Epidural Steroids for Cervical and Lumbar Radicular Pain and Spinal Stenosis Systematic Review Summary

Epidural steroid injections (ESIs) are commonly used for managing spinal pain, particularly in cases of radiculopathy and spinal stenosis. The evidence suggests that ESIs are probably effective for reducing short-term pain and disability in radiculopathy but only possibly effective for short-term disability in lumbar spinal stenosis. However, there is insufficient evidence to support their effectiveness in providing long-term pain relief for either condition. Studies comparing different corticosteroid formulations, injection techniques (interlaminar, transforaminal, or caudal), and spinal levels (cervical vs lumbar) found no significant differences in outcomes. Additionally, there is no evidence that ESIs reduce the likelihood of requiring surgery compared to epidural injections without steroids.

Safety concerns surrounding ESIs include potential complications, ranging from minor side effects like increased pain and numbness to rare but serious risks such as epidural hematoma, nerve injury, stroke, or paralysis. The frequency of adverse effects varies significantly, with major complications being rare but possible. Cost-effectiveness data on ESIs remain inconclusive, with some studies suggesting short-term economic benefits due to reduced work absenteeism, while others indicate no significant advantage over standard medical management. The effectiveness of repeated ESIs is also unclear, though they are commonly used in clinical practice, raising concerns about long-term corticosteroid-related risks such as epidural lipomatosis.

Future research should focus on addressing gaps in the evidence, particularly regarding the impact of ESIs on quality of life, daily activities, and opioid use. More studies are needed for cervical radiculopathy and stenosis, as well as to determine the true placebo effect of ESIs compared to active control interventions. Understanding the reasons behind differences in clinical guidelines, such as those of NICE and the US Centers for Medicare & Medicaid Services, could provide insight into the continued use of ESIs in chronic pain management despite limited long-term efficacy.

Epidural Steroids for Cervical and Lumbar Radicular Pain and Spinal Stenosis Systematic Review Summary: Report of the AAN Guidelines Subcommittee

Authors: Armon C, Narayanaswami P, Potrebic S, Gronseth G, Bačkonja MM, Cai VL, Dorman J, Gilligan C, Heller SA, Silsbee HM, Smith DB.

Neurology
2025 Mar 11;104(5):e213361. | DOI: https://doi.org/10.1212/WNL.0000000000213361