Lumbar Epidural Injections

Epidural injections with or without steroids have been extensively used across the world. In fact, epidural injections continue to be the most commonly performed interventional technique. The underlying mechanism of action for epidurally administered local anesthetic and steroids has been described, even though descriptions continue to evolve. The various modes of actions of corticosteroids include membrane stabilization, inhibition of neural peptide synthesis in action, blockade of phospholipase activity, prolonged suppression of ongoing neuronal discharge, and suppression of sensitization and dorsal horn neuron. Further, local anesthetics have been postulated to provide relief by suppression of multiple mechanisms including suppression of nociceptive discharge, the blockade of sympathetic reflex arc, the blockade of axonal transport, the blockade of sensitization, and anti-inflammatory effects. Based on best evidence synthesis, Level I–II evidence is available for long-term improvement of the treatment of low back and lower extremity pain secondary to disc herniation with radicular pain with three approaches, Level II evidence for central spinal stenosis with neurogenic claudication with three approaches, and Level II evidence for post-lumbar surgery syndrome with caudal approach. There is also Level II evidence in managing discogenic pain without facet joint pain with lumbar interlaminar and caudal epidural injections. However, these procedures for discogenic pain are not allowed in the USA.