Inpatient management of low back pain & lumbar epidural steroid injections

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.

Preamble

  • 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).

Initial management

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.

Process

 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

Outcomes

  • 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 ©