Skip to main content

Fluoroscopically guided caudal epidural steroid injections for axial low back pain associated with central disc protrusions: a prospective outcome study



To determine if axial low back pain (LBP) associated with central disc protrusions can be improved by caudal epidural steroid injections (ESIs).


Adults with chronic (> 3 months) moderate-to-severe axial LBP with L4–5 and/or L5-S1 central disc protrusions were enrolled in this prospective study. Participants underwent caudal ESIs under standard-of-care practice. The numerical rating scale (NRS) pain score, modified North American Spine Society satisfaction, and Roland Morris Disability Questionnaire (RMDQ) were collected at one week, one month, three months, six months, and one year post-injection. Pre-injection magnetic resonance images were assessed by a musculoskeletal radiologist.


Sixty-eight participants (42 males, 26 females) were analyzed. There were statistically significant improvements in all outcome measures at all follow-up time points, with the exception of NRS best pain at six months. Clinically significant improvements in outcomes were observed at various time points: at three months and one year for current pain; at one week, one month, three months, six months, and one year for worst pain; and at one month and one year for RMDQ. The proportion of satisfied participants ranged from 57 to 69% throughout the study. No adverse events were observed.


This study demonstrated significant improvements in pain and function following caudal ESIs in a cohort of axial LBP with associated central disc protrusions. Further studies, including the use of randomized controlled trials, are needed to determine the ideal subset of candidates for this treatment and to explore additional applications that caudal ESIs may have for chronic LBP.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3


  1. Frank JW, Kerr MS, Brooker AS, DeMaio SE, Maetzel A, Shannon HS, Sullivan TJ, Norman RW, Wells RP (1996) Disability resulting from occupational low back pain. Part I: what do we know about primary prevention? A review of the scientific evidence on prevention before disability begins. Spine (Phila Pa 1976) 21(24):2908–2917.

    Article  CAS  Google Scholar 

  2. Frymoyer JW, Cats-Baril WL (1991) An overview of the incidences and costs of low back pain. Orthop Clin N Am 22(2):263–271

    CAS  Google Scholar 

  3. Cassidy JD, Cote P, Carroll LJ, Kristman V (2005) Incidence and course of low back pain episodes in the general population. Spine (Phila Pa 1976) 30(24):2817–2823.

    Article  Google Scholar 

  4. Schwarzer AC, Aprill CN, Derby R, Fortin J, Kine G, Bogduk N (1995) The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine (Phila Pa 1976) 20(17):1878–1883.

    Article  CAS  Google Scholar 

  5. Saal JA (1996) Natural history and nonoperative treatment of lumbar disc herniation. Spine (Phila Pa 1976) 21(24 Suppl):2s–9s.

    Article  CAS  Google Scholar 

  6. Deyo RA, Weinstein JN (2001) Low back pain. N Engl J Med 344(5):363–370.

    Article  CAS  PubMed  Google Scholar 

  7. Suseki K, Takahashi Y, Takahashi K, Chiba T, Yamagata M, Moriya H (1998) Sensory nerve fibres from lumbar intervertebral discs pass through rami communicantes. A possible pathway for discogenic low back pain. J Bone Joint Surg (Br) 80(4):737–742.

    Article  CAS  Google Scholar 

  8. Jensen TS, Albert HB, Soerensen JS, Manniche C, Leboeuf-Yde C (2006) Natural course of disc morphology in patients with sciatica: an MRI study using a standardized qualitative classification system. Spine (Phila Pa 1976) 31(14):1605–1612; discussion 1613.

    Article  Google Scholar 

  9. Conn A, Buenaventura RM, Datta S, Abdi S, Diwan S (2009) Systematic review of caudal epidural injections in the management of chronic low back pain. Pain Physician 12(1):109–135

    PubMed  Google Scholar 

  10. Lee JH, Shin KH, Bahk SJ, Lee GJ, Kim DH, Lee CH, Kim DH, Yang HS, Lee SH (2018) Comparison of clinical efficacy of transforaminal and caudal epidural steroid injection in lumbar and lumbosacral disc herniation: a systematic review and meta-analysis. Spine J.

  11. Banaszkiewicz PA, Kader D, Wardlaw D (2003) The role of caudal epidural injections in the management of low back pain. Bull Hosp Jt Dis 61(3–4):127–131

    PubMed  Google Scholar 

  12. Barre L, Lutz GE, Southern D, Cooper G (2004) Fluoroscopically guided caudal epidural steroid injections for lumbar spinal stenosis: a restrospective evaluation of long term efficacy. Pain Physician 7(2):187–193

    PubMed  Google Scholar 

  13. Southern D, Lutz GE, Cooper G, Barre L (2003) Are fluoroscopic caudal epidural steroid injections effective for managing chronic low back pain? Pain Physician 6(2):167–172

    PubMed  Google Scholar 

  14. Cha SO, Jang CH, Hong JO, Park JS, Park JH (2014) Use of magnetic resonance imaging to identify outcome predictors of caudal epidural steroid injections for lower lumbar radicular pain caused by a herniated disc. Ann Rehabil Med 38(6):791–798.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Pfirrmann CW, Metzdorf A, Zanetti M, Hodler J, Boos N (2001) Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine (Phila Pa 1976) 26(17):1873–1878.

