.Google Scholar
  97. 97.
    Park CH, Lee SH, Kim BI. Comparison of the effectiveness of lumbar transforaminal epidural injection with particulate and nonparticulate corticosteroids in lumbar radiating pain. Pain Med. 2010;11:1654–1658.PubMedGoogle Scholar
  98. 98.
    Park CH, Lee SH, Park HS. Lumbar retrodiscal versus post-ganglionic transforaminal epidural steroid injection for the treatment of lumbar intervertebral disc herniations. Pain Physician. 2011;14:353–360.PubMedGoogle Scholar
  99. 99.
    Park KD, Lee J, Jee H, Park Y. Kambin triangle versus the supraneural approach for the treatment of lumbar radicular pain. Am J Phys Med Rehabil. 2012;91:1039–1050.PubMedGoogle Scholar
  100. 100.
    Parr AT, Manchikanti L, Hameed H, Conn A, Manchikanti KN, Benyamin RM, Diwan S, Singh V, Abdi S. Caudal epidural injections in the management of chronic low back pain: a systematic appraisal of the literature. Pain Physician. 2012;15:E159–E198.PubMedGoogle Scholar
  101. 101.
    Pasqualucci A. Experimental and clinical studies about the preemptive analgesia with local anesthetics: possible reasons of the failure. Minerva Anestesiol. 1998;64:445–457.PubMedGoogle Scholar
  102. 102.
    Pasqualucci A, Varrassi G, Braschi A, Peduto VA, Brunelli A, Marinangeli F, Gori F, Colò F, Paladín A, Mojoli F. Epidural local anesthetic plus corticosteroid for the treatment of cervical brachial radicular pain: single injection versus continuous infusion. Clin J Pain. 2007;23:551–557.PubMedGoogle Scholar
  103. 103.
    Pinto RZ, Maher CG, Ferreira ML, Hancock M, Oliveira VC, McLachlan AJ, Koes B, Ferreira PH. Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Ann Intern Med. 2012;157:865–877.PubMedGoogle Scholar
  104. 104.
    Pirbudak L, Karakurum G, Oner U, Gulec A, Karadasli H. Epidural corticosteroid injection and amitriptyline for the treatment of chronic low back pain associated with radiculopathy. Pain Clinic. 2003;15:247–253.Google Scholar
  105. 105.
    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, iii.Google Scholar
  106. 106.
    Quraishi NA. Transforaminal injection of corticosteroids for lumbar radiculopathy: systematic review and meta-analysis. Eur Spine J. 2012;21:214–219.PubMedCentralPubMedGoogle Scholar
  107. 107.
    Rados I, Sakic K, Fingler M, Kapural L. Efficacy of interlaminar vs transforaminal epidural steroid injection for the treatment of chronic unilateral radicular pain: prospective, randomized study. Pain Med. 2011;12:1316–1321.PubMedGoogle Scholar
  108. 108.
    Rasmussen S, Krum-Møller DS, Lauridsen LR, Jensen SE, Mandøe H, Gerlif C, Kehlet H. Epidural steroid following discectomy for herniated lumbar disc reduces neurological impairment and enhances recovery: a randomized study with two-year follow-up. Spine (Phila Pa 1976). 2008;33:2028–2033.Google Scholar
  109. 109.
    Rho ME, Tang CT. The efficacy of lumbar epidural steroid injections: transforaminal, interlaminar, and caudal approaches. Phys Med Rehabil Clin N Am. 2011;22:139–148.PubMedGoogle Scholar
  110. 110.
    Ridley MG, Kingsley GH, Gibson T, Grahame R. Outpatient lumbar epidural corticosteroid injection in the management of sciatica. Br J Rheumatol. 1988;27:295–299.PubMedGoogle Scholar
  111. 111.
    Riew KD, Park JB, Cho YS, Gilula L, Patel A, Lente LG, Bridwell KH. 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.PubMedGoogle Scholar
  112. 112.
    Riew KD, Yin Y, Gilula L, Bridwell KH, Lenke LG, Lauryssen C, Goette K. 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;82:1589–1593.PubMedGoogle Scholar
  113. 113.
    Roberts ST, Willick SE, Rho ME, Rittenberg JD. Efficacy of lumbosacral transforaminal epidural steroid injections: a systematic review. PM R. 2009;1:657–668.PubMedGoogle Scholar
  114. 114.
    Rogers P, Nash T, Schiller D, Norman J. Epidural steroids for sciatica. Pain Clinic. 1992;5:67–72.Google Scholar
  115. 115.
    Sato C, Sakai A, Ikeda Y, Suzuki H, Sakamoto A. The prolonged analgesic effect of epidural ropivacaine in a rat model of neuropathic pain. Anesth Analg. 2008;106:313–320.PubMedGoogle Scholar
  116. 116.
    Sayegh FE, Kenanidis EI, Papavasiliou KA, Potoupnis ME, Kirkos JM, Kapetanos GA. Efficacy of steroid and nonsteroid caudal epidural injections for low back pain and sciatica: a prospective, randomized, double-blind clinical trial. Spine (Phila Pa 1976). 2009;34:1441–1447.Google Scholar
  117. 117.
    Selim AJ, Ren XS, Fincke G, Deyo RA, Rogers W, Miller D, Linzer M, Kazis L. The importance of radiating leg pain in assessing health outcomes among patients with low back pain: results from the Veterans Health Study. Spine (Phila Pa 1976). 1998;23:470–474.Google Scholar
  118. 118.
    Snoek W, Weber H, Jorgensen B. Double-blind evaluation of extradural methylprednisolone for herniated lumbar disc. Acta Orthop Scand. 1977;48:635–641.PubMedGoogle Scholar
  119. 119.
    Staal JB, de Bie RA, de Vet HC, Hildebrandt J, Nelemans P. Injection therapy for subacute and chronic low back pain: an updated Cochrane review. Spine (Phila Pa 1976). 2009;34:49–59.Google Scholar
  120. 120.
    Tachihara H, Sekiguchi M, Kikuchi S, Konno S. Do corticosteroids produce additional benefit in nerve root infiltration for lumbar disc herniation. Spine (Phila Pa 1976). 2008;33:743–747.Google Scholar
  121. 121.
    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.PubMedCentralPubMedGoogle Scholar
  122. 122.
    Thomas E, Cyteval C, Abiad L, Picot MC, Taourel P, Blotman F. Efficacy of transforaminal versus interspinous corticosteroid injection in discal radiculalgia—a prospective, randomised, double-blind study. Clin Rheumatol. 2003;22:299–304.PubMedGoogle Scholar
  123. 123.
    Tubach F, Beauté J, Leclerc A. Natural history and prognostic indicators of sciatica. J Clin Epidemiol. 2004;57:174–179.PubMedGoogle Scholar
  124. 124.
    Vad VB, Bhat AL, Lutz GE, Cammisa F. Transforaminal epidural steroid injections in lumbosacral radiculopathy: a prospective randomized study. Spine (Phila Pa 1976). 2002;27:11–16.Google Scholar
  125. 125.
    Valat JP, Genevay S, Marty M, Rozenberg S, Koes B. Sciatica. Best Pract Res Clin Rheumatol. 2010;24:241–252.PubMedGoogle Scholar
  126. 126.
    Valat JP, Giraudeau B, Rozenberg S, Goupille P, Bourgeois P, Micheau-Beaugendre V, Soubrier M, Richard S, Thomas E. Epidural corticosteroid injections for sciatica: a randomised, double blind, controlled clinical trial. Ann Rheum Dis. 2003;62:639–643.PubMedCentralPubMedGoogle Scholar
  127. 127.
    Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Hanscom B, Skinner JS, Abdu WA, Hilibrand AS, Boden SD, Deyo RA. Surgical vs nonoperative treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006;296:2441–2450.PubMedCentralPubMedGoogle Scholar
  128. 128.
    Wilson-MacDonald J, Burt G, Griffin D, Glynn C. Epidural steroid injection for nerve root compression: a randomized, controlled trial. J Bone Joint Surg Br. 2005;87:352–355.PubMedGoogle Scholar
  129. 129.
    Wittenberg RH, Greskötter KR, Steffen R, Schoenfeld BL. [Is epidural injection treatment with hypertonic saline solution in intervertebral disk displacement useful? (The effect of NaCl solution on intervertebral disk tissue)] [in German]. Z Orthop Ihre Grenzgeb. 1990;128:223–226.PubMedGoogle Scholar
  130. 130.
    Zahaar MS. The value of caudal epidural steroids in the treatment of lumbar neural compression syndromes. J Neurol Orthop Med Surg. 1991;12:181–184.Google Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2014

