Practice Patterns and Perspectives on Epidural Steroid Injections by Interventional Pain Physicians

Abstract

Introduction

Epidural steroid injections (ESIs) are commonly used to manage chronic spinal pain. However, variations in ESI practices remain prevalent among interventional pain physicians. This study evaluates current practice patterns and perceptions of ESI efficacy to identify areas for potential standardization in clinical application.

Methods

A structured survey was distributed to interventional pain physicians via email and social media outlets, collecting data on several aspects of ESI practice: (1) the importance of precise injectate placement, (2) perceived effectiveness for axial versus limb pain, and (3) preference for fixed versus variable injectate volume based on contrast pattern spread. Responses were collected and analyzed to understand prevailing practice trends. The survey included a diverse group of pain management physicians representing different primary specialties and practice settings.

Results

Of the 94 respondents, 77.7% (73/94) selected that precise injectate placement is crucial for optimal outcomes, while 22.3% (21/94) did not view it as essential. Regarding pain type, 61.7% (58/94) selected that ESIs help with axial and limb pain, while 36.2% (34/94) found ESIs primarily effective for limb pain. Only 1.1% (1/94) selected that ESIs were beneficial solely for axial back pain, with one respondent selecting ineffectiveness for either pain type. For injectate volume, 69.2% (65/94) selected that they use a fixed volume for injection, while 30.9% (29/94) adjusted injectate volume based on contrast spread.

Conclusion

This survey highlights practice patterns among interventional pain physicians regarding ESIs, underscoring the value placed on targeted injectate placement and the perceived broad efficacy of ESIs for axial and limb pain. However, the variability in volume administration suggests a need for further research to explore the impact of fixed versus variable injectate volumes on clinical outcomes. These findings may influence future standardization efforts in ESI practice.

Key Summary Points

Why carry out this study?

ESIs are commonly used to manage multiple spinal pain conditions, but there is significant variation in how they are performed across interventional pain physicians, including differences in technique, injectate volume, and targeted pain types.

This variability reflects a need for greater clarity and potential standardization in clinical practice.

The study was conducted to evaluate current perspectives and practice patterns related to ESIs among interventional pain physicians in order to identify consensus areas and highlight where further research is needed to improve consistency and outcomes.

The study surveyed physicians to determine their views on the importance of precise injectate placement, perceived efficacy of ESIs for axial versus limb pain, and preferences for fixed versus variable injectate volume, hypothesizing that practice patterns vary significantly despite widespread use.

What was learned from the study?

The majority of physicians (77.7%) emphasized that precise delivery of injectate to the site of pathology is essential for achieving optimal pain relief.

There is broad consensus that ESIs work well for limb/radicular pain, as 61.7% believe ESIs are effective for both axial and limb/radicular pain and 36.2% think they are primarily effective for limb pain. Over 97% of physicians believe ESIs are effective for radicular pain.

The majority of physicians (69.2%) utilize a fixed injectate volume during epidural steroid injections, whereas 30.9% adjust the volume based on contrast spread.

The study confirms that, although there is broad agreement on certain aspects of ESI use, such as efficacy for radicular pain and value of targeted placement, significant variability remains in other technical parameters, particularly injectate volume.

Introduction

Epidural steroid injections (ESIs) are commonly performed minimally invasive procedures used to manage chronic spinal and radicular pain commonly caused by disc herniations, spondylosis, and spinal stenosis [1, 2]. Since their introduction, ESIs have been among interventional pain physicians’ most frequently performed procedures [3]. They are widely recognized for their effectiveness in reducing inflammation and alleviating nerve-related pain [4–6], with evidence supporting lumbar ESIs for pain relief, particularly in cases of disc herniation and spinal stenosis [7, 8]. However, the duration of pain relief varies depending on the underlying condition, often necessitating additional treatments for long-term management [9–11].

These procedures involve injecting a corticosteroid into the epidural space to reduce inflammation and modulate pain pathways associated with spinal and radicular pain [3]. ESIs can be administered at the cervical, thoracic, or lumbar levels. They can be performed using different approaches, including interlaminar and transforaminal techniques, as well as the caudal approach, which is commonly used for lumbosacral pain [12–14]. Despite the widespread use of ESIs, significant variability persists in multiple aspects of practice. Key differences include needle placement precision, the type of pain targeted (axial vs. limb pain), and the approach to injectate volume [15–18]. Some physicians prioritize precise targeting of the injectate to the site of pathology, while others adopt a broader distribution strategy. Additionally, there is variability in how practitioners adjust injectate volume, with some adhering to a fixed amount and others modifying the volume depending on contrast dispersion [19–21].

