Effectiveness of epidural steroid injections for low back pain in older adults: a systematic review

Abstract

Background

Low back pain (LBP) is a global health problem that contributes to disability, psychological distress, and reduced quality of life in older adults. Current treatment guidelines for LBP support the use of conservative therapies such as physical therapy alongside medication management. However, interventional pain management strategies for LBP such as lumbar epidural steroid injection (LESI) are rarely mentioned.

Aims

We conducted this systematic review to characterize and evaluate the use and effectiveness of LESI amongst older adults with LBP.

Methods

We conducted a systematic English-language literature search of Ovid MEDLINE, Ovid EMBASE, and Cochrane Library. We used an iterative approach to identify both keywords and controlled vocabulary related to treatment outcomes of epidural interventions for LBP among older adults. The results were reviewed by three members of the team.

Results

Our search of 3 databases produced a total of 2657 studies and 12 met final inclusion criteria. In all studies, the use of LESI was associated with improvement in pain and/or quality of life.

Discussion

As compared to medication management, LESI was associated with statistically significant improvements in pain and functional status. The addition of physical therapy was not superior to LESI alone.

Conclusions

This systematic review is the first that focuses on the effectiveness of LESI in managing LBP in older adults. This review suggests that LESI may reduce pain and improve functional status in older adults, particularly as compared to medication management.

Prospero registration

The study was prospectively registered on Prospero (ID # 422087).

Clinical trial number

Not Applicable.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-026-03336-0.

Introduction

Low back pain (LBP) is a leading global health problem associated with increased pain and healthcare utilization as well as with decreased quality of life [1, 2]. The prevalence and burden of LBP increase with age [3, 4]. The prevalence of LBP is 21–75% in the geriatric population and older adults also are at increased risk for chronic and disabling LBP [5]. Treatment for chronic LBP typically consists of conservative therapies, pharmacologic management, and interventional pain therapies, though there are unique challenges for utilizing conservative therapies and pharmacologic management for older adults. Conservative therapies may include a variety of approaches including physical therapy, acupuncture, mindfulness and yoga, among others. However, these therapies have been found to have minimal to no benefit in pain and functional status in older adults [6, 7]. Medication management may involve use of opioids, non-steroidal anti-inflammatory drugs (NSAIDs), or other medications. Yet, due to age-related changes in pharmacokinetics and pharmacodynamics [8] and high rates of polypharmacy [9], national guidelines recommend limiting opioid prescriptions for older adults [10, 11]. Similarly, many nonopioid pain medications may be inappropriate for older adults given their potential for adverse effects, such as non-steroidal anti-inflammatory drugs (NSAIDs) and COX-2 selective inhibitor-related gastrointestinal toxicity, cardiovascular events, and interference with renal function [10], and tricyclic antidepressant-related anticholinergic effects causing an increased risk for confusion and falls [11].

Interventional pain management techniques such as lumbar epidural steroid injections (LESI), have fewer systemic side effects than pharmacologic interventions and may help reduce the need for pain medications in older adults with chronic LBP. Analysis of Medicare data from 2019 suggests that among older adults, epidural procedures comprise 38% of all interventional pain management techniques and that interlaminar LESI comprise 39% of those epidural procedures [12]. Current national and international guidelines for the treatment of chronic LBP rarely mention LESI [13–16], though they support the utilization of conservative therapies and pharmacological management [17]. Systematic reviews also present conflicting conclusions on the benefit of LESI [18–20], and no prior reviews have focused on LESI in the older adult population.

Given the significant impact of chronic LBP on pain, function, and quality of life in an aging population, greater evidence to guide care for older adults is necessary [21, 22]. We conducted this systematic review to characterize and evaluate the use and effectiveness of LESI amongst older adults with LBP as compared to usual conservative care, related to key outcomes such as pain, function and quality of life.

Methods

This systematic review adhered to Preferred Reporting Items for Systematic Reviews and Meta‑Analyses (PRISMA) guidelines [23]. Our search strategy was collaboratively developed with the guidance of a medical research librarian (L.H.). The search used keywords and medical subject headings representing low back pain and epidural use, such as “lumbar epidural steroid injection” AND “low back pain.” The databases searched were MEDLINE (Ovid Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations, Daily and Versions 1946 to October 2023), Embase (Ovid 1974–2023) and Cochrane Library. All searches were performed on April 17, 2023. Hand searching revealed additional terms and an updated search was performed on November 5, 2024. The study was registered on Prospero (ID # 422087).

