Epidurals Steroid Injections

There is a recent article that may affect the public perception of epidural steroid injections.

A new meta-analysis by Dr. Roger Chou published in the Annals of Internal Medicine finds that epidural injections are associated with only short-term relief when used to treat lumbar radiculopathy, a condition in which a pinched nerve root in the low back shoots pain to the leg. It is commonly also referred to as sciatica.

There has been some alarmist commentary on epidurals, including one discussion forum foreboding “Roger Chou and the end of epidurals…” While this finding may be portrayed in a sensational manner, the short-term efficacy of epidurals is not a new discovery to the medical field.

I do not know of any quality scientific article (or pain or spine doctor, for that matter) that would describe an epidural as curative. Within the field of low back pain management, it is practically a consensus that epidurals diminish pain in lumbar radiculopathy in some patients for some duration of time. The average length of benefit is debatable, but prior quality studies find that it is typically on the short-term (weeks to a few months) when it does work.

As a general physical medicine and rehabilitation doctor, I see patients with lumbar radiculopathy in nearly every clinic. I am not trained to perform epidurals but I continue to regularly refer patients for them because the literature supports some benefit and I commonly see patients who have improved by undergoing an injection.

Every month I see outlier patients who endorse a year or more of diminished pain. More common, though, are patients with significant short-term benefit. In a sizable number, there is no pain relief at all. How to present the efficacy of epidurals, emphasizing its limitations and its potential benefit, is a matter of communication style.

One prominent spine physician I trained with avoids describing an epidural as a “good treatment.”

“You should just tell the patient that they are a candidate for the procedure,” he said, and not project any improvement. He had this preference for liability reasons, he explained, but also, I presume, because a measured tone set the right level of expectation. When patients pressed further, that spine physician would remain noncommittal and say something to the effect of, “We don’t know if you’ll benefit until you try it. You might not.”

I educate patients to temper their expectations and anticipate either no benefit or moderate, short-term benefits. Revealing the lukewarm findings of the scientific literature does not necessarily diminish patient enthusiasm either. After failing to improve with other mainstays of treatment such as physical therapy and medications, an epidural is a logical step because something that might help is better than doing nothing additional.

In effect, my perceptions about epidural injections have not changed compared to before. Unlike some defenders of epidurals, I do not question the quality of Dr. Chou’s meta-analyses or the limitations posed by his findings. Other studies and meta-analyses have come to similar conclusions.

Held in the proper context, epidurals remain a viable option: best considered for lumbar radiculopathy, not expected to be curative, and with evidence showing a short-term benefit in pain.