Effectiveness of Therapeutic Lumbar Transforaminal Epidural Steroid Injections in Managing Lumbar Spinal Pain

Background: Among the multiple interventions used in managing chronic spinal pain, lumbar epiduralinjections have been used extensively to treat lumbar radicular pain. Among caudal, interlaminar, andtransforaminal, transforaminal epidural injections have gained rapid and widespread acceptance for thetreatment of lumbar and lower extremity pain. The potential advantages of transforaminal over interlaminarand caudal, include targeted delivery of a steroid to the site of pathology, presumably onto an inflamednerve root. However, there are only a few well-designed, randomized, controlled studies on the effectivenessof steroid injections. Consequently, multiple systematic reviews with diverse opinions have been published.Study Design: A systematic review of therapeutic transforaminal epidural injection therapy for lowback and lower extremity pain.Objective: To evaluate the effect of therapeutic transforaminal lumbar epidural steroid injections inmanaging low back and lower extremity pain.Methods: The available literature on lumbar transforaminal epidural injections in managing chronic low backand lower extremity pain was reviewed. The quality assessment and clinical relevance criteria utilized werethe Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomizedtrials and by the Newcastle-Ottawa Scale criteria for observational studies. Data sources included relevantliterature identified through searches of PubMed and EMBASE from 1966 to December 2011, andmanual searches of the bibliographies of known primary and review articles.The level of evidence was classified as good, fair, or poor based on the quality of evidence developed bythe U.S. Preventive Services Task Force (USPSTF).Outcome Measures: The primary outcome measure was pain relief (short-term relief = up to 6months and long-term > 6 months). Secondary outcome measures were improvement in functionalstatus, psychological status, return to work, and reduction in opioid intake.Results: For this systematic review, 70 studies were identified. Of these, 43 studies were excluded and atotal of 27 studies met inclusion criteria for methodological quality assessment with 15 randomized trials(with 2 duplicate publications) and 10 non-randomized studies.For lumbar disc herniation, the evidence is good for transforaminal epidural with local anesthetic and steroids,whereas it was fair for local anesthetics alone and the ability of transforaminal epidural injections to preventsurgery. For spinal stenosis, the available evidence is fair for local anesthetic and steroids. The evidence for axiallow back pain and post lumbar surgery syndrome is poor, inadequate, limited, or unavailable.Limitations: The limitations of this systematic review include the paucity of literature.Conclusion: In summary, the evidence is good for radiculitis secondary to disc herniation with localanesthetics and steroids and fair with local anesthetic only; it is fair for radiculitis secondary to spinalstenosis with local anesthetic and steroids; and limited for axial pain and post surgery syndrome usinglocal anesthetic with or without steroids.Key words: Spinal pain, chronic low back pain, lower extremity pain, transforaminal epidural steroids,radiculopathy, sciatica, steroids, local anesthetic