Expert Commentary

Epidural Injections—Pros and Cons: A Comprehensive Review of Evidence, Epidural Cytokine Therapy, and Complications in the Treatment of Chronic Pain

Salim M. Hayek, MD, PhD

Associate Professor
Case Western Reserve University
Chief—Division of Pain Medicine
Department of Anesthesiology
University Hospitals Case Medical Center
Cleveland, OH

Despite the limited long-term evidence, epidural steroid injections remain the most commonly performed procedure in pain clinics across the United States. This has led to increased rates of procedure-related complications, including notably neuraxial injuries, which may occur not only as result of direct trauma during the procedure but also due to bleeding, infection, and embolic events believed to occur with periradicular injections of particulate steroids. Moreover, these injections may be less beneficial in patients with litigation or worker compensation issues, or in those who have undergone previous back surgery. At the 2010 Annual Meeting of the American Academy of Pain Medicine, Dr. Hayek participated in a debate session on the evidence supporting epidural steroid injections in various contexts, the ideal candidates for such treatment, whether this therapy is effective in preventing surgery, and emerging clinical advances in epidural injections.


  1. Cohen SP, Bogduk N, Dragovich A, et al. Randomized, double-blind, placebo-controlled, dose-response, and preclinical safety study of transforaminal epidural etanercept for the treatment of sciatica. Anesthesiology. 2009;110(5):1116-1126.
  2. Manchikanti L, Boswell MV, Singh V, et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. 2009;12(4):699-802.
  3. Armon C, Argoff CE, Samuels J, Backonja MM. Assessment: use of epidural steroid injections to treat radicular lumbosacral pain: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2007;68(10):723-729.
  4. Riew KD, Park JB, Cho YS, et al. Nerve root blocks in the treatment of lumbar radicular pain. A minimum five-year follow-up. J Bone Joint Surg Am. 2006;88(8):1722-1725.
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