Epidural Steroid Injection: A Need for a New Clinical Practice Guideline

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. There is no denying that chronic spinal pain originating from a degenerative spinal disease is one of the most common causes of disability in the industrialized world. It is also associated with escalating pain control costs and a significant loss of work and productivity. In order to manage the pain, to improve the patient's daily functioning , to enable their return to work, as well as to avoid surgery , multiple conservative treatment methods are provided. With the absence of a fully reliable and effective treatment method, epidural steroid injections (ESI) have become the most commonly performed spinal intervention in the world today. One report showed that the ESI in Medicare beneficiaries had increased significantly from 2000 to 2011 by an overall 130% per 100,000 Medicare beneficiaries, with an annual increase of 7.5% in the USA [1]. Perhaps a similar situation or even higher increase will be observed in Korea. Despite the explosive growth of epidural steroid injections , their cost-effectiveness and levels of effectiveness and safety as reported by recently-published systematized review articles, have failed to meet pain special-ists' expectations. In a number of thought-provoking review articles published between 2012 and 2014, the evidence of the effect of ESI for radiculitis on the lumbosacral and cervical region was only fair to good [2-4] and the evidence of the effectiveness of ESI for back pain with or without sciatica was limited to moderate [3,5-12]. Furthermore , ESI offers only short-term relief of pain and disability , with no long-term effects. A group of authors even insisted that " moderate and high-quality evidence for nonoperative treatment is lacking and thus prohibits recommendations for guiding clinical practice " [8]. The misreading and/or misunderstanding of ESI as an ineffective treatment for pain by non-specialist doctors and the healthcare system may lead to a completely wrong decision. According to the conclusions of these papers, should we then consider ESI as an out-of-date technique? Even though excellent information has been provided through appropriate search strategies and quality assessments, some points of concern persist that make it difficult for us to draw a wise clinical decision. As mentioned in their conclusions, most systematized review articles suffer from a limitation in …