title: Comparison of the efficacy of caudal, interlaminar, and transforaminal epidural injections in managing lumbar disc herniation: is one method superior to the other?
abstract: BACKGROUND
  Epidural injections are performed utilizing 3 approaches in the lumbar spine: caudal, interlaminar, and transforaminal. The literature on the efficacy of epidural injections has been sporadic. There are few high-quality randomized trials performed under fluoroscopy in managing disc herniation that have a long-term follow-up and appropriate outcome parameters. There is also a lack of literature comparing the efficacy of these 3 approaches.
  
  
  METHODS
  This manuscript analyzes data from 3 randomized controlled trials that assessed a total of 360 patients with lumbar disc herniation. There were 120 patients per trial either receiving local anesthetic alone (60 patients) or local anesthetic with steroids (60 patients).
  
  
  RESULTS
  Analysis showed similar efficacy for caudal, interlaminar, and transforaminal approaches in managing chronic pain and disability from disc herniation. The analysis of caudal epidural injections showed the potential superiority of steroids compared with local anesthetic alone a 2-year follow-up, based on the average relief per procedure. In the interlaminar group, results were somewhat superior for pain relief in the steroid group at 6 months and functional status at 12 months. Interlaminar epidurals provided improvement in a significantly higher proportion of patients. The proportion of patients nonresponsive to initial injections was also lower in the group for local anesthetic with steroid in the interlaminar trial.
  
  
  CONCLUSIONS
  The results of this assessment show significant improvement in patients suffering from chronic lumbar disc herniation with 3 lumbar epidural approaches with local anesthetic alone, or using steroids with long-term follow-up of up to 2 years, in a contemporary interventional pain management setting.
authors.affiliation: Pain Management Center of Paducah, Paducah, KY, USA. ; Pain Management Center of University of Louisville, Louisville, KY, USA.
authors.forename: Laxmaiah
authors.initials: L
authors.lastname: Manchikanti
authors.affiliation: Spine Pain Diagnostics Associates, Niagara, WI, USA.
authors.forename: Vijay
authors.initials: V
authors.lastname: Singh
authors.affiliation: Pain Management Center of Paducah, Paducah, KY, USA.
authors.forename: Vidyasagar
authors.initials: V
authors.lastname: Pampati
authors.affiliation: Mid Atlantic Spine & Pain Physicians, Newark, DE, and Temple University Hospital, Philadelphia, PA, USA.
authors.forename: Frank Je
authors.initials: FJ
authors.lastname: Falco
authors.affiliation: Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
authors.forename: Joshua A
authors.initials: JA
authors.lastname: Hirsch
keywords: Caudal epidural steroids; Disc herniation; Local anesthetic; Lumbar interlaminar steroids; Radiculitis; Transforaminal epidural steroids