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.


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.

Armon, C., Argoff, C. E., Samuels, J., Backonja, M. M., & Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. (2010). Assessment: Use of epidural steroid injections to treat radicular lumbosacral pain: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology, 68 (10), 723-729.

Candido, K. D., Rana, M. V., Sauer, R., Chupatanakul, L., Tharlan, A., Vasic, V., et al. (2013). Concordant pressure paresthesia during interlaminar lumbar epidural steroid injections correlates with pain relief in patients with unilateral radicular pain. Pain Physician, 16 (5), 497-511. (Level 3 Evidence - Independent study)

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

Kreiner, D. S., Shaffer, W. O., Baisden, J. L., Gilbert, T. J., Summers, J. T., Toton, J. F., et al. (2013). An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). The Spine Journal, 13 (7), 734-743.

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., Cash, K. A., McManus, C. D., Pampati, V., & Benyamin, R. M. (2013). A randomized, double-blind, active-controlled trial of fluoroscopic lumbar interlaminar epidural injections in chronic axial or discogenic low back pain: Results of 2-year follow-up. Pain Physician, 16 (5), e491-e504. (Level 3 Evidence - Independent study)

Pinto, R. Z., Maher, C. G., Ferreira, M. L., Hancock, M., Oliveira, V. C., McLachlan, A. J., et al. (2012). Epidural corticosteroid injections in the management of sciatica: A systematic review and meta-analysis. Annals of Internal Medicine, 157 (12), 865-877.

Radcliff, K., Kepler, C., Hilibrand, A., Rihn, J., Zhao, W., Lurie, J., et al. (2013). Epidural steroid injections are associated with less improvement in patients with lumbar spinal stenosis: A subgroup analysis of the Spine Patient Outcomes Research Trial. Spine, 38 (4), 279-291. (Level 1 Evidence - Industry sponsored)

Winifred S. Hayes, Inc. Medical Technology Directory. (2013, January, last update search January 2014). Epidural steroid injections for low back pain and sciatica. Retrieved February 21, 2014 (73 articles and/or guidelines reviewed)

Wisconsin Physicians Service Insurance Corporation. Government Benefits Administrator. Local Coverage Determinations (LCD). (2014, February). Epidural and transforaminal epidural injections (L30481).Retrieved February 21, 2014 from




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