    Article  CAS  Google Scholar 

  16. Modic MT, Masaryk TJ, Ross JS, Carter JR (1988) Imaging of degenerative disk disease. Radiology 168(1):177–186.

    Article  CAS  PubMed  Google Scholar 

  17. Weishaupt D, Zanetti M, Boos N, Hodler J (1999) MR imaging and CT in osteoarthritis of the lumbar facet joints. Skelet Radiol 28(4):215–219.

    Article  CAS  Google Scholar 

  18. Childs JD, Piva SR, Fritz JM (2005) Responsiveness of the numeric pain rating scale in patients with low back pain. Spine (Phila Pa 1976) 30(11):1331–1334.

    Article  Google Scholar 

  19. Stratford PW, Binkley J, Solomon P, Finch E, Gill C, Moreland J (1996) Defining the minimum level of detectable change for the Roland-Morris questionnaire. Phys Ther 76(4):359–365; discussion 366-358.

    Article  CAS  PubMed  Google Scholar 

  20. Carlson BB, Albert TJ (2019) Lumbar disc herniation: what has the spine patient outcomes research trial taught us? Int Orthop 43(4):853–859.

    Article  PubMed  Google Scholar 

  21. Ajiboye LO, Alimi M, Gbadegesin SA, Oboirien M (2019) Treatment outcome of quality of life and clinical symptoms in patients with symptomatic lumbar degenerative disc diseases: which treatment modality is superior? Int Orthop 43(4):875–881.

    Article  PubMed  Google Scholar 

  22. Shin EH, Cho KJ, Kim YT, Park MH (2019) Risk factors for recurrent lumbar disc herniation after discectomy. Int Orthop 43(4):963–967.

    Article  PubMed  Google Scholar 

  23. Nie HY, Qi YB, Li N, Wang SL, Cao YX (2018) Comprehensive comparison of therapeutic efficacy of radiofrequency target disc decompression and nucleoplasty for lumbar disc herniation: a five year follow-up. Int Orthop 42(4):843–849.

    Article  PubMed  Google Scholar 

  24. Abdi S, Datta S, Trescot AM, Schultz DM, Adlaka R, Atluri SL, Smith HS, Manchikanti L (2007) Epidural steroids in the management of chronic spinal pain: a systematic review. Pain Physician 10(1):185–212

    PubMed  Google Scholar 

  25. Benzakour T, Igoumenou V, Mavrogenis AF, Benzakour A (2019) Current concepts for lumbar disc herniation. Int Orthop 43(4):841–851.

    Article  PubMed  Google Scholar 

  26. Liu J, Zhou H, Lu L, Li X, Jia J, Shi Z, Yao X, Wu Q, Feng S (2016) The effectiveness of transforaminal versus caudal routes for epidural steroid injections in managing lumbosacral radicular pain: a systematic review and meta-analysis. Medicine (Baltimore) 95(18):e3373.

    Article  Google Scholar 

  27. Nakamura SI, Takahashi K, Takahashi Y, Yamagata M, Moriya H (1996) The afferent pathways of discogenic low-back pain. Evaluation of L2 spinal nerve infiltration. J Bone Joint Surg (Br) 78(4):606–612.

    Article  CAS  Google Scholar 

  28. Murphey F (1968) Sources and patterns of pain in disc disease. Clin Neurosurg 15:343–351

    Article  CAS  Google Scholar 

  29. Edgar MA (2007) The nerve supply of the lumbar intervertebral disc. J Bone Joint Surg (Br) 89(9):1135–1139.

    Article  CAS  Google Scholar 

  30. McLain RF, Kapural L, Mekhail NA (2005) Epidural steroid therapy for back and leg pain: mechanisms of action and efficacy. Spine J 5(2):191–201.

    Article  PubMed  Google Scholar 

Download references


We thank Dr. Paul Cooke, Dr. Jennifer Solomon, Dr. Vincenzo Castellano, Dr. Matthew Diamond, Elizabeth LaSalle, and Kristen Santiago for their contributions to this study.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Gregory E. Lutz.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Lee, J.J., Nguyen, E.T., Harrison, J.R. et al. Fluoroscopically guided caudal epidural steroid injections for axial low back pain associated with central disc protrusions: a prospective outcome study. International Orthopaedics (SICOT) 43, 1883–1889 (2019).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Low back pain
  • Caudal epidural steroid injection
  • Axial
  • Central disc protrusion
  • Outcomes