Comparison of Clinical Efficacy of Epidural Injection
With or Without Steroid in Lumbosacral Disc
Herniation: A Systematic Review and Meta-analysis
Authors: Lee Jung Hwan 
Published: October 2019

Background: Epidural injection is performed for treatment of back and radicular pain
in patients with lumbosacral disc herniation (LDH). Steroids are usually administered to
effectively remove inflammatory mediators, and local anesthetics or saline also contribute
to pain reduction by washing out chemical mediators or blocking the nociceptor activity.
Controversy exists regarding whether steroids produce superior clinical effects compared with
local anesthetics or saline.
Objectives: This study investigated whether epidural injection of steroids produces better
clinical effects than local anesthetics or saline in the treatment of LDH.
Study design: A literature search was performed in MEDLINE, EMBASE, Cochrane review,
and KoreaMed for studies published from January 1996 until July 2017. From among the
studies fulfilling the search criteria, those that compared the clinical efficacy of steroids and
control agents, such as local anesthetics or saline, in terms of pain control and functional
improvement were included in this study. Exclusion criteria included a previous history
of lumbosacral surgery, non-specific low back pain, severe spinal stenosis, and severe disc
degeneration.
Setting: A systematic review and meta-analysis using a random effects model on randomized
controlled studies (RCTs).
Methods: After reviewing titles, abstracts, and full texts of 6,711 studies that were chosen
following removal of duplicates after the initial database search, 15 randomized controlled
studies were included in our qualitative synthesis. Data including pain score, functional score,
and follow-up period were extracted from 14 studies and analyzed using a random effects
model to calculate the effect size and its corresponding statistical significance. Quality and
level of evidence were established in accordance with the Grading of Recommendations
Assessment, Development and Evaluation (GRADE) methodology.
Results: Steroids and local anesthetics were shown to be effective. Steroid showed
significantly better pain control than control agents at 1 month, 3 months, and 6 months.
The superiority of steroid in pain control was more prominent at one month, but diminished
from 3 months to 1 year, showing no significant superiority in terms of mean difference,
With respect to functional score, no significant difference was observed between steroids and
control agents. The subgroup analysis showed that steroid revealed significant superiority in
pain and functional score at 1 month to saline rather than local anesthetics. Generally, the
quality of included studies was evaluated as high-grade, but the evidence level was determined
to be moderate, due to inconsistencies.
Limitation: Analyses of safety or adverse effects could not be performed due to a lack of
available data from the included studies.
Conclusions: Steroid is recommended over local anesthetics or saline for pain control in
Systematic Review
Comparison of Clinical Efficacy of Epidural Injection
With or Without Steroid in Lumbosacral Disc
Herniation: A Systematic Review and Meta-analysis
From: 1
Department of Physical
and Rehabilitation Medicine,
Spine Health Wooridul
Hospital, Seoul, South Korea;
2
Department of Physical and
Rehabilitation Medicine, Kyung
Hee University, Hospital, Seoul,
South Korea; 3
Department of
Physical and Rehabilitation
Medicine,Dongsan Medical
Center, School of Medicine,
Keimyung University, Daegu,
South Korea; 4
Heal & Teun
Rehabilitation & Pain Clinic,
Bundang, South Korea; 5
Seocho
SeBarun Hospital , Department
of Physical and Rehabilitation
Medicine, Seoul, South Korea;
6
Chungbuk National University
Hospital,, Department of
Physical and Rehabilitation
Medicine, Cheongjoo, South
Korea; 7
Department of Physical
and Rehabilitation Medicine,
Pusan National University
Yangsan Hospital, School of
Medicine, Pusan National
University, Yangsan, South
Korea; 8
Department of Physical
and Rehabilitation Medicine,
Veterans Medical Center, Seoul,
South Korea
Address Correspondence:
Jung Hwan Lee, MD, PhD
Department of Physical and
Rehabilitation Medicine
Spine Health Wooridul Hospital
445, Hakdong-ro, Gangnam-gu,
Seoul, South Korea
E-mail: j986802@hanmail.net
Disclaimer: There was no
external funding in the
preparation of this manuscript.
Conflict of interest: Each author
certifies that he or she, or a
member of his or her immediate
family, has no commercial
association (i.e., consultancies,
stock ownership, equity interest,
patent/licensing arrangements,
etc.) that might pose a conflict of
Jung Hwan Lee, MD, PhD1
, Dong Hwan Kim, MD, PhD2
, Du Hwan Kim, MD, PhD3
,
Kyoung-ho Shin, MD4
, Sung Jin Park, MD5
, Goo Joo Lee, MD6
, Chang-Hyung Lee, MD, PhD7
,
and Hee Seung Yang, MD8
www.painphysicianjournal.com
Pain Physician 2018; 21:449-467 • ISSN 1533-3159
patients with LDH, with a weak strength of recommendation. The superiority of steroids was
remarkable, especially at relatively short-term follow-ups, and maintained until the 1 year followup. The clinical benefits of steroids at 1 month were more prominent when compared with saline,
than when compared with local anesthetics.
Key words: Steroid, local anesthetics, saline, epidural injection, pain, function, meta-analysis,
systemic review