Table 2.
Epidural steroid injections for canal stenosis studies.
| Authors, Year | Study Design | Study Protocol | Outcome Measures | Summary of Findings | |
|---|---|---|---|---|---|
| Intervention | Control | ||||
| Sabbaghan S et al., 2020 [53] |
Retrospective, single arm | Bupivacaine hydrochloride 0.5% (3 mL) + triamcinolone acetonide 80 mg (2 mL) | Baseline | VAS for lumbar pain, VAS for lower limb pain and ODI | Improvement in pain (both lumbar than lower limb) and ability |
| Park CH et al., 2014 [54] |
Prospective, single arm | 2 mg preservative-free ropivacaine + 1500 units hyaluronidase + 40 mg triamcinolone acetonide | Baseline | 5-point patient satisfaction scale at 2 and 8 weeks post-treatment | The ESI seems to provide effective short-term pain relief from LSS. The grade of LSS appears to have no effect on the degree of pain relief |
| Cosgrove JL et al., 2011 [55] |
Prospective, single arm | Steroids, not specified | Baseline | Self-reported activity level and measured walking ability using the SSSQ and SMWT. The results were correlated through demographic data, magnetic resonance imaging (MRI) characteristics and electrodiagnostic results | Significant improvement as measured by changes in SMWT and SSSQ. Relative youth and female sex are associated with a more favorable response |
| Farooque M et al., 2017 [56] |
Case series | 10 mg dexamethasone (1 mL) + an equal volume of 2% preservative-free lidocaine on each side (transforaminal) | Baseline | Pain score and Swiss Spinal Stenosis score at baseline, 1, 3 and 6 months | Reduction of ≥ 50% in numeric pain scale score in 30% of participants at 1 month, 53% at 3 months and 44% at 6 months. Swiss Spinal Stenosis subscale scores indicated a significant reduction in the proportion of participants reporting the presence of severe pain in the back, buttocks and legs during FU compared to baseline (p < 0.05) |
| Hammerich A et al., 2019 [57] |
Randomized parallel-group trial | 1.5 mL steroid (not specified) at each site injected. Reassess at 3–4 and 6–8 weeks for potential second and third injections | 1.5 mL of steroid (not specified) at each site injected. Reassess at 3–4 and 6–8 weeks for potential second and third injections + physical therapy (PT) | Disability, pain, quality of life and global rating of change were collected at 10 weeks, 6 months and 1 year, and then analyzed using linear mixed model analysis | The ESI plus PT was not superior to ESI alone for reducing disability in individuals with LSS. |
| Brown LL et al., 2012 [58] |
Randomized controlled trial | 80 mg triamcinolone acetate (40 mg for diabetic patients) mixed with 6 mL preservative-free saline injected in divided doses at the treated levels | MILD procedure: a minimally invasive posterior lumbar decompression performed fluoroscopically through a small 6-gauge port | Visual Analog Scale, Oswestry Disability Index and Zurich Claudication Questionnaire (ZCQ) for patient satisfaction | MILD procedure was superior compared to ESI in pain reduction and the improvement of functional mobility |
| Kim HJ et al., 2013 [62] |
Prospective, single arm | 40 mg (1 mL) triamcinolone acetonide suspension + 1 mL bupivacaine hydrochloride 0.5% + 1 mL of saline | Baseline | Pain sensitivity questionnaire (PSQ), Oswestry Disability Index (ODI), and Visual Analog Scale (VAS) for back and leg pain | Significant decreases in VAS for back/leg pain and ODI 2 months after ESI. Individual pain sensitivity does not influence the outcomes of ESI treatment in patients with LSS |
| Campbell MJ et al., 2007 [60] |
Controlled clinical trial | Steroids (not specified) once a week for 3 weeks | Baseline | Spinal canal dimension, resolution of symptoms after ESI, necessity of surgery after ESI | Spinal canal dimension is not predictive of the success or failure of ESIs in patients with LSS |
| Milburn J et al., 2014 [63] |
Randomized controlled trial | 2 mL 40 mg/mL methylprednisolone + 2 mL bupivacaine 0.25% + 2 mL normal saline at the most stenotic level | 2 mL 40 mg/mL methylprednisolone + 2 mL bupivacaine 0.25% + 2 mL normal saline at 2 intervertebral levels cephalad of the level of maximal stenosis | Analog pain scale from 0 to 10 during ambulation and at rest, Roland–Morris Disability Questionnaire (RDQ) at baseline, immediately after ESI and at 1, 4, and 12 weeks post-injection | Symptom improvement is optimized when the ESI is performed at the intervertebral level of maximal stenosis |
| Bajpai S et al., 2020 [64] |
Randomized controlled trial | 5 mL bupivacaine (0.25%) + 2 mL methylprednisolone acetate (40 mg/mL) + 1 mL normal saline at maximal stenotic intervertebral level | 5 mL bupivacaine (0.25%) + 2 mL methylprednisolone acetate (40 mg/mL) + 1 mL normal saline 2 intervertebral levels cephalad to the level of maximal stenosis | Numeric Pain Rating Scale (NPRS) and Oswestry Disability Index (ODI) at 2, 6 and 12 weeks after the intervention | Pain relief improvement is optimized when the ESI is performed at the maximum stenotic intervertebral level |
