Guidelines for the proper use of epidural steroid injections for the chronic pain patient

The use of epidural steroids has been a cornerstone of interventional pain medicine as it has evolved as a specialty over the past few decades. These injections, which have been documented in the literature for more than 50 years, have been used for both radicular and axial pain throughout the neuroaxis. Studies have been performed that both support and distract from the evidence for these interventions. Many of the studies that have shown little or no support for the therapies have been flawed, by poor methodologies, lack of fluoroscopic guidance, and use of proceduralists with minimal training. Some clinicians have used these injections in excessive numbers in inappropriate patients. It is the goal of this paper to give guidelines for the proper use of this important therapy. Recommendations have been made on the frequency, route of administration, use of fluoroscopy, and type and dose of steroid but there does not currently exist a specific set of guidelines to address these issues. An extensive review of the available literature was performed, and evidence-based guidelines are established for the first time in an attempt to provide the interventional pain physician with specific guidelines concerning the administration of epidural steroids in patients with axial and radicular pain of spinal origin.