1. 2005;8;127-143Role of Epidural Steroids in the Management of Chronic Spinal Pain: A Systematic Review of Effectiveness and Complications
   A Systematic Review
   Salahadin Abdi, MD, PhD, Sukdeb Datta, MD, and Linda F. Lucas, MD.

Background: Epidural steroid  injections are commonly used for chronic spinal pain.  However, there is no conclusive evidence regarding their effectiveness, and  debate continues as to their value in managing chronic spinal pain. 

Objective: To evaluate various types of epidural injections (interlaminar, transforaminal, and caudal) for managing chronic spinal pain (axial and radicular).

Study Design: A systematic review utilizing the criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials, and criteria of the Cochrane Musculoskeletal Review Group for randomized trials. 

Methods: Data sources included relevant English literature identified through searches of MEDLINE and EMBASE (January 1966 to November 2004), manual searches of bibliographies of known primary and review articles and abstracts from scientific meetings within the last 2 years.
Three reviewers independently assessed the trials for the quality of their methods.  Subgroup analyses were performed for trials with different control groups, with different modes of epidurals (interlaminar, transforaminal, and caudal), with different injection sites (cervical/thoracic, lumbar/sacral), and with timing of outcome measurement (short- and long-term).

Outcome Measures: The primary outcome measure was pain relief.  Other outcome measures were functional improvement, improvement of psychological status, and return to work.  Short-term improvement was defined as less than 6 weeks, and long-term  improvement was defined as 6 weeks or longer. 

Results: For lumbar radicular pain with interlaminar lumbar epidural steroid injections, the level of evidence was strong for short-term relief and limited for long-term relief.  For cervical radicular pain with cervical interlaminar epidural steroid injections, the evidence was moderate. 
The evidence for lumbar transforaminal epidural steroid injections for lumbar nerve root pain was strong for short-term and moderate for long term  improvement.  The evidence for cervical transforaminal epidural steroid injections for cervical nerve root pain was moderate.  The evidence was limited for lumbar radicular pain in post lumbar laminectomy syndrome. 
The evidence for caudal epidural steroid injections was strong for short-term relief and moderate for long-term relief. For managing chronic postlumbar laminectomy syndrome and spinal stenosis the evidence was limited for low back and radicular pain.  The evidence was moderate for chronic low back pain.

Conclusion: The evidence for effectiveness of epidural injections in managing chronic spinal pain ranged from limited to strong.

Keywords: Spinal pain, low back pain, epidural steroids, interlaminar, caudal, transforaminal, radiculopathy, axial pain, spinal stenosis