Inclusion and exclusion criteria are presented in full in Table 1. In brief, studies were included if the mean age of the study population was 65 or older, or they included a subgroup analysis of patients over the age of 65. Studies also needed to mention conservative care in some form. Outcomes of interest were at least one measure of pain, functional outcome or quality of life.

Table 1.

PICOTS Question & Study Inclusion and Exclusion Criteria

PICOTS Question: For patients 65 years and older, how does the use of an epidural steroid injection as compared to usual conservative care influence pain, function, and quality of life. Population: Patients 65 or older Intervention: Epidural Steroid Injection of any approach Comparator: Usual conservative care Outcome: Any outcome related to pain, function or quality of life
Inclusion Criteria: Patients where the mean age of the group was 65 or older with low back pain who have received a lumbar epidural steroid injection OR paper includes a subgroup analysis of patients over the age of 65 Includes as least one measure of pain, functional outcome or quality of life Includes some mention of conservative care Published before 6/23/24	Exclusion Criteria: Articles not published in the English language Non- peer- reviewed publications Comparison to another injection therapy, including placebo or local anesthetic injections Comparison to surgery Injections not done under fluoroscopy Review articles Case reports/series with N<5

Data from full- text articles were abstracted into a pre-formatted table by one team member and checked by the other member. The template table included the following: first author, publication year, title, country, study design, utilization of conservative therapy, sample size, clinical indication for LESI, mean age, intervention type, and outcome(s) of interest. The Interventional Pain Management Techniques – Quality Appraisal of Reliability and Risk of Bias Assessment for Nonrandomized Studies (IPM-QRBNR) was utilized to appraise the quality of non- randomized studies [24]. Randomized studies were appraised using the Interventional Pain Management Techniques–Quality Appraisal of Reliability and Risk of Bias Assessment Tool (IPM–QRB) for randomized controlled trials [25]. Based on IPM–QRB and IPM-QRBNR criteria, studies were considered low quality if they scored less than 16, moderate quality of they scored from 16 to 31 and high-quality if they scored 32–48. Based on this criteria, if studies met inclusion criteria but scored less than 16, they were excluded. Due to the limited number of studies and their heterogeneity, we could not conduct a meta- analysis, and data were instead synthesized for patterns and salient findings. We present the data in a tabular format.

Results

The final searches retrieved a total of 2,657 references, which were pooled in EndNote™ (Clarivate Analytics, Philadelphia, PA) and de-duplicated to 2,260. This set was uploaded to Covidence© review software (Covidence, Melbourne, AU) where an additional 78 duplicates were found and removed. A total of 2,182 title and abstract records were reviewed by two study team members (AZ and CM) and conflicts were resolved through group discussion. All search strategies are available from the authors, and Fig. 1 documents the PRISMA flowchart. The Ovid Medline strategy is available in Supplemental Figure S1. 294 studies remained after title and abstract screening, and 12 studies met final inclusion criteria (Fig. 1) [26–37].

Fig. 1.

PRISMA Diagram

Among these 12 studies (Table 2), seven [26–28, 30, 31, 33, 35] were conducted in the United States, two [29, 34] in South Korea, and one [32, 36, 37] each in Nepal, Turkey and Japan. Studies were published between 2004 and 2023 with four [32, 34, 36, 37] studies published in or after 2020. Five studies [26, 31, 34, 36, 37] were retrospective or case series, and four [27, 28, 32, 35] studies were prospective. One [29] study was a randomized, active control trial, one [30] study was an uncontrolled single- cohort design and one [33] study was a randomized parallel- group trial. The included studies had cohorts ranging from 16 to 128 patients. Studies were inconsistent on reporting maximum and minimum ages of included patients, but all studies reported on mean age of patients. Nine studies [26–34] included patients where the mean age was ≥ 65 with only two [35, 37] studies specifically recruiting patients over the age of 65. One [36] study included patients where the mean age of all patients was < 65 but incorporated a report of results from a subgroup of patients over the age of 70. One [29] study compared two groups with one being adults ≥ 65. The primary aim of 11 of the included studies was clinical efficacy of LESI. One [32] study evaluated the clinical efficacy of LESI, but its primary aim was to assess the predictive value of a positive response to a transforaminal epidural steroid injection on overall surgical outcome.

Table 2.