To gain a clearer understanding of these practice variations, we developed a survey to assess current ESI techniques among interventional pain physicians. The survey aimed to identify prevailing perspectives and practice patterns while highlighting areas where standardization could improve consistency and patient outcomes.

The aim of this study is to examine whether physicians prioritize precise needle placement during ESIs, whether they consider ESIs effective for treating axial pain, radicular/limb pain, or both, and whether they adjust the injectate volume based on contrast spread or use a fixed volume for all procedures. The ultimate purpose is to identify areas of consistency, highlight differences in clinical practice, and contribute evidence that may guide future research, training, and the development of standardized best practices for commonly performed interventions.

Methods

A comprehensive survey was developed to assess various practice patterns among physicians performing ESIs. It was designed by a panel of board-certified interventional pain physicians, focusing on clinically relevant topics within the interventional pain community. An initial draft was reviewed by academic pain specialists for clinical relevance and clarity, with revisions made based on their feedback. The final version received Institutional Review Board (IRB) approval from The University of Texas Health Science Center at Houston (HSC-MS-23-0490). The study was performed in accordance with the Helsinki Declaration of 1964 and its later amendments. Participants were informed in advance of data collection and the intent to publish results. Participation was anonymous and voluntary.

The survey was distributed over a three-month period (March 1–May 31, 2024) via email and online platforms, targeting physicians in both academic and private practice settings. Participation was voluntary and anonymous. The first page outlined the study’s intent to collect data for publication and served as informed consent. Physicians who did not wish to participate or did not perform ESIs could exit at any time. Similar methodologies have been published in our previous studies [11, 13].

Given the broad scope of the survey, key clinical findings have been categorized and will be published separately. The three questions and answer choices related to this study are shown in Table 1.

Table 1.

Survey questions and answer choices

Question	Answer choices
1. Do you believe that injectate reaching the exact site of pathology is important for outcomes?	Yes No
2. Do you believe based on the impression of your outcomes that ESIs help with:	Axial pain Limb pain Both axial and limb pain Neither
3. Do you use fixed volume injectate or do you vary it depending on contrast spread?	Fixed volume Vary depending on contrast spread

Results

The survey was conducted from March 1 to May 31, 2024. The questionnaire was emailed to physicians in ACGME-accredited fellowship programs and through various social media platforms to those practicing interventional pain medicine. Due to the survey being distributed through multiple channels, including email, web links, and social media, we are only able to report on respondents who both initiated and completed the survey. As a result, calculating an exact response rate is not possible. Nonetheless, we believe these results provide valuable preliminary insights into the practice patterns of interventional pain physicians. This survey gathered responses from 96 interventional pain physicians, with each question receiving 94 responses and two physicians skipping each question. The analysis below includes the responses to each question.

In response to the question regarding the importance of injectate placement during ESIs, 77.7% (73/94) of physicians indicated that accurate delivery of the injectate to the exact site of pathology is crucial for achieving optimal pain relief. In contrast, 22.3% (21/94) believed that precise placement is not essential for effective outcomes (Fig. 1). These findings suggest that the majority of interventional pain physicians consider targeted medication delivery to the area of pathology to be important for maximizing procedural effectiveness. It is worth noting that two respondents did not answer this question.

Fig. 1.

Physicians who consider precise injectate placement crucial for pain relief. Responses of interventional pain physicians on the importance of injectate placement reaching the exact site of pathology for optimal outcomes in ESIs

When asked about the perceived efficacy of ESIs for different types of pain, 61.7% (58/94) of physicians reported that ESIs are effective for both axial and limb pain, suggesting a broad range of applicability. Additionally, 36.2% (34/94) believed ESIs are specifically effective for treating limb pain. A small minority, 1.1% (1/94), indicated that ESIs are effective only for axial pain, while another 1.1% (1/94) considered ESIs ineffective for both types of pain (Fig. 2). Two respondents did not answer this question.

Fig. 2.

Reported effectiveness of ESIs in for different types of pain. Responses of interventional pain physicians on the perceived effectiveness of ESIs for different types of pain

In regard to the injectate volume administered when performing ESIs, 69.2% (65/94) physicians expressed preference for a fixed injectate volume, while 30.9% (29/94) providers indicated variable injectate volume based on the contrast spread observed intra-procedurally (Fig. 3). The survey responses illustrate that a majority of interventional pain physicians utilize a standardized approach during ESIs, while a smaller, yet considerable, subset of proceduralists tailor the injectate amount to achieve specific spread patterns. It is noteworthy that two respondents did not provide response to this question.

Fig. 3.

