Recommendation ID

Epidurals:- What is the clinical and cost effectiveness of image-guided compared with non-image-guided epidural injections for people with acute sciatica?

Any explanatory notes
(if applicable)

Why this is important:- Epidural injection of treatments, including corticosteroids, is commonly offered to people with sciatica. Epidural injection might improve symptoms, reduce disability and speed up return to normal activities. Several different procedures have been developed for epidural delivery of corticosteroids. Some practitioners inject through the caudal opening to the spinal canal in the sacrum (caudal epidural), but others inject through the foraminal space at the presumed level of nerve root irritation (transforaminal epidural).
Some people believe transforaminal epidurals might be most effective because they deliver corticosteroids directly to the region where the nerve root might be compromised. But becausetransforaminal epidural injection needs imaging, usually within a specialist setting, this potentially limits treatment access and increases costs. Caudal epidural injection can be done without imaging, or with ultrasound guidance in a non-specialist setting. But it has been argued the treatment might not reach the affected nerve root, meaning this method might not be as effective as transforaminal injection.
Evidence that one method is clearly better than the other is currently lacking. Use of the 2 methods varies between healthcare providers, and people whose sciatica does not respond to caudal corticosteroid injection might go on to have image-guided epidural injection. This means people with sciatica might currently experience unnecessary symptoms at unnecessary cost to the NHS than they would if the most clinically and cost-effective way of delivering epidural corticosteroid injections was always used.

Source guidance details

Comes from guidance
Low back pain and sciatica in over 16s: assessment and management
Date issued
November 2016

Other details

Is this a recommendation for the use of a technology only in the context of research? No  
Is it a recommendation that suggests collection of data or the establishment of a register?   No  
Last Reviewed 30/11/2016