Epidural Injections for Lumbar Radiculopathy and Spinal Stenosis: A Comparative Systematic Review and Meta-Analysis

Background: The prevalence of chronic low back pain and related disability is rapidly increasing as arethe myriad treatments, including epidural injections. Even though epidural injections are one of the mostcommonly performed procedures in managing low back and lower extremity pain, starting in 1901 withlocal anesthetic alone, conflicting recommendations have been provided, despite the extensive literature.Recently Chou et al performed a technology assessment review for Agency for Healthcare Research andQuality (AHRQ) part of which was published in Annals of Internal Medicine showing lack of effectivenessof epidural steroid injections in managing lumbar radiculopathy and spinal stenosis. In contrast, multipleother publications have supported the efficacy and use of epidural injections.Purpose: To assess the efficacy of 3 categories of epidural injections for lumbar and spinal stenosis:performed with saline with steroids, local anesthetic alone, or steroids with local anesthetic andseparate facts from opinions.Data Sources: PubMed, Cochrane Library, US National Guideline Clearinghouse, prior systematicreviews, and reference lists. The literature search was performed through August 2015.Study Selection: Randomized trials, either placebo or active control, of epidural injections for lumbarradiculopathy and spinal stenosis.Data Extraction: Data extraction and methodological quality assessment were performedutilizing Cochrane review methodologic quality assessment and Interventional Pain ManagementTechniques - Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB). Evidence wassummarized utilizing principles of best evidence synthesis.Data Synthesis: Thirty-nine randomized controlled trials met inclusion criteria. There were 9placebo-controlled trials evaluating epidural corticosteroid injections, either with sodium chloridesolution or bupivacaine, compared to placebo injections. There were 12 studies comparing localanesthetic alone to local anesthetic with steroid.Results A meta-analysis of 5 studies utilizing sodium chloride or bupivacaine with steroid showeda lack of efficacy.A comparison of lidocaine to lidocaine with steroids in 7 studies showed significant effectivenessfrom baseline to long-term follow-up periods. Meta-analysis showed a similar effectiveness for painand function without non-inferiority of lidocaine compared to lidocaine with steroid at 3 monthsand 12 months.Limitations: The review was restricted to the data available with at least 3 months of followup, which excluded some studies. The inclusion criteria were restricted to English language studies.Conclusion: Epidural corticosteroid injections for radiculopathy or spinal stenosis with sodiumchloride solution or bupivacaine were shown to be ineffective. Lidocaine alone or lidocaine inconjunction with steroids were significantly effective.Key Words: Epidural injections, epidural steroids, lumbar radiculopathy, spinal stenosis, lidocaine,steroids, bupivacaine