Study characteristics of included studies

Paper ID	Study and Methods			Participants			Intervention			Outcomes
	Title	Country	Study Design	Conservative Therapy	Number of Patients and Clinical Indication for ESI	Mean Age (range or ±SD)	Type of ESI Performed and Injectate	Fluoroscopic Guidance	Follow Up Time after ESI	Pain Scale	Pain Results	Functional Status/Quality of Life Scales	Functional Status/Quality of Life Results	Adverse Events
Botwin 2002 [28]	Fluoroscopically Guided Lumbar Transforamational Epidural Steroid Injections in Degenerative Lumbar Stenosis	USA	Prospective Cohort Design	All patients received at least 6 wk of treatment with a combination of analgesics, anti-inflammatories, or physical therapy prior to intervention	34, 34 at 2 months, 28 at 12 months Patients were included if they had a history consistent with unilateral radicular pain for greater than 12 weeks.	77.4 (62–87)	Transforaminal epidural steroid injection Injectate: 2 mL 1% lidocaine, 12 mg of betamethasone	Yes	2 months and 12 months	Visual Analogue Scale	Mean pain scores decreased by over 4 points at 2 months and 12 months and was a statistically significant improvement at both time points.	Roalnd 5- point pain scale, Standing and walking tolerance	There was a statistically significant improvement in standing and walking tolerance and a statistically significant decrease in Roland 5-point pain rating at 12 months.	No adverse events observed.
Barre 2004 [26]	Fluroscopically guided caudal epidural steroid injections for lumbar spinal stenosis: A retrospective evaluation of long term efficacy	USA	Retrospective Chart Review and follow-up study	All patients had failed conservative treatment including PT and NSAIDS prior to intervention. All patients were concurrently enrolled in a 4–6 week physical therapy program.	80 Patients were included if they had documented magnetic resonance imaging (MRI) findings of lumbar central spinal stenosis, lateral stenosis or a combined stenotic picture with a clinical history consistent with back or bilateral leg pain for greater than three months.	69±9.8 (40–91)	Caudal epidural steroid injection Injectate: 80 mg of triamcinolone and 8 cc of 0.5% lidocaine (perservative free)	Yes	Followed up at 1 week, up to 3 injections were scheduled at successive two week intervals if partial relief	Visual Numeric Scale	50% of patients had a visual numeric scale improvement of 2 points or more, 35% of patients had at least a 50% improvement.	Roland-Morris Disablity Questionnaire, North American Spine Society Patient Satisfaction Index, and subsequent surgery	36% of patients reported an RMDQ improvement of 2 points or great. 42% of patients reported that the procedure fully met their expectations. 15% of patients required subsequent surgery	No adverse events observed.
Botwin 2007 [27]	Fluoroscopically Guided Caudal Epidural Steroid Injections in Degenerative Lumbar Spinal Stenosis	USA	Prospective cohort	All patients did not improve with 6 weeks of analgesics, anti-inflammatories, and physical therapy prior to intervention	34 Patients were included if they had symptoms of lower back pain and bilateral radicular pain. Patients were excluded with a pain duration of less than 12 weeks.	74.6 (65–89)	Caudal epidural steroid injection Injectate: Total volume 14 ml consisting of 10 ml 0.5% lidocaine and 80 mg triamcinolone	Yes	6 weeks, 6 months, 12 months	Visual Analogue Scale	Patients had a 65%, 62% and 54% improvement in pain score as compared to baseline at 6 weeks, 6 months and 12 months respectively which was statistically significant.	Standing Tolerance, Walking Tolerance, Oswestry Disability Index	Statistically significant improvement was seen in standing tolerance, walking tolerance and Oswestry low back pain disability index.	No adverse events observed.
Cosgrove 2011 [30]	Epidural Steroid Injections in the Treatment of Lumbar Spinal Stenosis Efficacy and Predictabilty of Successful Response	USA	Uncontrolled single-cohort design	All patients had failed routine treatment with oral anti-inflammatory medications and PT (at least 3 weeks) prior to intervention.	16 Patients were included if they presented with symptoms of back and leg pain greater than one month that were aggravated by walking with MRI confirmation of lumbar spinal stenosis.	68.5 (48–82)	Interlaminar epidural steroid injection Injectate: Unknown	Yes	4–6 weeks after the last injection	None	None	Swiss Spinal Stenosis Questionnaire and the 6 min Walk Test	Statistically significant improvement in both SSSQ and SMWT	One subject had a presumptive postdural puncture headache and received an epidural blood patch.