| Koc Z et al., 2009 [59] |
Randomized controlled trial | Group 1: inpatient physical therapy program for 2 weeks Group 2: 60 mg triamcinolone acetonide + 15 mg 0.5% bupivacaine hydrochloride + 5.5 mL saline |
Group 3: no intervention | Pain severity by Visual Analog Scale (VAS), Finger Floor Distance (FFD) (cm), Treadmill Walk Test, Sit-to-Stand Test (Seconds), Weight-Carrying (WC) Test (Seconds) | Both ESI and physical therapy groups demonstrated an improvement in symptoms and in outcomes measured without any significant differences |
| Manchikanti L et al., 2015 [65] |
Randomized controlled trial | Local anesthetic (lidocaine 0.5%) 5 mL mixed + 6 mg betamethasone (1 mL) | 6 mL local anesthetic (lidocaine 0.5%) | Numeric Pain Rating Rcale (NPRS) and Oswestry Disability Index (ODI) at 3, 6, 12, 18 and 24 months post-treatment | Epidural injections of local anesthetic with or without steroids provide relief in a significant proportion of patients with LSS |
| Shamov T et al., 2020 [61] |
Prospective, two arms | Group 1: 10 mg dexamethasone in 3 cc 0.25% bupivacaine for patients with discogenic sciatica Group2: 10 mg dexamethasone in 3 cc 0.25% bupivacaine for patients with LSS |
Pain intensity was assessed by VAS at baseline and on days 1, 15 and 30 after intervention | ESIs are more effective in patients with discogenic sciatica than in single level LSS. In multiple level LSS, results are disappointing | |
| Friedly JL et al., 2014 [66] |
Randomized controlled trial | 1 to 3 mL 0.25% to 1% lidocaine followed by 1 to 3 mL triamcinolone (60 to 120 mg), betamethasone (6 to 12 mg), dexamethasone (8 to 10 mg) or methylprednisolone (60 to 120 mg) | 1 to 3 mL 0.25% to 1% lidocaine alone | Roland–Morris Disability Questionnaire (RDQ) and the rating of leg pain intensity (on a scale from 0 to 10) at 6 weeks after injection | Epidural injections of glucocorticoids plus lidocaine offered minimal or no short-term benefits compared to epidural injections of lidocaine alone |
| Makris UE et al., 2017 [66] |
Subsequent analysis of a randomized controlled trial (Friedly JL et al., 2014 [58]) |
1 to 3 mL 0.25% to 1% lidocaine followed by 1 to 3 mL triamcinolone (60 to 120 mg), betamethasone (6 to 12 mg), dexamethasone (8 to 10 mg) or methylprednisolone (60 to 120 mg) | 1 to 3 mL 0.25% to 1% lidocaine alone | RDQ (Roland–Morris Disability Questionnaire), Sickness Impact Profile (SIP) weights assigned to the RDQ items and patient-prioritized RDQ items at 6 weeks after injection | No significant difference between groups for the RDQ or patient-prioritized RDQ, and while the difference between groups for RDQ using SIP weights was statistically significant, this was not clinically important |
| Tomkins-Lane CC et al., 2012 [68] |
Prospective, single arm | Steroids, not specified | Baseline | Total activity (performance) measured over 7 days and maximum continuous activity (capacity), walking capacity was also assessed with the Self-Paced Walking Test and subjects completed the ODI, SSSQ, Medical Outcomes Study 36-Item Short-Form Health Survey, Visual Analog Pain scales and body diagrams | At 1 week postinjection, 58.8% of the subjects demonstrated increased total activity and 53% had increased maximum continuous activity, although neither change was statistically significant. Patients perceived improvements in symptoms, but these were not reflected in significant changes in performance or capacity |
| Rivest C et al., 1998 [69] |
Prospective, two arms | Group 1: 3 mL 0.5% lidocaine and 3 mL methylprednisolone acetate, followed by 3 mL saline for patients with LSS Group 2: 3 mL 0.5% lidocaine and 3 mL methylprednisolone acetate, followed by 3 mL saline for patients with discogenic sciatica |
Pain was assessed at baseline and 2 weeks following a single ESI using a Visual Analog Scale | LSS patients have worse responses to ESIs than herniated disk patients | |
| Fukusaki M et al., 1998 [70] |
Randomized controlled trial | Group 3: 8 mL 1% mepivacaine and 40 mg methylprednisolone | Group 1: 8 mL saline Group 2: 8 mL 1% mepivacaine |
Evaluation of improvement on pseudo-claudication associated with LSS as follows: excellent effect, > 100 m in walking distance; good effect, 20–100 m in walking distance; poor effect, < 20 m in walking distance | ESIs have no beneficial effects on walking ability associated with LSS compared to epidural injections with a LA alone |
ESI = epidural steroid injection; LSS = lumbar spinal stenosis; LA = local anesthetic; FU = follow-up; VAS = Visual Analog Scale; ODI = Oswestry Disability Index; SSSQ = Swiss Spinal Stenosis Questionnaire; SMWT = 6-Minute Walk Test; MRI = magnetic resonance imaging; PT = physical therapy; MILD = minimally invasive lumbar decompression; ZCQ = Zurich Claudication Questionnaire; PSQ = Pain Sensitivity Questionnaire; FFD = Finger Floor Distance; SIP = Sickness Impact Profile.