A systemic review has shown that epidural steroid injections demonstrated limited efficacy in reducing back pain and disability.
The review by the American Academy of Neurology (AAN) found that in cervical and lumbar radiculopathies, they probably reduced short-term pain and disability, and possibly decreased long-term disability, reported Carmel Armon, MD, of Loma Linda University School of Medicine in California, and members of the AAN guidelines subcommittee in Neurology.
And in lumbar spinal stenosis, epidural steroid injections possibly reduced short-term and long-term disability, but not short-term pain. There was insufficient evidence to determine whether epidural steroids reduced long-term pain.
There was also insufficient evidence to determine the effectiveness of epidural steroids in cervical spinal stenosis.
“Chronic back pain is common and can have a negative impact on a person’s quality of life, making it difficult to move, sleep and participate in daily activities,” Armon.
“In our review, studies show epidural steroid injections may have limited efficacy – they may modestly reduce pain in some situations for up to three months and reduce disability for some people for up to six months or more.”
The review updates a 2007 AAN assessment that reported epidural steroids may improve radicular lumbosacral pain for between two and six weeks after the injection, but they did not improve function or reduce the need for surgery, reports Medpage Today.
The latest report, directed to neurologists, physiatrists, pain management specialists, orthopoedic specialists, neurosurgeons, spine specialists, and primary care clinicians, incorporated new evidence about epidural steroid injections in cervical and lumbar spinal stenosis and radiculopathies, assessing short-term (three months or less) and long-term (six months or more) improvements in pain and disability.
The AAN subcommittee searched databases for randomised controlled trials about epidural steroid efficacy published between January 2005 and January 2021, selecting 90 studies for its systematic review.
Trials compared epidural shots against placebo or active control. A panel of epidural steroid experts interpreted the evidence in a clinical context.
Most trials focused on lumbar disease; only two class 2 studies evaluated cervical radiculopathy and none assessed cervical spinal stenosis.
Because the trials used a wide variety of efficacy measures, the subcommittee reported differences based on any measure of success as the success rate difference (SRD).
For radiculopathies:
• The SRD for short-term pain was -24.0% (95% CI -34.9 to -12.6), with a number needed to treat (NNT) of 4
• The SRD for short-term disability was -16.0% (95% CI -26.6 to -5.0), with a NNT of 6
• The SRD for long-term disability was -11.1% (95% CI -25.3 to 3.6), with a NNT of 9
In lumbar spinal stenosis:
• The SRD for short-term disability was -26.2% (95% CI -52.4 to 3.6), with a NNT of 4
• The SRD for long-term disability was -11.8% (95% CI -26.9 to 3.8), with a NNT of 8
There’s controversy about the appropriate choice of inactive comparator treatments as a true placebo in clinical trials of epidural steroids, the AAN subcommittee noted. Future studies should use minimal meaningful clinical difference as the measure of efficacy and paraspinal muscle injections of saline as an inactive placebo, the group suggested.
“We found no studies looking at whether repeated treatments are effective or examining the effect of treatment on daily living and returning to work,” noted subcommittee member Pushpa Narayanaswami, MD, of Beth Israel Deaconess Medical Centre in Boston.
“Future studies should address these gaps.”
Study details
Epidural Steroids for Cervical and Lumbar Radicular Pain and Spinal Stenosis Systematic Review Summary
Carmel Armon, Pushpa Narayanaswami, Sonja Potrebic et al.
Published in Neurology on 11 March 2025
Abstract
Background and Objectives
This review systematically evaluates and incorporates evidence for the use of epidural steroid injections (ESIs) in cervical and lumbar spinal stenosis and radiculopathies, assessing short-term (≤3 months) and long-term (≥6 months) improvements in pain and disability.
Methods
We searched databases for randomised controlled trials (RCTs) on the efficacy of ESIs published between January 2005 and January 2021. Data analysis was performed by American Academy of Neurology methodologists. A panel of ESI experts was engaged to interpret the evidence in a clinical context. Owing to the great variability in efficacy measures used in the articles, we report differences based on any measure of success: the success rate difference (SRD).
Results
Ninety RCTs met inclusion criteria. In cervical and lumbar radiculopathies, ESIs probably reduce short-term pain (SRD -24.0%, 95% CI −34.9 to −12.6, number needed to treat [NNT] 4) and disability (SRD −16.0%, 95% CI −26.6 to −5, NNT 6) and possibly decrease long-term disability (SRD −11.1%, 95% CI −25.3 to 3.6, NNT 9). There is insufficient evidence to determine whether ESIs reduce long-term pain in radiculopathies (SRD −10.3%, 95% CI −27.8 to 7.6). In lumbar spinal stenosis, ESIs possibly reduce short-term (SRD −26.2%, 95% CI −52.4 to 3.6, NNT 4) and long-term (SRD −11.8%, 95% CI −26.9 to 3.8, NNT 8) disability, but not short-term pain (SRD −3.5%, 95% CI −12.6 to 5.6). In lumbar stenosis, there is insufficient evidence to determine whether ESIs reduce long-term pain (SRD −6.5%, 95% CI −22.5 to 9.8). For cervical spinal stenosis, evidence is insufficient to determine the effectiveness of ESIs.
Discussion
The review affirms limited efficacy of ESIs in reducing pain and disability in cervical and lumbar radiculopathies and possibly in lumbar spinal stenosis, largely in the short term. The heterogeneity of outcome measures reported preclude presenting integrated data regarding effect size. There is controversy regarding the appropriate choice of inactive comparator treatments as a true placebo in clinical trials of ESIs. The panel recommends that future trials of ESIs use minimal meaningful clinical difference as the measure of efficacy and paraspinal muscle injection of saline as an inactive placebo.
Neurology article – Epidural Steroids for Cervical and Lumbar Radicular Pain and Spinal Stenosis Systematic Review Summary (Open access) https://www.neurology.org/doi/10.1212/WNL.0000000000213361
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