Chun 2015 [29]	Effect of High-Volume Injectate in Lumbar Transforaminal Epidural Steroid Injections: A Randomized, Active Control Trial	South Korea	Prospective, randomized, active control trial	All patients received conservative treatment including medication (such as pregabalin, nonopioid) and physical therapy prior to the procedure and had not shown any significant improvement in radicular pain.	62 Patients were included if they had lumbar radicular pain with a diagnosis of herniated nucleus pulposus or spinal stenosis after physical, neurologic, and radiologic examinations for greater than 6 weeks.	64±11 (DL8) 68±11 (DL3)	Transforaminal epidural steroid injection Injectate: 4 mg of dexamethasone with either a total of 3 ml injectate or 8 ml injectate. 0.33% lidocaine was used to make up the volume.	Yes	4 weeks after Tf-ESI	Visual Analogue Scale (0–100)	Both groups demonstrated clinically and statistically significant improvement in radicular pain according to the VAS	Roland-Morris Disability Questionnaire	Both groups demonstrated clinically and statistically significant improvement in the functional status according to the RMDQ	One patient in each group (n=2) reported increased pain after injection and underwent underwent epidural adhesiolysis and neuroplasty after the study ended.
Farooque 2017 [31]	Effectiveness of Bilateral Transforaminal Epidural Steroid Injections in Degenerative Lumbar Spinal Stenosis Patients With Neurogenic Claudication: A Case Series	USA	Clinical Case Series	Over-the-counter and prescription pain medication usage varied. At baseline, 7 of 26 enrolled patients had evidence of prescription pain medication use.	26 Patients were included if they had a history of degenerative lumbar spinal stenosis and a history of subacute or chronic neurogenic claudication with imaging demonstrating at least moderate central canal stenosis.	74.7 (57.7–88.1.7.1) Median	Bilateral transforaminal epidural steroid injections Injectate: 10 mg dexamethasone and an equal volume of 2% Xylocaine (preservative free) per side	Yes	1, 3, and 6 months after injection	Numeric pain scale	Statistically significant changes in the proportion of patients reporting severe pain. 30% of patients reported a reduction of pain score of at least 50% at 1 month, 53% at 3 months and 44% at 6 months.	Swiss Spinal Stenosis Questionnaire	There was a statistically significant decrease in patients reporting severe pain and severe weakness. >70% of patients were satistifed with treatment at 1, 3, and 6 months.	No adverse events observed.
Hammerich 2019 [33]	Effectiveness of Physical Therapy Combined With Epidural Steroid Injection for Individuals With Lumbar Spinal Stenosis: A Randomized Parallel-Group Trial	USA	Randomized Parrallel- Group Trial	All patients received The Back Book. The physical therapy group had multimodal PT	54 Patients were included if they had a chief complaint of pain in the low back, buttocks and/or lower extremities, symptoms consistent with neurogenic claudication and with MRI findings consistent with lateral foraminal and/or central lumbar spinal stenosis.	Overall: 67.2±9.7	Interlaminar epidural steroid injection or transforaminal epidural steroid inejction Injectate: 1.5 mL of steroid	Yes	10 weeks, 6 months, 1 year	Numeric Pain Rating Scale	All participants had significantly reduced pain at 1 year. There was no difference between groups.	Oswestry Disability Index, RAND 36 Item Health Survey, Global Rating of Change	All participants in the study had significantly reduced disability at 10 weeks, and at 1 year as well as statistically significant improvement in quality of life. There was no difference between groups.	3 participants reported adverse events: 2 reported mild allergic reaction and 1 reported increased pain symptoms.
Przkora 2019 [35]	Funcitonal Improvements Utilizing the Short Physical Performance Battery (SPPB) in the Elderly After Epidural Steorid Injection	USA	Prospective Cohort Design	Medication	16 Patients were included if they were older than 65 and had symptomatic back and/or leg pain secondary to lumbar stenosis for at least four weeks. Patients could self-select to undergo an interlaminar lumbar ESI or to enroll in medication management with gabapentin and tramadol, the doses of which were titrated on an individual basis according to side effects and dose response	Injection Group: 75.0±5.0 Medication Group: 76.6±4.7	Interlaminar epidural steroid injection Injectate:10 mg dexamethasone	Yes	1 month	Numeric Pain Score	Statistically significant decrease in mean pain score in the LESI group but not medication group	Short Physical Performance Battery	There were statistically significant improvements from baseline to 1-month follow-up in the injection group for total SPPB scores. There was no difference in the medication management group	No adverse events observed.