Physician preferences for fixed versus variable injectate volumes in ESIs. Responses of interventional pain physicians on the preferences for injectate volume administered during ESIs

Discussion

ESIs remain one of the most common intervention in the management of spinal pain syndromes, particularly those involving nerve root inflammation or compression. Despite their widespread use, practice patterns among interventional pain physicians vary considerably. These technical nuances play a critical role in determining the effectiveness and safety of the procedure. This discussion explores physician perspectives and existing literature on optimal injectate placement, comparative effectiveness across different pain types, and the clinical reasoning behind fixed versus variable injectate volumes.

Injectate Placement

The importance of precise injectate placement is a widely shared perception amongst interventional pain physicians, as it is often deemed to be pivotal to improving the efficacy of epidural steroid injections [22]. The accuracy of the needle placement is confirmed with the contrast spread seen under fluoroscopy which can vary depending on the anatomy and the severity of the pathology [15, 21, 22]. Transforaminal epidural steroid injections are commonly utilized for their targeted delivery, allowing precise placement of medication near the affected nerve root. This approach is also valuable for its diagnostic utility in identifying specific pain generators [12, 23]. In contrast, interlaminar epidural steroid injections are often chosen for their broader distribution of medication within the epidural space, which can be beneficial when treating multi-level spinal pathology [12]. Although the interlaminar approach may not require as precise needle placement as the transforaminal technique, studies suggest that understanding and optimizing contrast flow patterns remains important [21]. These patterns help assess injectate spread and ensure effective delivery of the therapeutic agent. This has been reported in studies evaluating contrast spread patterns during both cervical and lumbar injections [24, 25].

Some have proposed the use of CT imaging during epidural steroid injections to enhance the precision of needle placement and assist in procedural planning through direct visualization of soft tissue structures [26]. However, CT-guided injections are associated with increased radiation exposure for both patients and providers. Additionally, the potential benefits may be offset by the higher cost, longer procedure time, and greater resource utilization, raising concerns about the overall risk–benefit balance of this approach [27]. In certain cases, to minimize the exposure to radiation, ultrasonography with color Doppler can be employed to accurately identify the target area of injection [28]. Yoon et al. conducted a comparative study that delineates the effectiveness of ultrasonography that rivals that of fluoroscopy in visualizing and correctly placing the needles into the epidural space when performing caudal epidural steroid injection.

It is logical to assume that delivering medication directly to the site of pathology is critical for achieving optimal therapeutic outcomes. This is reflected in the majority of pain physicians emphasizing the importance of precise injectate placement. These findings highlight the value of preprocedural imaging review and having interventional procedures performed by trained specialists using fluoroscopic guidance and contrast patterns to ensure accurate delivery of medication to the targeted area for maximum therapeutic benefit [11, 29].

Effectiveness for Pain Types

Among physicians surveyed on the perceived efficacy of ESIs for various pain types, 61.7% reported that they are effective for both axial and limb pain, while 36.2% believed they are specifically effective for treating limb (radicular) pain. Overall, there was strong consensus regarding the effectiveness of ESIs for radicular limb pain, with over 97% of respondents endorsing their benefit. This correlates with the mixed evidence found in the literature [30, 31].

The perceived benefit for axial pain may be due to the medication reaching structures such as intervertebral discs, potentially alleviating discogenic pain, or spreading to posterior elements like the facet joints, thereby reducing nociceptive input from multiple spinal pain generators.

The majority belief that ESIs are effective for both axial and radicular pain likely reflects the clinical reality that many patients present with overlapping symptoms. In these cases, a single injection may provide relief by targeting multiple pain sources. Additionally, for appropriately selected patients, ESIs may reduce the need for surgical intervention [32].

Fixed versus Variable Volume

The survey results indicate that most interventional pain physicians administer a fixed volume of injectate irrespective of the contrast spread seen under imaging guidance. However, a significant proportion, nearly one-third, reported adjusting the injectate volume based on the observed contrast distribution.

A randomized controlled trial evaluating lumbar transforaminal ESIs found that higher injectate volumes may lead to greater pain reduction [33]. In this trial, achievement of “meaningful pain relief,” assessed with a visual analogue scale was compared between two groups receiving differing volumes (3 mL vs. 8 mL) during the same dose of dexamethasone injectate. Both groups experienced pain relief, but the group receiving the higher volume showed a significantly greater reduction in pain scores on the visual analogue scale.

Another study examined the effect of ventral contrast spread during transforaminal epidural steroid injection in addressing lumbosacral radiculopathy in the setting of disc herniation [34]. It found no significant difference in pain reduction between patients with both dorsal and ventral contrast spread compared to those with dorsal spread alone.

