Background: Epidural steroid injection is a low-risk alternative to
surgical intervention in the treatment of lumbar disc herniation. The
objective of this study was to determine the efficacy of epidural steroid
injection in the treatment of patients with a large, symptomatic lumbar
herniated nucleus pulposus who are surgical candidates.
Methods: One hundred and sixty-nine patients with a large herniation
of the lumbar nucleus pulposus (a herniation of >25% of the cross-sectional
area of the spinal canal) were followed over a three-year period. One hundred
patients who had no improvement after a minimum of six weeks of noninvasive
treatment were enrolled in a prospective, non-blinded study and were randomly
assigned to receive either epidural steroid injection or discectomy.
Evaluation was performed with the use of outcomes scales and neurological
Results: Patients who had undergone discectomy had the most rapid
decrease in symptoms, with 92% to 98% of the patients reporting that the
treatment had been successful over the various follow-up periods. Only 42% to
56% of the fifty patients who had undergone the epidural steroid injection
reported that the treatment had been effective. Those who did not obtain
relief from the injection had a subsequent discectomy, and their outcomes did
not appear to have been adversely affected by the delay in surgery resulting
from the trial of epidural steroid injection.
Conclusions: Epidural steroid injection was not as effective as
discectomy with regard to reducing symptoms and disability associated with a
large herniation of the lumbar disc. However, epidural steroid injection did
have a role: it was found to be effective for up to three years by nearly
one-half of the patients who had not had improvement with six or more weeks of
Level of Evidence: Therapeutic study, Level I-1a
(randomized controlled trial [significant difference]). See Instructions to
Authors for a complete description of levels of evidence.