title: Should routine MRI of the lumbar spine be required prior to lumbar epidural steroid injection for sciatica pain?
abstract: BACKGROUND
  We describe three patients who received lumbar epidural steroid injections (LESI) for lumbosacral radicular pain that resulted in worsening of their symptoms. The procedures were performed following a review of remote diagnostic imaging studies. These cases demonstrate the lack of consensus in pain management domains for how to approach the workup and treatment of persistent/chronic low back pain, with a noted fragmentation in pain management strategies and applied therapies.
  
  
  METHODS
  We present three patients; two female patients (37 and 38 years old) undergoing LESI for remotely diagnosed disc herniations, and one 61-year-old male receiving an LESI for a presumed, unverified lumbar intervertebral disc disorder. Following a worsening of symptoms after LESI, neurosurgical consultations ultimately determined the presence of, respectively, an epidural hematoma, a neurilemoma, and a lung cancer metastasis to the sacrum as the source of symptoms, instead of being due to the intervertebral disc pathology.
  
  
  CONCLUSIONS
  We would like to emphasize several principles in the diagnosis and use of imaging of the lumbosacral region prior to undertaking invasive neuraxial procedures.
authors.affiliation: Ghaly Neurosurgical Associates, Aurora, IL, USA ; Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA ; Department of Anesthesiology, University of Illinois, Chicago, IL, USA.
authors.forename: Ramis F
authors.initials: RF
authors.lastname: Ghaly
authors.affiliation: Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA.
authors.forename: Alexei
authors.initials: A
authors.lastname: Lissounov
authors.affiliation: Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA ; Department of Anesthesiology, University of Illinois, Chicago, IL, USA.
authors.forename: Kenneth D
authors.initials: KD
authors.lastname: Candido
authors.affiliation: Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA ; Department of Anesthesiology, University of Illinois, Chicago, IL, USA.
authors.forename: Nebojsa Nick
authors.initials: NN
authors.lastname: Knezevic
keywords: Epidural steroid injection; low back pain; magnetic resonance imaging; pain management