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. 2025 Mar 11;104(5):e213361.
doi: 10.1212/WNL.0000000000213361. Epub 2025 Feb 12.

Epidural Steroids for Cervical and Lumbar Radicular Pain and Spinal Stenosis Systematic Review Summary: Report of the AAN Guidelines Subcommittee

Carmel Armon  1 , Pushpa Narayanaswami  2 , Sonja Potrebic  3 , Gary Gronseth  4 , Misha-Miroslav Bačkonja  5 , Viet L Cai  6 , James Dorman  7 , Christopher Gilligan  8 , Scott A Heller  9 , Heather M Silsbee  10 , Don B Smith  11
Affiliations

Epidural Steroids for Cervical and Lumbar Radicular Pain and Spinal Stenosis Systematic Review Summary: Report of the AAN Guidelines Subcommittee

Carmel Armon et al. Neurology. .

Abstract

Background and objectives: This review systematically evaluates and incorporates evidence for the use of epidural steroid injections (ESIs) in cervical and lumbar spinal stenosis and radiculopathies, assessing short-term (≤3 months) and long-term (≥6 months) improvements in pain and disability.

Methods: We searched databases for randomized controlled trials (RCTs) on the efficacy of ESIs published between January 2005 and January 2021. Data analysis was performed by American Academy of Neurology methodologists. A panel of ESI experts was engaged to interpret the evidence in a clinical context. Owing to the great variability in efficacy measures used in the articles, we report differences based on any measure of success: the success rate difference (SRD).

Results: Ninety RCTs met inclusion criteria. In cervical and lumbar radiculopathies, ESIs probably reduce short-term pain (SRD -24.0%, 95% CI -34.9 to -12.6, number needed to treat [NNT] 4) and disability (SRD -16.0%, 95% CI -26.6 to -5, NNT 6) and possibly decrease long-term disability (SRD -11.1%, 95% CI -25.3 to 3.6, NNT 9). There is insufficient evidence to determine whether ESIs reduce long-term pain in radiculopathies (SRD -10.3%, 95% CI -27.8 to 7.6). In lumbar spinal stenosis, ESIs possibly reduce short-term (SRD -26.2%, 95% CI -52.4 to 3.6, NNT 4) and long-term (SRD -11.8%, 95% CI -26.9 to 3.8, NNT 8) disability, but not short-term pain (SRD -3.5%, 95% CI -12.6 to 5.6). In lumbar stenosis, there is insufficient evidence to determine whether ESIs reduce long-term pain (SRD -6.5%, 95% CI -22.5 to 9.8). For cervical spinal stenosis, evidence is insufficient to determine the effectiveness of ESIs.

Discussion: The review affirms limited efficacy of ESIs in reducing pain and disability in cervical and lumbar radiculopathies and possibly in lumbar spinal stenosis, largely in the short term. The heterogeneity of outcome measures reported preclude presenting integrated data regarding effect size. There is controversy regarding the appropriate choice of inactive comparator treatments as a true placebo in clinical trials of ESIs. The panel recommends that future trials of ESIs use minimal meaningful clinical difference as the measure of efficacy and paraspinal muscle injection of saline as an inactive placebo.

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Conflict of interest statement

The AAN is committed to producing independent, critical, and trustworthy clinical practice guidelines and evidence-based documents. Significant efforts are made to minimize the potential for conflicts of interest to influence the recommendations of this evidence-based document. Management and disclosure of document developer relationships is conducted in compliance with the 2017 AAN process manual section titled, “Implementing the AAN Conflict of Interest Policy for Guidelines and Case Definitions,” which can be viewed at aan.com.