Shrestha 2020 [36]	Outcome of transforaminal epidural steroid injection for lumbar radiculopathy: initial three-year experience at Upendra Devkota Memorial-National Institute of Neurological and Allied Sciences, Nepal	Nepal	Retrospective Case Series	All patients did not respond to standard management prior to receiving an intervention.	35 Patients were included if they had chronic radicular pain defined as greater than one month.	55.8 (32–80)+ +Subgroup Analysis: 10 patients older than the age of 70	Transforaminal epidural steroid injection Injectate: 1 mL 0.5% bupivicaine and 40 mg of depomedrol	Yes	3 months	Numeric Rating Scale	75.3% (26/35) of patients had more than 50% of pain relief compared to baseline at 3 months. 9 out of 10 patients older than the age of 70 had more than 50% pain relief as compared to baseline at 3 months	None	None	No adverse events observed.
Tasdogan 2020 [37]	Outcome Measurements for Pain Relief in Elderly Patients with Spinal Stenosis Undergoing Epidural Steroid Injection: Is Conservative Approach an Option?	Turkey	Retrospective Study	All patients had no response to non-steroidal anti-inflammatory drugs and neuropathic pain medications for at least six months.	44 Patients were included if they were older than 65, and had symptoms of low back pain with or without radiculopathy for at least six months.	78.50± 10.61	Interlaminar epidural steroid injection, Transforaminal epidural steroid injection Injectate: Uknown volume consisting of unknown amount of dexamethasone diluted in 0.9% normal saline	Yes	2 weeks, 1 month, 3 months	Numeric Rating Scale	Mean numeric rating scale score went from 7.82 at baseline to 3.14 at 3 months* *Interpreted through figure	Oswestry Disability Index, Istanbul Low Back Pain Disability Index	Improvement was noted in both the Oswestry Disability Index and Istanbul Low Back Pain Disability Index *Interpreted through figure	No adverse events observed.
Fujiwara 2023 [32]	Does a Positive Response to Transforaminal Epidural Steroid Injection Identify Patients Who Can Avoid Surgery for Two Years?	Japan	Prospective observational study	Orally administered drugs including NSAIDs, tramadol, antiepileptic drugs, and antidepressants administered before the start of treatment were assessed	76 Patients were included if they had lower extremity pain with or without low back pain due to lumbar spinal canal stenosis, herniated disc or lumbar spondylolisthesis with consistent imaging findings.	Positive Response: 73.0 ± 11 No Response: 72.0 ± 10.0	Transforaminal epidural steroid injection (unilateral or bilateral) Injectate: 2mL of 0.5% mepivicaine with 1.65 mg of dexamethasone	Yes	1 Month post injection for pain score, followed up to two years to see if patients underwent surgery	Numerical Rating Scale	36 of 76 patients had a positive response to injection therapy.	EuroQOL 5 Dimension 5-Level, Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale	Equation 5D5L after one month was statistically significantly higher in the positive response group.	No adverse events observed.
Kim 2023 [34]	Changes in Pain Scores and Walking Distance after Transforaminal Epidural Steroid Injections in Patients with Lumbar Foraminal Spinal Stenosis	South Korea	Retrospective Study	Patients also received nonsteroidal anti- inflammatory drugs, muscle relaxants, neuromodulators (pregabalin and/or gabapentin), and limaprost	128 Patients were included if they had a greater than three month history of symptomatic lumbar radicular pain, walking impairment due to lumbar foraminal stenosis with positive provocation factors, and moderate or severe foraminal stenosis in the lumbar spine MRI within 6 months before intervention	Moderate stenosis group: 67.4±8.9 Severe stenosis group: 68.2±8.8	Transforaminal epidural steroid injection Injectate: 5 mg dexamethasone, 2 mL saline, 2 mL lidocaine hydrochloride 1%	Yes	4 weeks after Tf-ESI	Roland 5- point patient satisfaction scale (0–5 representing degrees of pain. Scale rating of 0–2 were considered successful responders with improvement)	59% of patients in the moderate group reported a reduction in pain of ≥50% and 33% of patients in the severe group reported a reduction in pain of ≥50%	Walking capacity	There was a statistically significant improvement in walking distance before and after LESI. The proportion of patients who experienced at least 30% improvement in walking distance in the moderate and severe groups was 27% and 22% respectively	No adverse events observed.

