By Janis C. Kelly
When a mainstay of symptom relief for a widespread type of chronic pain has been demonstrated to be of questionable effectiveness and is implicated in soaring healthcare costs, will physicians counsel patients to seek alternative treatments or continue practicing as before?
Such is the issue raised by epidural steroid injections (ESIs) for central lumbar spinal stenosis. ESIs in Medicare patients increased nearly 300% between 1994 and 2001.[1] But data from a double-blind, randomized trial published by Janna L. Friedly and colleagues in 2014 the New England Journal of Medicine[2] suggested that epidural injections of glucocorticoids plus lidocaine offer little or no short-term benefit over lidocaine alone in providing relief to the legions of aging baby boomers and patients in other age cohorts suffering from central lumbar spinal stenosis. 
Moreover, at a time when the nation is seeking ways to reduce wasteful healthcare spending, the total inflation-adjusted reimbursed costs (professional fees only) for lumbosacral injections shot from $24 million to over $175 million over the study period.[1]
“Less than half [of lumbosacral injections] were performed for sciatica or radiculopathy, where the evidence of benefit is available,” Friedly and colleagues concluded in an earlier study.[1] “These findings suggest a lack of consensus regarding the indications for ESIs and are cause for concern given the large expenditures for these procedures.”
Internist Stephen J. Atlas, MD, MPH, director of the Practice-Based Research and Quality Improvement Network at Massachusetts General Hospital and an associate professor of medicine at Harvard Medical School, Boston, Massachusetts, says that a brief course of ESIs might be appropriate for helping the patient with otherwise uncontrolled spinal stenosis symptoms and pain “cool down” symptomatically enough to begin physical therapy, but that there is little long-term benefit to be expected from repeated ESIs.