C. Armon serves on the editorial boards of Neurology® and Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration; has served on the editorial board of Annals of Neurology; received personal compensation in the range of $5,000–$9,999 for serving as a consultant for Inbal Insurance Company; has received personal compensation in the range of $5,000–$9,999 for serving as an editor, associate editor, or Editorial Advisory Board member for the Journal of Neurological Sciences; has received personal compensation in the range of $10,000–$49,999 for serving as an expert witness for individual attorney offices, or as a court-appointed expert; and has received publishing royalties from a publication relating to health care. P. Narayanaswami has received grant support from the Agency for Healthcare Research and Quality (AHRQ), the Patient-Centered Outcomes Research Institute (PCORI), and Momenta Pharmaceuticals; serves on the editorial boards of Neurology®, the Journal of Clinical Neuromuscular Disease, and Annals of Neurology; serves as an associate editor for Muscle and Nerve; has received personal compensation in the range of $500–$4,999 for serving as a consultant for Momenta and Novartis; has received personal compensation in the range of $5,000–$9,999 for serving on a scientific advisory or data safety monitoring board for Alexion/AstraZeneca Rare Disease; has received personal compensation in the range of $5,000–$9,999 for serving on a scientific advisory or data safety monitoring board for ARGENX US Inc.; has received personal compensation in the range of $10,000–$49,999 for serving as a consultant to UCB Pharmaceuticals; has received personal compensation in the range of $500–$4,999 for serving on a scientific advisory or data safety monitoring board for Sanofi; has received personal compensation in the range of $5,000–$9,999 for serving on a scientific advisory or data safety monitoring board for Janssen; has received personal compensation for serving as a consultant or member of an advisory board for Amgen, CVS, Dianthus, and UCB; has received personal compensation below $500 for serving as a consultant for Sarepta Pharmaceuticals; has received personal compensation in the range of $500–$4,999 for serving as an editor, associate editor, or editorial advisory board member for Muscle and Nerve; holds stock in Moderna, Pfizer, Viatris, Dr. Reddys laboratories, and Doximity; has received personal compensation in the range of $500–$4,999 for serving as a member on the Pharmacy and Therapeutics Committee with Blue Cross Blue Shield of MA; has a noncompensated relationship as a member on the Medical and Scientific Advisory Board with Myasthenia Gravis Foundation of America; has a noncompensated relationship as a Member, Board of Directors, with the American Association of Neuromuscular and Electrodiagnostic Medicine; and has received royalties from Springer Nature for a publication related to health care. The institution of P. Narayanaswami has received research support from AHRQ, PCORI, Alexion/AstraZeneca Rare Disease, Ra/UCB, and Momenta/Janssen. S. Potrebic has received funding for travel from the AAN to attend Guidelines International Network meetings; has received honoraria and a subscription to Continuum from the AAN for her work on the AAN Residency In-service Training Examination (RITE) exam work group; and has received personal compensation in the range of $500–$4,999 for serving as a consultant for the Center for Diagnostic Imaging Quality Institute. G. Gronseth has received travel funding from the AAN to attend Guidelines Subcommittee meetings; serves as an associate editor for Neurology®; has received personal compensation in the range of $0-$499 for serving as an editor, associate editor, or Editorial Advisory Board member for Brain & Life; and has received personal compensation in the range of $0–$499 for serving as an evidence-based medicine consultant for the AAN Guidelines Subcommittee. M.-M. Bačkonja has served on the editorial boards of the Clinical Journal of Pain, the European Journal of Pain, Journal of Pain, and Pain; and is currently employed by PRA Health Sciences. V.L. Cai held stock in Nevro Corp (spinal cord stimulators) while a pain fellow and relinquished stocks in June 2018 while serving as an attending physician at Beth Israel Deaconess Medical Center (BIDMC); served as a subinvestigator for the Sollis Therapeutics trial on epidural depot clonidine for lumbar radiculopathy, and serves as a subinvestigator for the Boston Scientific Corporation RELIEF study, which focuses on spinal cord stimulation; has an academic appointment at Harvard Medical School under BIDMC; and receives travel stipends from BIDMC to attend conferences; serves as a practicing pain physician. Dr. Cai's spouse holds patents in the fecal microbiota private sector. J. Dorman's spouse, Dr. Josune Iglesias, participated in a “vaccine hesitancy” panel as a representative of the American College of Physicians and received travel expenses of $6,000 from Merck pharmaceuticals. The institution of Dr. Dorman has received research support from NIH. C. Gilligan has served on scientific advisory boards for Eli Lilly, Medtronic, Abbott, Saluda, Cubist Pharmaceuticals, Mainstay Medical, Spine Biopharma, Persica, and Medasense; has had research support paid directly to his department from Mainstay Medical and Sollis Therapeutics; has received honoraria from the American Society of Regional Anesthesia and from the Principles and Practice of Pain Medicine Course at Harvard Medical School; performs ESIs as 15% of his clinical effort in his practice, which overlaps with the content of this evidence-based study; receives financial research support from the NIH; has served as an expert witness for the US Attorney and Federal Bureau of Investigation and for 3 malpractice cases; and serves as Editor-in-Chief of Pain Practice. S.A. Heller reports no relevant disclosures. H.M. Silsbee is an employee of the AAN. D.B. Smith is a paid evidence-based medicine consultant for the AAN. Go to Neurology.org/N for full disclosures.

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