Conservative therapy

As shown in Table 2, in five [26–30] studies, patients trialed both medication and physical therapy prior to LESI where lack of response from these therapies prompted an intervention. In one [37] study, patients trialed medication management without benefit prior to LESI. In one [36] study, undescribed conservative therapy was trialed without benefit prior to LESI. Four studies [31, 32, 34, 35] included concurrent use of physical therapy and/or medication management with LESI, with one [35] specifically comparing LESI to medication management. A final study [33] compared LESI alone to LESI with physical therapy.

Intervention

LESI was performed under fluoroscopy in all studies. Two [33, 37] studies included delivery of LESI injections by multiple routes (caudal, transforaminal or interlaminar). Two [26, 27] performed caudal epidural steroid injections only, six [28, 29, 31, 32, 34, 36] studies performed transforaminal epidural steroid injections only and two [30, 35] studies performed interlaminar epidural steroid injections only. Studies used different steroid types, dosages, and different volumes of injectate. Three studies did not identify the dose of steroid or volume of injectate [30, 33, 37]. Steroid injectates used included dexamethasone, triamcinolone and betamethasone typically administered with a local anesthetic such as lidocaine, bupivacaine or mepivacaine at various concentrations with or without normal saline.

Patient indications and pain duration

Indications for LESI included a clinical history of LBP, radicular pain and symptoms of neurogenic claudication. Seven [26, 29–34] studies required an imaging diagnosis consistent with diagnoses of interest such as lumbar central spinal canal stenosis, lateral stenosis, herniated disc, or lumbar spondylolisthesis. Pain duration was listed as an inclusion or exclusion criteria in 9 studies, with values ranging from 4 weeks to 6 months [26–30, 34–37]. One study did not identify pain duration but included patients with “subacute” or “chronic” pain [31]. Two studies did not identify a specific pain duration in their exclusion or inclusion criteria but listed a symptom duration in their results [32, 33].

Follow- up

Follow- up after LESI differed in all studies with seven [26–28, 31–33, 37] studies with follow-up performed at multiple time points, The most common follow up time was at least one follow-up 4 weeks after LESI which was seen in six [29, 30, 32, 34, 35, 37] studies. The range of follow up encompassed by all 12 studies in Table 2 was 1 week after injection to 12 months after injection.

Pain outcomes

As shown in Table 2, 11 [26–29, 31–37] of the included studies assessed pain reduction after LESI. Six [31–33, 35–37] studies utilized some form of numeric rating scale (NRS), three [27–29] studies used the visual analogue scale (VAS), and one [26] study used the visual numeric scale (VAN).

Six studies [27–29, 31, 33, 35] explicitly reported statistically significant (p < 0.05) reductions in pain from baseline. Of these six studies, four [27, 28, 31, 33] included follow ups at different time points while the remaining two assessed a single time point after injection. In those studies which assessed multiple time points, both studies published by Botwin et al. and the study published by Hammerich et al. noted that there were statistically significant improvements in pain scores through all follow up time points [27, 28, 33]. Farooque et al. noted statistically significant decreases in the proportion of patients reporting severe pain at 1, 3, and 6 months [31]. Przorka et al.. reported statistically significant improvements in pain for the LESI group, but not for the medication management group [35]. Additionally, Hammerich et al.. did not note any difference in pain reduction when comparing the LESI to the LESI and physical therapy group with both groups demonstrating statistically significant decreases in pain from baseline [33].

The remaining five [26, 32, 34, 36, 37] studies did not demonstrate a statistically significant reduction in pain but still demonstrated a reduction in pain post LESI. Notably, one study performed a subgroup analysis on older adults which showed that 9 out of 10 patients older than the age of 70 had more than 50% pain relief as compared to baseline at 3 months [36].

Functional outcome measures

As shown in Table 2, 11[26–35, 37] studies included some measure of functional status or quality of life, with measures including the Oswestry Disability Index, Swiss Spinal Stenosis Questionnaire, Roland- Morries Disability Questionnaire (RMDQ), walking capacity and/or standing capacity.

Nine [27–35] studies concluded that their results represented a statistically significant improvement in functional status and/or quality of life. Of the studies representing multiple time points, functional status improvements were seen at all time points. Additionally, Hammerich et al.. did not note any difference in quality of life improvement when comparing the LESI to the LESI and physical therapy group with both groups demonstrating statistically significant improvements in quality of life from baseline [33].

Of the remaining two studies, while results for Tasdogan et al. required interpretation through a figure, the text did note that there were significant improvements in functional status in their cohort [37]. Barre et al. reported 36% of patients showed an RMDQ improvement of 2 points or greater with 42% of patients reporting that the procedure fully met their expectations [26].

