Review article
Lumbar epidural steroid injections in the patient with lumbar spinal stenosis

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History

The use of injections in the epidural space was first described by Evans in 1930 [11]. Epidural steroid injections were used for the first time in the treatment of lumbar radicular pain syndromes by Robechi in 1952 [12]. They were first reported in the United States in 1960 and were found to benefit conditions causing nerve root irritation [13].

There has been a paucity of controlled studies to evaluate the effectiveness of epidural injections in the treatment of radicular pain [14], [15], [16],

Indications and contraindications

The use of epidural steroid injections in LSS should be viewed as only one of the components of a comprehensive functional rehabilitation program. Patient education regarding the pathophysiology of neurogenic claudication is often helpful to the patient's independent pain-control efforts. A comprehensive flexion-biased physical therapy program is an essential component in the overall management of the LSS patient. Pain relief obtained with epidural steroid injections often facilitates the

Mechanism of action

Lumbar spinal stenosis typically results in a dynamic mechanical compression of the dura and nerve root sheaths of the cauda equina. Symptoms have been hypothesized to be a result of a combination of ischemic neuritis of the cauda equina or nerve root, impaired epidural venous return resulting from an increase in cerebrospinal fluid pressure below the level of compression, or disruption of nerve root microcirculation when standing [27], [28], [29]. This process can result in the formation of

Outcome

The results of a recent meta-analysis of non–fluoroscopically guided epidural steroid therapy have suggested that although there is a slight treatment benefit from epidural steroids, no more than 14% of individuals were relieved of pain [47].

The initial rationale for using epidural steroids was based on the clinical observations that nerve roots appeared indurated at the time of decompression. Fluoroscopic control for needle placement has rarely been used in any series. Careful studies of

Technique

There are several accepted techniques to access the lumbar epidural space. These techniques include the interlaminar technique, the caudal technique, and the transforaminal technique.

The use of fluoroscopy and contrast enhancement to improve the accuracy of these selective spinal injection procedures is now a well-accepted component of the technique. Although the caudal and translaminar epidural steroid injection can be completed without fluoroscopy, doing so risks possible inadvertent soft

Complications

The risks and complications of epidural steroid injections using a lumbar translaminar approach have been studied [13], [48], [51], [68], [71]. The incidence of headache is 1.4% to 6% in lumbar translaminar injections [72], [73]. Headache has occurred in up to 21% of caudal epidural injections [15]. Dural puncture is a common complication of lumbar translaminar epidural injections, with an incidence of 5% [74] to 17% [18]. The incidence of a spinal headache following dural puncture has been

Summary

Epidural steroid injections seem to be a useful component of a comprehensive and functionally oriented rehabilitation program for the patient with LSS. Review of the literature indicates the injections seem to be effective and are safe when performed with proper technique.

Acknowledgements

The authors thank Carol Barragan and Claudine Harker for their help in preparation of this manuscript.

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