title: Efficacy of Epidural Injections in Managing Chronic Spinal Pain: A Best Evidence Synthesis.
abstract: Epidural injections have been used since 1901 in managing low back pain and sciatica. Spinal pain, disability, health, and economic impact continue to increase, despite numerous modalities of interventions available in managing chronic spinal pain. Thus far, systematic reviews performed to assess the efficacy of epidural injections in managing chronic spinal pain have yielded conflicting results.
  
  
  
  To evaluate and update the clinical utility of the efficacy of epidural injections in managing chronic spinal pain.
  
  
  
  A systematic review of randomized controlled trials of epidural injections in managing chronic spinal pain.
  
  
  
  In this systematic review, randomized trials with a placebo control or an active-control design were included. The outcome measures were pain relief and functional status improvement. The quality of each individual article was assessed by Cochrane review criteria, as well as the Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment (IPM-QRB). Best evidence synthesis was conducted based on the qualitative level of evidence (Level I to V). Data sources included relevant literature identified through searches of PubMed for a period starting in 1966 through August 2015; Cochrane reviews; and manual searches of the bibliographies of known primary and review articles.
  
  
  
  A total of 52 trials met inclusion criteria. Meta-analysis was not feasible. The evidence in managing lumbar disc herniation or radiculitis is Level II for long-term improvement either with caudal, interlaminar, or transforaminal epidural injections with no significant difference among the approaches. The evidence is Level II for long-term management of cervical disc herniation with interlaminar epidural injections. The evidence is Level II to III in managing thoracic disc herniation with an interlaminar approach. The evidence is Level II for caudal and lumbar interlaminar epidural injections with Level III evidence for lumbar transforaminal epidural injections for lumbar spinal stenosis. The evidence is Level III for cervical spinal stenosis management with an interlaminar approach. The evidence is Level II for axial or discogenic pain without facet arthropathy or disc herniation treated with caudal or lumbar interlaminar injections in the lumbar region; whereas it is Level III in the cervical region treated with cervical interlaminar epidural injections. The evidence for post lumbar surgery syndrome is Level II with caudal epidural injections and for post cervical surgery syndrome it is Level III with cervical interlaminar epidural injections.
  
  
  
  Even though this is a large systematic review with inclusion of a large number of randomized controlled trials, the paucity of high quality randomized trials literature continues to confound the evidence.
  
  
  
  This systematic review, with an assessment of the quality of manuscripts and outcome parameters, shows the efficacy of epidural injections in managing a multitude of chronic spinal conditions.
authors.forename: Alan D
authors.initials: AD
authors.lastname: Kaye
authors.affiliation: Pain Management Center of Paducah, Paducah, KY, and University of Louisville, Louisville, KY.
authors.forename: Laxmaiah
authors.initials: L
authors.lastname: Manchikanti
authors.affiliation: University of Texas, MD Anderson Cancer Center, Houston, TX.
authors.forename: Salahadin
authors.initials: S
authors.lastname: Abdi
authors.forename: Sairam
authors.initials: S
authors.lastname: Atluri
authors.forename: Sanjay
authors.initials: S
authors.lastname: Bakshi
authors.forename: Ramsin
authors.initials: R
authors.lastname: Benyamin
authors.affiliation: Department of Anesthesiology and Perioperative Medicine, University of Louisville.
authors.forename: Mark V
authors.initials: MV
authors.lastname: Boswell
authors.forename: Ricardo
authors.initials: R
authors.lastname: Buenaventura
authors.forename: Kenneth D
authors.initials: KD
authors.lastname: Candido
authors.forename: Harold J
authors.initials: HJ
authors.lastname: Cordner
authors.forename: Sukdeb
authors.initials: S
authors.lastname: Datta
authors.forename: Gulshan
authors.initials: G
authors.lastname: Doulatram
authors.forename: Christopher G
authors.initials: CG
authors.lastname: Gharibo
authors.forename: Vahid
authors.initials: V
authors.lastname: Grami
authors.affiliation: Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK.
authors.forename: Sanjeeva
authors.initials: S
authors.lastname: Gupta
authors.forename: Sachin
authors.initials: S
authors.lastname: Jha
authors.affiliation: Optimum Health Medical Group, Clifton Park, NY, Kaplan Headache and Facial Pain Center, Clifton Park, NY, and Comprehensive Interventional Pain Management Center, Clifton Park, NY.
authors.forename: Eugene D
authors.initials: ED
authors.lastname: Kaplan
authors.forename: Yogesh
authors.initials: Y
authors.lastname: Malla
authors.forename: Dharam P
authors.initials: DP
authors.lastname: Mann
authors.affiliation: New York University School of Medicine, New York, NY.
authors.forename: Devi E
authors.initials: DE
authors.lastname: Nampiaparampil
authors.forename: Gabor
authors.initials: G
authors.lastname: Racz
authors.forename: Prithvi
authors.initials: P
authors.lastname: Raj
authors.forename: Maunak V
authors.initials: MV
authors.lastname: Rana
authors.forename: Manohar Lal
authors.initials: ML
authors.lastname: Sharma
authors.affiliation: Spine Pain Diagnostics Associates, Niagara, WI.
authors.forename: Vijay
authors.initials: V
authors.lastname: Singh
authors.forename: Amol
authors.initials: A
authors.lastname: Soin
authors.affiliation: Premier Pain Centers, Shrewsbury, NJ and Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Peter S
authors.initials: PS
authors.lastname: Staats
authors.forename: Ricardo
authors.initials: R
authors.lastname: Vallejo
authors.forename: Bradley W
authors.initials: BW
authors.lastname: Wargo
authors.affiliation: Massachusetts General Hospital and Harvard Medical School, Boston, MA.
authors.forename: Joshua A
authors.initials: JA
authors.lastname: Hirsch
mesh_terms: D000700:Analgesics / Q000008:administration & dosage*; D000767:Anesthesia, Epidural / Q000379:methods; D000775:Anesthesia, Spinal / Q000379:methods; D059350:Chronic Pain / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D019317:Evidence-Based Medicine / Q000379:methods*; D006801:Humans; D007268:Injections, Epidural; D007405:Intervertebral Disc Displacement / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology; D017116:Low Back Pain / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology; D059408:Pain Management / Q000379:methods*; D011843:Radiculopathy / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology; D016032:Randomized Controlled Trials as Topic / Q000379:methods; D015203:Reproducibility of Results; D013130:Spinal Stenosis / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology; D016896:Treatment Outcome
chemical_list: D000700:Analgesics