Adverse events

All 12 studies included a statement regarding complications or adverse events though no studies fully defined what major or minor complications from LESI would entail. Nine of the 12 studies reported no adverse events. Three [26, 32, 36] of those nine studies defined potential complications such as spinal cord infarction, nerve injury, epidural hematoma, epidural abscess, arterial injection, infection or dural tear which did not occur. One study reported that one patient had a presumptive post dural puncture headache and received an epidural blood patch [30]. Two [29, 33] studies reported increased pain after epidural steroid injection. One [33] study reported two patients with mild allergic reactions.

Quality appraisal

The results of our risk of bias/quality assessment are shown in Supplemental Tables 1 and 2. Two [29, 33] studies utilized the IPM-QRB while the other 10 utilized the IPM-QRBNR. The 12 included studies scored between 18 and 31 with scores not reaching their full allocation in most assessed categories. Full allocation of points was not achieved by any study for sample size, with zero points allocated to eight [26–31, 36, 37] studies given small sample sizes as discussed prior. Another low scoring category was study design given many studies were retrospective or case series as previously discussed. All studies received full point allocation for utilizing fluoroscopic guidance and most studies scored well for undergoing a trial of conservative therapy as previously discussed.

Discussion

This systematic review provides initial evidence that the use of LESI for chronic LBP due to a wide range of pathologies, is potentially associated with improvement in pain and functional status with potential benefits reaching up to 12 months with limited adverse effects. Twelve studies were identified, all deemed of moderate quality based on IPM- QBR and IPM-QRBNR criteria [24] meaning they were of a high enough quality to be included in this review. Collectively, these studies also suggest that improvements in pain and quality of life after LESI are not impacted by either previous or concurrent utilization of medications and physical therapy, and that LESI may be more beneficial than medication management.

Our findings build upon previous systematic reviews conducted among general adult samples and extends them to older adults [38, 39]. Support for LESI is mixed in the general adult literature with a recent Cochrane review published by Oliveira et al. concluding limited support for the use of LESI for lumbosacral radicular pain [19]. However, a comparative systematic review was performed in response showing strong evidence for LESI at 3 months with moderate evidence at 6 and 12 months and suggest that differing findings in the Cochrane review were due to lack of clinical applicability, potential systematic bias and wrong estimation of effect [18]. In contrast to the Cochrane review, our study results address potential lack of clinical applicability through multiple means. First, we included only papers that utilized fluoroscopic guidance LESI, currently the standard of care. Secondly, due to the evidence that both local anesthetic and saline are not true placebo controls, we did not include studies that used these as a comparator arm [40–44]. Finally, we did not include any studies that compared LESI to anything other than usual care and specifically excluded studies comparing LESI to surgery as well as any studies utilizing comparators other than steroids, local anesthetics or saline in the epidural space.

Chronic LBP in older adults is often multifactorial. While some LBP etiologies, such as spinal stenosis or disc herniation, can lead to pain in both older and younger adults, older adults are more likely to suffer from intervertebral disc degeneration leading to greater disc space narrowing that is significantly associated with greater LBP [45]. The cause of this progressive degeneration in older adults has been postulated to be secondary to microRNAs and altered autophagy processes with increased levels of inflammatory mediators [46]. Older adults are also more likely to suffer from severe facet joint degeneration in the lumbar region which is associated with significantly increased chronic LBP [47]. In the studies included in our review, the indications for LESI were varied and several studies recruited patients with clinically symptomatic low back pain and/or leg pain alone. A large prospective study by Curatolo et al. comparing pain and function in older adults who did and did not receive LESI suggested that 13.2% of patients receiving LESI did not have radicular pain [48]. The results of our review are in contrast to current recommendations by the American Academy of Family Physicians, which recommends LESI only for radicular pain [49].

Major research gaps and future directions

Several major gaps in research knowledge and recommendations for future work are worth highlighting. First, as per Table 2, only two [29, 33] of the twelve studies included in this review utilized a randomized controlled design. The lack of rigorous experimental design increases the risk of bias and confounding variables, making it difficult to distinguish whether improvements in outcomes are directly attributable to LESI or influenced by other factors (e.g., concurrent treatments, individual patient characteristics). Additionally, sample sizes in these included studies were small, which could potentially lead to overestimation of effect size. We recommend further large scale randomized controlled trials to be conducted – including those that compare LESI to evidence-based pain treatments, rather than conservative care alone – to improve our understanding of the efficacy of LESI in older adults.

