EPIDURAL STEROIDS
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Epidural steroid injections (ESIs) were endorsed by the North American Spine Society and the Agency for Health Care Policy and Research as an integral part of nonsurgical management of radicular pain from lumbar spine disorders. Radicular pain is described as a sharp, lancinating, and radiating pain, often shooting from the low back down into the lower extremity in a radicular distribution. Radicular pain is the result of a nerve root lesion or inflammation. ESIs have been recommended to deliver steroids in a more localized fashion to the area of affected nerve roots, thereby decreasing the systemic effect of the administered steroid. Studies have indicated that ESIs are most effective in the presence of acute nerve root inflammation. Clinical manifestations of nerve root inflammation include some or all of the following: radicular pain, dermatomal hypesthesia, weakness of muscle groups innervated by the involved nerve roots, diminished deep tendon reflexes, and positive straight leg-raising tests. The first epidural injection using the caudal approach was performed in 1901 when cocaine was injected to treat lumbago and sciatica (presumably pain referred from lumbar nerve roots). Reports of the epidurals from the 1920s-1940s involved using high volumes of normal saline and local anesthetics. Injection of corticosteroids into the epidural space for the management of lumbar radicular pain was first recorded in 1952. ESIs can provide both diagnostic and therapeutic benefits. Diagnostically, ESIs may help identify the region and spinal column of potential pain generation through pain relief after local anesthetic injection to the site of presumed anatomic pathology. In addition, if the patient receives several weeks or more of pain relief, then it may be reasonable to assume that an element of inflammation was involved in his or her pathophysiology. This last element of diagnostic information is also the therapeutic element. Since prolonged pain relief is presumed to be due to a reduction in an inflammatory process, it is also reasonable to assume that during the prolonged pain relief, the afflicted nerve roots are also relatively protected from the deleterious effects of inflammation. In these authors' opinion, ESIs are performed best in combination with a well-designed spinal rehabilitation program. In most cases, epidural injections are considered after other attempts of treatment (eg, physical therapy, manual therapy, medications) have failed to improve patients' symptoms. A variety of procedural approaches can be used to inject corticosteroids into the epidural space (see Approaches for Epidural Injections). For purposes of this article, the authors generally refer to all epidural steroid injections as ESIs, only specifying the specific type of approach if needed for a point of distinction or clarification.
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