Caudal Epidural Injections in the Management
of Chronic Low Back Pain: A Systematic
Appraisal of the Literature
Authors: Parr Allan T. 
Published: March 2021

Background: Epidural injections with local anesthetics and steroids are one of the most commonly used
interventions in managing chronic low back pain and lower extremity pain of various causes. However, despite their
extensive use, debate continues on their effectiveness due to the lack of well-designed, randomized, controlled
studies to determine the effectiveness of epidural injections in general, and caudal epidural injections in particular.
Study Design: A systematic review of caudal epidural injections with or without steroids in managing chronic
pain secondary to lumbar disc herniation or radiculitis, post lumbar laminectomy syndrome, spinal stenosis, and
discogenic pain without disc herniation or radiculitis.
Objective: To evaluate the effect of caudal epidural injections with or without steroids in managing various
types of chronic low back pain with or without lower extremity pain emanating as a result of disc herniation or
radiculitis, post lumbar laminectomy syndrome, spinal stenosis, and chronic discogenic pain.
Methods: The available literature on caudal epidural injections with or without steroids in managing various
types of chronic low back pain with or without lower extremity pain was reviewed. The quality assessment
and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized
for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale
criteria for fluoroscopic observational studies.
The level of evidence was classified as good, fair, or poor based on the quality of evidence developed by the U.S.
Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches
of PubMed and EMBASE from 1966 to December 2011, and manual searches of the bibliographies of known
primary and review articles.
Outcome Measures: The primary outcome measure was pain relief (short-term relief = up to 6 months
and long-term > 6 months). Secondary outcome measures of improvement in functional status, psychological
status, return to work, and reduction in opioid intake were utilized.
Results: For this systematic review, 73 studies were identified. Of these, 51 were excluded and a total of
16 studies met inclusion criteria for methodological quality assessment with 11 randomized trials and 5 nonrandomized studies.
For lumbar disc herniation, the evidence is good for short- and long-term relief of chronic pain secondary to disc
herniation or radiculitis with local anesthetic and steroids and fair relief with local anesthetic only. In managing
chronic axial or discogenic pain, spinal stenosis, and post surgery syndrome, the indicated evidence is fair.
Limitations: The limitations of this study include the paucity of literature, specifically for chronic pain without
disc herniation.
Conclusion: There was good evidence for short- and long-term relief of chronic pain secondary to disc
herniation or radiculitis with local anesthetic and steroids and fair relief with local anesthetic only. Further, this
systematic review also provided indicated evidence of fair for caudal epidural injections in managing chronic
axial or discogenic pain, spinal stenosis, and post surgery syndrome.
Key words: Chronic low back pain, lower extremity pain, lumbar disc herniation, lumbar radiculitis, lumbar
discogenic pain, post lumbar laminectomy or surgery syndrome, spinal stenosis, caudal epidural injections,
steroids, local anesthetic