BlueCross BlueShield of Tennessee Medical Policy Manual

Lumbar Epidural Steroid Injections for Treatment of Low Back Pain


The purpose of a lumbar epidural steroid injection is to achieve relief from nerve root irritation (i.e., radicular pain or sciatica) related to encroachment by bone or disk herniation, or by various causes of neuritis (e.g., radiation, chemical or autoimmune). The techniques are most accurately performed using fluoroscopy visualization for needle placement. The procedure may generally be safely performed in the outpatient setting. There are three basic techniques for lumbar epidural steroid injections:

The scientific literature does not reveal a consensus of definition for acute and chronic low back pain. The following definitions will be used for the purpose of this policy:

It is also recognized that acute exacerbations or new acute episodes may be superimposed on otherwise chronic conditions.


Policies with similar titles:   Lumbar Facet Steroid Injections for treatment of Low Back Pain




In order to minimize the risks from large doses of steroids, more than 3 (three) injection sessions within a 6-month period is not generally appropriate. It is not appropriate to repeat a procedure a third time without improvement from the two prior injections.

Contrast-enhanced fluoroscopy is recommended to guide epidural steroid injections to improve the accuracy of medication delivery.


Agency for Healthcare Research and Quality Technology Assessment. (March, 2015). Pain management injection therapies for low back pain. Retrieved August 18, 2015 from

American Society of Anesthesiologists Task Force on Chronic Pain Management and American Society of Regional Anesthesia and Pain Medicine. (2010). Practice guidelines for chronic pain management: An updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology, 112 (4), 810-833.

Cahaba Government Benefit Administrators, LLC. (2012, January). LCD for Surgery: Injections of the spinal canal (L32112). Retrieved August 18, 2015 from

Friedly, J. L., Comstock, B.A., Turner, J.A., Heagerty, P.J., Deyo, R. A., et al. (2014). A randomized trial of epidural glucocorticoid injections for spinal stenosis. The New England Journal of Medicine, 371 (1), 11-31. (Level 1 evidence)

Institute for Clinical Systems Improvement. (2012). Adult acute and subacute low back pain. Retrieved February 21, 2014 from

Institute for Clinical Systems improvement. (November, 2013). Assessment and management of chronic pain. Retrieved August 18, 2015 from the National Guideline Clearinghouse (NGC:010140).

Liu, K., Liu, P., Liu, R., Wu, X., & Cai, M. (2015). Steroid for epidural injection in spinal stenosis: a systematic review and meta-analysis. Drug Design, Development and Therapy, 2015 (9), 707-716. (Level 1 evidence)

Manchikanti, L., Abdi, S., Atluri, S., Benyamin, R. M., Boswell, M. V., Buenaventura, R. M., et al. (2013). An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: Guidance and recommendations. Pain Physician, 16 (2 Suppl.), S49-S283.

Manchikanti, L., Buenaventura, R. M., Manchikanti, K. N., Ruan, X., Gupta, S., Smith, H. S., et al. (2012). Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician, 15 (3), E199-E245.

Manchikanti, L., Kaye, A.D., Manchikanti, K., Boswell, M., Pampati, V., & Hirsch, J. (2015). Efficacy of epidural injections in the treatment of lumbar central spinal stenosis: a systematic review. Anesthesiology and Pain Medicine, 5 (1), e23139. (Level 1 evidence)

North American Spine Society. (2011). Evidence-based clinical guidelines for multidisciplinary spine care: diagnosis and treatment of degenerative lumbar spinal stenosis. Retrieved August 18, 2015 from

North American Spine Society. (2012). Evidence-based clinical guidelines for multidisciplinary spine care: clinical guidelines for diagnosis and treatment of lumbar disc herniation with radiculopathy. Retrieved August 18, 2015 from

Winifred S. Hayes, Inc. Medical Technology Directory. (2015, January). Epidural steroid injections for low back pain and sciatica. Retrieved August 18, 2015 from (73 articles and/or guidelines reviewed)




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