The following are practical suggestions for;
- Inpatient management of severe low back pain and /or(lumbar) radicular leg pain.
- The role of lumbar epidural steroid injections.
- A patient who is admitted for low back pain is ‘out-of-the-box’…
- ‘Different’ to the 10% of population with LBP at any given time.
The patient either has a;
- Red flag condition:
- TINT (Tumour, Inflammation/Infection [discitis], Neurological [radiculopathy, [cauda equina], Trauma [fracture])
- and/or a;
- Yellow flag condition: Psychosocial driver of pain & distress (anxiety, poor coping).
Exclude red flags (MRI spine is the most sensitive ‘screening’ investigation).
- Consider yellow flags (anxiety, passive-coping, medication overuse).
- Multimodal analgesia for acute or acute-on-chronic LBP.
- Paracetamol, celecoxib, tapentadol IR, SR, buprenorphine s/L prn (short term).
- Pregabalin (neuropathic pain, e.g. radicular leg pain).
- Physical comfort measures; heat packs, TENS, physiotherapy.
Lumbar epidural steroid injection
- The only specific indication for a lumbar epidural steroid injection is;
- Severe acute/subacute (<6M) radicular leg pain +/- disability
- NO indication for low back pain (facet, disc) or chronic radicular leg pain.
Severe leg pain ( +/- LBP) and/or disability
e.g. Can’t get out of bed, or out of hospital
Suspected radicular leg pain?
MRI or CT of lumbosacral spine
If disc/nerve root ‘pathology’ (protrusion, herniation, extrusion, sequestration, NOT a bulge) in keeping with the clinical picture
Transforaminal epidural steroid injection (TFESI) at affected level (nearly always L4/5 or L5/S1)
Specifically, do NOT order a nerve root sleeve injection which is only a diagnostic nerve block
Radiology is an appropriate avenue for ordering a TFESI for inpatients, but ask specifically for a TFESI
- NNT for improvement in acute/sub-acute radicular leg pain is 2-3.
- Can take up to 7 days for steroid to take effect, so may be a delay.
General educational advice only. No responsibility taken for effects of this information.
EJ Visser 2018 ©