Epidural steroid injections for lumbar spinal stenosis

Abstract

Degenerative lumbar stenosis is a common source of pain and disability in the elderly. It presents clinically with a variety of symptoms, though neurogenic claudication is the hallmark. There is a multifactorial pathogenesis to lumbar stenosis and its symptoms, and thus, there are multiple management approaches available. Epidural steroid injections (ESIs) are a popular choice in management, however, the literature is vague in definitive support of their use, and providers that utilize injections can use variable techniques to access the spinal canal in order to deposit the steroid at the appropriate site. This article will review degenerative lumbar stenosis in general and focus on the use of ESIs to better define their role in this management process. In addition, the evidence to discern the optimal injection route will be presented.

Figures

Fig. 1

An 64-year-old female with symptoms of bilateral lower limb neurogenic claudication with symptomatic improvement with a caudal epidural steroid injection. An interlaminar approach could have been considered appropriate, as well. (a) Sagittal view of a T2-weighted MRI of the lumbar spine. Note the grade I spondylolisthesis of L4 on L5 with severe central canal stenosis. (b) and (c) Axial views of a T2-weighted MRI through L4–5. Note the diffuse disc bulge in (b) and the marked ligamentum flavum hypertophy in (c), both contributing to the severe central stenosis. (d) The L5-S1 level showing no evidence of stenosis

Fig. 2

An 84-year-old male with low back pain and right L4 radicular symptoms to the ankle worsened with walking with symptomatic improvement with a right L4-5 transforaminal epidural steroid injection. (a) Right sagittal view of a T2-weighted MRI of the lumbar spine. Note the multilevel degenerative changes and the foraminal stenosis at L4-5 related to disc bulge and facet hypertrophy. (b) Axial view of a T2-weighted MRI through L4-5. Note severe central stenosis on imaging, though symptomatically, he described right L4 radicular symptoms and thus a transforaminal route was chosen

Fig. 3

Fluoroscopic images of an L3-4 interlaminar approach. (a) AP view, pre-contrast, (b) Lateral view, pre-contrast, and (c) Lateral view, post-contrast

Fig. 4

Fluoroscopic images of a caudal approach. (a) Lateral view, pre-contrast and (b) lateral view, post-contrast

Fig. 5

Fluoroscopic images of a right L5-S1 transforaminal approach targeting the right L5 nerve root. (a) AP view, pre-contrast and (b) AP view, post-contrast