Back Pain and Needles: Epidural Steroid Injections for Radicular Back Pain

The use of Epidural Steroid Injections (ESIs) to treat radicular back pain (sciatica) due to nerve root irritation can be very effective and safe when proper patient selection and contemporary techniques are used. Just as there are multiple types of back pain, several techniques and approaches for delivering ESIs have evolved with experience. Historically, ESI was performed at the bedside without radiographic guidance by an anesthesiologist or other physician trained in spinal injections. There was little or no insight into the anatomic origin of the pain, and the goal was simply to get the drug somewhere in the lumbar epidural space. Modern techniques employ fl uoroscopic guidance as the standard of care to ensure safe and accurate placement of injectate in the epidural space via one of three routes of entry – transforaminal, caudal, and interlaminar. All have excellent effi cacy and safety profi les, but different pluses and minuses. Transforaminal ESI delivers the most site-specifi c concentrated steroid but at an increased risk of neurological complication; caudal ESI delivers the least drug but with the lowest risk; interlaminar ESI delivers more site-specifi c drug than the caudal approach with limited long term benefi t . . . ESI should be part of a multimodal approach to reduce painful symptoms of nerve root irritation with the goal of avoiding surgery and achieving self-healing. Although there is inevitably a subset of patients for whom surgery is the best option, it is usually elective, and should be reserved for those who do not respond to non-surgical treatment or have serious neurological compromise.