title: Comparison of the efficacy of saline, local anesthetics, and steroids in epidural and facet joint injections for the management of spinal pain: A systematic review of randomized controlled trials.
abstract: BACKGROUND
  The efficacy of epidural and facet joint injections has been assessed utilizing multiple solutions including saline, local anesthetic, steroids, and others. The responses to these various solutions have been variable and have not been systematically assessed with long-term follow-ups.
  
  
  METHODS
  Randomized trials utilizing a true active control design were included. The primary outcome measure was pain relief and the secondary outcome measure was functional improvement. The quality of each individual article was assessed by Cochrane review criteria, as well as the criteria developed by the American Society of Interventional Pain Physicians (ASIPP) for assessing interventional techniques. An evidence analysis was conducted based on the qualitative level of evidence (Level I to IV).
  
  
  RESULTS
  A total of 31 trials met the inclusion criteria. There was Level I evidence that local anesthetic with steroids was effective in managing chronic spinal pain based on multiple high-quality randomized controlled trials. The evidence also showed that local anesthetic with steroids and local anesthetic alone were equally effective except in disc herniation, where the superiority of local anesthetic with steroids was demonstrated over local anesthetic alone.
  
  
  CONCLUSIONS
  This systematic review showed equal efficacy for local anesthetic with steroids and local anesthetic alone in multiple spinal conditions except for disc herniation where the superiority of local anesthetic with steroids was seen over local anesthetic alone.
authors.affiliation: Medical Director of the Pain Management Center of Paducah, 2831 Lone Oak Road, Paducah, KY, 42003, and Clinical Professor, Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA.
authors.forename: Laxmaiah
authors.initials: L
authors.lastname: Manchikanti
authors.affiliation: Rehabilitation Medicine, New York University School of Medicine, New York, NY, USA.
authors.forename: Devi E
authors.initials: DE
authors.lastname: Nampiaparampil
authors.affiliation: Fourth Year Resident in Department of Physical Medicine and Rehabilitation at the University of Kentucky, Lexington, KY, USA.
authors.forename: Kavita N
authors.initials: KN
authors.lastname: Manchikanti
authors.affiliation: Medical Director of Mid Atlantic Spine and Pain Physicians, Newark, DE, Pain Medicine Fellowship Program, Temple University Hospital, Philadelphia, PA, Department of PM and R, Temple University Medical School, Philadelphia, PA, USA.
authors.forename: Frank J E
authors.initials: FJ
authors.lastname: Falco
authors.affiliation: Medical Director, Spine Pain Diagnostics Associates, Niagara, WI, USA.
authors.forename: Vijay
authors.initials: V
authors.lastname: Singh
authors.affiliation: Medical Director, Millennium Pain Center, Bloomington, IL, and Clinical Assistant Professor of Surgery, College of Medicine, University of Illinois, Urbana-Champaign, IL, USA.
authors.forename: Ramsin M
authors.initials: RM
authors.lastname: Benyamin
authors.affiliation: Department of Anesthesia, LSU Health Science Center, New Orleans, LA, USA.
authors.forename: Alan D
authors.initials: AD
authors.lastname: Kaye
authors.affiliation: Interventional Pain Program, Professor and Director Pain Fellowship, Department of Orthopedics and Rehabilitation Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
authors.forename: Nalini
authors.initials: N
authors.lastname: Sehgal
authors.affiliation: Ohio Pain Clinic, Centerville, OH, USA.
authors.forename: Amol
authors.initials: A
authors.lastname: Soin
authors.affiliation: Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA., USA.
authors.forename: Thomas T
authors.initials: TT
authors.lastname: Simopoulos
authors.affiliation: President of Manhattan Spine and Pain Medicine, Department of Anesthesiology, NYU Langone-Hospital for Joint Diseases, NYU School of Medicine, New York, NY, USA.
authors.forename: Sanjay
authors.initials: S
authors.lastname: Bakshi
authors.affiliation: Medical Director of Pain Medicine and Associate Professor of Anesthesiology and Orthopedics, Department of Anesthesiology, NYU Langone-Hospital for Joint Diseases, NYU School of Medicine, New York, NY, USA.
authors.forename: Christopher G
authors.initials: CG
authors.lastname: Gharibo
authors.affiliation: Department of Anesthesia, Critical Care, and Pain Medicine at Beth Israel Deaconess Medical Center, Boston, MA, and Assistant Professor of Anesthesiology at Harvard Medical School, Harvard Medical School, Boston, MA, USA.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Gilligan
authors.affiliation: Vice Chief of Interventional Care, Chief of Minimally Invasive Spine Surgery, Service Line Chief of Interventional Radiology, Director of Endovascular Neurosurgery and Neuroendovascular Program, Massachusetts General Hospital; and Associate Professor, Department of Radiology, Harvard Medical School, Boston, MA, USA.
authors.forename: Joshua A
authors.initials: JA
authors.lastname: Hirsch
keywords: Chronic pain; epidural injections; facet joint injections; local anesthetic; saline; spinal pain; steroids