Efficacy of Epidural Injections in Managing
Chronic Spinal Pain: A Best Evidence Synthesis
Authors: Kaye Alan David 
Published: February 2021

Background: Epidural injections have been used since 1901 in managing low back
pain and sciatica. Spinal pain, disability, health, and economic impact continue to
increase, despite numerous modalities of interventions available in managing chronic
spinal pain. Thus far, systematic reviews performed to assess the efficacy of epidural
injections in managing chronic spinal pain have yielded conflicting results.
Objective: To evaluate and update the clinical utility of the efficacy of epidural
injections in managing chronic spinal pain.
Study Design: A systematic review of randomized controlled trials of epidural
injections in managing chronic spinal pain.
Methods: In this systematic review, randomized trials with a placebo control or
an active-control design were included. The outcome measures were pain relief and
functional status improvement.
The quality of each individual article was assessed by Cochrane review criteria, as well
as the Interventional Pain Management Techniques - Quality Appraisal of Reliability and
Risk of Bias Assessment (IPM-QRB). Best evidence synthesis was conducted based on the
qualitative level of evidence (Level I to V).
Data sources included relevant literature identified through searches of PubMed for a
period starting in 1966 through August 2015; Cochrane reviews; and manual searches
of the bibliographies of known primary and review articles.
Results: A total of 52 trials met inclusion criteria. Meta-analysis was not feasible.
The evidence in managing lumbar disc herniation or radiculitis is Level II for long-term
improvement either with caudal, interlaminar, or transforaminal epidural injections with
no significant difference among the approaches.
The evidence is Level II for long-term management of cervical disc herniation with
interlaminar epidural injections.
The evidence is Level II to III in managing thoracic disc herniation with an interlaminar
approach.
The evidence is Level II for caudal and lumbar interlaminar epidural injections with Level
III evidence for lumbar transforaminal epidural injections for lumbar spinal stenosis.
The evidence is Level II for cervical spinal stenosis management with an interlaminar
approach The evidence is Level II for axial or discogenic pain without facet arthropathy or disc herniation
treated with caudal or lumbar interlaminar injections in the lumbar region; whereas it is Level
II in the cervical region treated with cervical interlaminar epidural injections.
The evidence for post lumbar surgery syndrome is Level II with caudal epidural injections and
for post cervical surgery syndrome it is Level II with cervical interlaminar epidural injections.
Limitations: Even though this is a large systematic review with inclusion of a large number
of randomized controlled trials, the paucity of high quality randomized trials literature
continues to confound the evidence.
Conclusion: This systematic review, with an assessment of the quality of manuscripts and
outcome parameters, shows the efficacy of epidural injections in managing a multitude of
chronic spinal conditions.
Key words: Chronic pain, spinal pain, epidural injections, local anesthetic, steroids,
interlaminar epidural injections, caudal epidural injections, transforaminal epidural injections