Second, there is a paucity of information regarding how older adults respond to LESI. There are unique aspects of the chronic pain state in older adults. A systematic review found that older adults have statistically significant differences in pain perception as compared to younger adults and that older adults may be more sensitive to mechanically evoked pain [50]. When transcutaneous electrical nerve stimulation (TENS) was used as a modality to reduce chronic LBP, older adults required a higher amplitude to achieve a response similar to those in younger adults [51]. Additionally, aging is associated with significant health- related complexity and geriatric syndromes such as frailty which is associated with decreased resiliency, poor stress responses and worsened health outcomes [52]. In fact, frailty and LBP are interrelated with frailty significantly more prevalent among older adults with LBP and frailty worsening LBP pain severity [53, 54]. However, none of the included studies included any information on frailty status of included patients. Notably, one of the included studies demonstrated that functional status improvements may continue despite plateaus in pain scores [28]. As such, despite mixed support for the utilization of interventional pain therapies in mixed- age cohorts, further investigation of the utilization of interventional pain therapies in older adults, especially regarding improvements in quality of life and function, is vital for improved patient selection and management of chronic LBP.

Third, given the nascent nature of this work, we elected to include studies that comprised patients with a mean age of ≥ 65. However, only two of the included studies were comprised solely of patients over the age of 65 [35, 37], whereas the remaining studies also included patients under the age of 65. Again, older adults are a unique population that requires specific empirical attention, and additional work is needed to clarify the efficacy of LESI among samples that are exclusively comprised of those aged ≥ 65 years. Moreover, future studies should also examine whether age moderates the efficacy of LESI among older adults.

Fourth, future research on the efficacy of LESI in older adults should explicitly incorporate the 5 M’s of geriatric care (i.e., mind, mobility, medications, what matters most, multicomplexity). For example, despite evidence that chronic LBP is associated with cognitive dysfunction [55], none of the studies included administered assessments of cognitive dysfunction. Future work should investigate how these elements affect LESI response and safety. In addition, given that 80% of people over the age of 65 have ≥ 2 chronic conditions [56] and over one-third are prescribed ≥ 5 medications [57] additional studies are needed to examine the efficacy of LESI in older adults with multimorbidity and determine whether LESI reduces polypharmacy and reliance on opioid pain medication and in older adults.

Finally, there was significant heterogeneity in types of injections, including variations in both the LESI approach and the composition of the injectate. In a 2025 survey administered by the International Pain and Spine Intervention Society (IPSIS) to members of their society assessed physician preferences and procedural selection using six hypothetical clinical scenarios, survey participants chose the transforaminal approach for LESI and dexamethasone as a steroid choice most consistently [58]. While there have been prior studies investigating differences in outcomes between LESI approaches (interlaminar vs. transforaminal vs. caudal), results have been mixed, with some studies finding greater efficacy through the transforaminal route while other studies finding nothing at all [59]. The utilization of dexamethasone, a non- particular steroid, does align with current safety guidelines as there is reduced risk of spinal cord infarction and embolic events with a non- particulate agent [60]. Notably, there have been no documented reports of spinal cord infarction with particulate- containing medications in inter-laminar ESI specifically. Despite existing literature, it remains that differences in approach and injectate limit our ability to determine the effectiveness and safety of LESI in older adults, as different formulations and techniques may potentially produce distinct therapeutic effects and side effect profiles in this population. Standardization of injection protocols across studies is critical for clarifying clinical recommendations for older adults.

Conclusions

This systematic review is the first to address the effectiveness of LESI in managing chronic LBP in older adults. Our findings suggest that LESI is likely to be beneficial in older adults with chronic LBP with or without leg pain. LESI may be associated with improved pain and quality of life in older adults with improvements seen up to one year after intervention and associated with minimal adverse events. These results provide preliminary support that LESI warrants further consideration as a clinical tool for managing chronic LBP in older adults. Nonetheless, further research is still needed, especially randomized placebo-controlled trials, to provide further evidence for effective clinical care for our aging population.

Supplementary Information

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Author contributions

All authors meet the criteria for authorship:1) Substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data: All Authors2) Drafting the article or revising it critically for important intellectual content: All Authors3) Final approval of the version to be published: All Authors4) Agree to be accountable for all aspects of the work: All Authors.

Funding

No funds, grants, or other support was received.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not Applicable.

Consent for publication

Not Applicable.

Competing interests

The authors declare that they have no competing interests to declare that are relevant to the content of this article.