These findings suggest that varying the injectate volume based on contrast spread may not necessarily lead to improved therapeutic outcomes. Instead, using larger, fixed injectate volumes could potentially enhance clinical efficacy while simplifying procedural protocols. Larger volumes may promote broader diffusion of medication, increasing the likelihood that the injectate reaches the intended site of pathology. However, this benefit may come at the expense of precision, reducing the diagnostic value of the procedure due to less-targeted delivery.

Additionally, caution is warranted when considering high-volume injections, particularly in patients with severe stenosis or significant neural compression. In such cases, increased injectate volume may elevate intraspinal or neural pressure, potentially worsening neural compression and exacerbating pain. Therefore, while higher volumes may improve therapeutic reach, further research is necessary to determine the optimal balance between efficacy, safety, and diagnostic utility for routine clinical practice.

Limitations

This survey-based study was designed to characterize variations in clinical practice among physicians performing ESIs. However, several limitations should be acknowledged. Due to the use of multiple distribution platforms, including email, web links, and social media, we were only able to report data from respondents who initiated and completed the survey, making it impossible to calculate an accurate response rate. Although the distribution strategy was aimed at targeting physicians likely to perform interventional pain procedures, the frequency with which each respondent performs ESIs in their daily practice was not captured. This introduces potential variability in experience and practice patterns among respondents.

Additionally, the interpretation of survey questions may have varied among participants, particularly regarding the distinctions between interlaminar and transforaminal approaches. For example, physicians may hold differing views on the efficacy of interlaminar versus transforaminal injections for treating axial versus limb/radicular pain, or in terms of drug dispersion and delivery.

Future studies should aim to clarify these distinctions by collecting more detailed data on procedural frequency, provider experience, and clinical decision-making related to specific injection techniques. This would help refine our understanding of practice variation and support the development of more standardized guidelines.

Despite these limitations, this study provides valuable real-world data and represents the first known effort to specifically examine physician perceptions and practice patterns related to key technical aspects of epidural steroid injections, including injectate placement, volume, and perceived efficacy for different pain types. The insights gained from this survey highlight important areas for future research and standardization, while also offering a foundation for better understanding how interventional pain physicians approach ESI procedures in everyday clinical practice.

Conclusion

This survey highlights key practice patterns among interventional pain physicians regarding ESIs. The majority of respondents found ESIs effective for limb/radicular pain, with a notable proportion also endorsing their use for axial pain. There was strong agreement that accurate injectate placement improves therapeutic outcomes, reinforcing the importance of image-guided techniques. Most physicians reported using a fixed injectate volume, while a significant minority varied the volume based on contrast spread, indicating ongoing variability in clinical practice. These findings underscore the need for further research to determine the optimal injectate volume and assess whether a fixed or variable approach yields better outcomes.

The survey provides valuable insights into areas where standardization may improve procedural consistency and patient care, while also recognizing the need for flexibility to accommodate individual patient anatomy and pathology.

Author Contributions

Sara Abdullah, Jun Beom Ku, and Olivia Sutton wrote the initial draft. Jatinder Gill, R. Jason Yong, Omar Viswanath, Christopher L. Robinson, and Jamal Hasoon proofread the manuscript. Jatinder Gill, Christopher Robinson, and Jamal Hasoon collected data. Jatinder Gill, Omar Viswanath, and Jamal Hasoon developed the idea. Jatinder Gill, R. Jason Yong, Omar Viswanath, and Jamal Hasoon supervised the project. All authors made edits and critical revisions to the manuscript and approved the final version. Sara Abdullah, Jun Beom Ku, and Olivia Sutton contributed equally to the work and are listed as co-first authors. Omar Viswanath, Christopher L. Robinson, and Jamal Hasoon contributed equally to the work and are listed as co-senior authors.

Funding

This study was not supported by any funding.

Data Availability

The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Conflict of Interest

Omar Viswanath is an Editorial Board member of Pain and Therapy. He was not involved in the selection of peer reviewers for this manuscript nor any of the subsequent editorial decisions. Christopher L Robinson, Jamal Hasoon, Sara Abdullah, Jun Beom Ku, Olivia Sutton, Jatinder Gill and Robert J. Yong declare no relevant conflicts of interest.

Ethical Approval

This study was approved by the Institutional Review Board at the University of Texas Health Science Center at Houston (HSC-MS-23–0490). The study was performed in accordance with the Helsinki Declaration of 1964 and its later amendments. Participants were informed in advance of data collection and the intent to publish results. Participation was anonymous and voluntary.