Authors and Affiliations

  • Laxmaiah Manchikanti
    • 2
    • 1
  • Ramsin M. Benyamin
    • 3
    • 4
  • Frank J. E. Falco
    • 5
    • 6
    • 7
  • Alan D. Kaye
    • 8
  • Joshua A. Hirsch
    • 9
    • 10
  1. 1.Pain Management Center of Paducah, KYPaducahUSA
  2. 2.Department of Anesthesiology and Perioperative MedicineUniversity of LouisvilleLouisvilleUSA
  3. 3.Millennium Pain CenterBloomingtonUSA
  4. 4.Department of Surgery, College of MedicineUniversity of IllinoisUrbana-ChampaignUSA
  5. 5.Mid Atlantic Spine & Pain PhysiciansNewarkUSA
  6. 6.Pain Medicine Fellowship ProgramTemple University HospitalPhiladelphiaUSA
  7. 7.Department of Physical Medicine and RehabilitationTemple University Medical SchoolPhiladelphiaUSA
  8. 8.Department of AnesthesiaLouisiana State University Health Science CenterNew OrleansUSA
  9. 9.Interventional Care, Minimally Invasive Spine Surgery, Interventional Radiology, Endovascular Neurosurgery and Neuroendovascular ProgramMassachusetts General HospitalBostonUSA
  10. 10.Harvard Medical SchoolBostonUSA

Personalised recommendations