Original research| Volume 98, ISSUE 8, P1499-1507.e2, August 2017

Long-Term Effects of Repeated Injections of Local Anesthetic With or Without Corticosteroid for Lumbar Spinal Stenosis: A Randomized Trial

Published:April 07, 2017DOI:



      To determine the overall long-term effectiveness of treatment with epidural corticosteroid injections for lumbar central spinal stenosis and the effect of repeat injections, including crossover injections, on outcomes through 12 months.


      Multicenter, double-blind, randomized controlled trial comparing epidural injections of corticosteroid plus lidocaine versus lidocaine alone.


      Sixteen clinical sites.


      Participants with imaging-confirmed lumbar central spinal stenosis (N=400).


      Participants were randomized to receive either epidural injections with corticosteroid plus lidocaine or lidocaine alone with the option of blinded crossover after 6 weeks to receive the alternate treatment. Participants could receive 1 to 2 injections from 0 to 6 weeks and up to 2 injections from 6 to 12 weeks. After 12 weeks, participants received usual care.

      Main Outcome Measures

      Primary outcomes were the Roland-Morris Disability Questionnaire (RDQ) (range, 0–24, where higher scores indicate greater disability) and leg pain intensity (range, 0 [no pain] to 10 [pain as bad as you can imagine]). Secondary outcomes included opioid use, spine surgery, and crossover rates.


      At 12 months, both treatment groups maintained initial observed improvements, with no significant differences between groups on the RDQ (adjusted mean difference, −0.4; 95% confidence interval [CI], −1.6 to 0.9; P=.55), leg pain (adjusted mean difference, 0.1; 95% CI, −0.5 to 0.7; P=.75), opioid use (corticosteroid plus lidocaine: 41.4% vs lidocaine alone: 36.3%; P=.41), or spine surgery (corticosteroid plus lidocaine: 16.8% vs lidocaine alone: 11.8%; P=.22). Fewer participants randomized to corticosteroid plus lidocaine (30%, n=60) versus lidocaine alone (45%, n=90) crossed over after 6 weeks (P=.003). Among participants who crossed over at 6 weeks, the 6- to 12-week RDQ change did not differ between the 2 randomized treatment groups (adjusted mean difference, −1.0; 95% CI, −2.6 to 0.7; P=.24). In both groups, participants crossing over at 6 weeks had worse 12-month trajectories compared with participants who did not choose to crossover.


      For lumbar spinal stenosis symptoms, epidural injections of corticosteroid plus lidocaine offered no benefits from 6 weeks to 12 months beyond that of injections of lidocaine alone in terms of self-reported pain and function or reduction in use of opioids and spine surgery. In patients with improved pain and function 6 weeks after initial injection, these outcomes were maintained at 12 months. However, the trajectories of pain and function outcomes after 3 weeks did not differ by injectate type. Repeated injections of either type offered no additional long-term benefit if injections in the first 6 weeks did not improve pain.


      List of abbreviations:

      CI (confidence interval), EMR (electronic medical record), ITT (intention-to-treat), LESS (Lumbar Epidural steroid injections for Spinal Stenosis), RDQ (Roland-Morris Disability Questionnaire)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Deyo R.A.
        Treatment of lumbar spinal stenosis: a balancing act.
        Spine J. 2010; 10: 625-627
        • Atlas S.J.
        • Keller R.B.
        • Robson D.
        • Deyo R.A.
        • Singer D.E.
        Surgical and nonsurgical management of lumbar spinal stenosis: four-year outcomes from the maine lumbar spine study.
        Spine (Phila Pa 1976). 2000; 25: 556-562
        • Deyo R.A.
        • Mirza S.K.
        • Martin B.I.
        • Kreuter W.
        • Goodman D.C.
        • Jarvik J.G.
        Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults.
        JAMA. 2010; 303: 1259-1265
        • Harrast M.A.
        Epidural steroid injections for lumbar spinal stenosis.
        Curr Rev Musculoskelet Med. 2008; 1: 32-38
        • Friedly J.L.
        • Comstock B.A.
        • Turner J.A.
        • et al.
        A randomized trial of epidural glucocorticoid injections for spinal stenosis.
        N Engl J Med. 2014; 371: 11-21
        • Bicket M.C.
        • Gupta A.
        • Brown 4th, C.H.
        • Cohen S.P.
        Epidural injections for spinal pain: a systematic review and meta-analysis evaluating the “control” injections in randomized controlled trials.
        Anesthesiology. 2013; 119: 907-931
        • Cohen S.P.
        • Bicket M.C.
        • Jamison D.
        • Wilkinson I.
        • Rathmell J.P.
        Epidural steroids: a comprehensive, evidence-based review.
        Reg Anesth Pain Med. 2013; 38: 175-200
        • Flores S.
        • Molina M.
        Is epidural steroid injection effective for degenerative lumbar spinal stenosis?.
        Medwave. 2015; : e6315
        • Chou R.
        • Hashimoto R.
        • Friedly J.
        • et al.
        Epidural corticosteroid injections for radiculopathy and spinal stenosis: a systematic review and meta-analysis.
        Ann Intern Med. 2015; 163: 373-381
        • Shaughnessy A.F.
        Epidural steroid not better than placebo injection for sciatica and spinal stenosis pain and function.
        Am Fam Physician. 2016; 93: 315-316
        • Liu K.
        • Liu P.
        • Liu R.
        • Wu X.
        • Cai M.
        Steroid for epidural injection in spinal stenosis: a systematic review and meta-analysis.
        Drug Des Devel Ther. 2015; 9: 707-716
        • Friedly J.L.
        • Bresnahan B.W.
        • Comstock B.
        • et al.
        Study protocol- Lumbar Epidural steroid injections for Spinal Stenosis (LESS): a double-blind randomized controlled trial of epidural steroid injections for lumbar spinal stenosis among older adults.
        BMC Musculoskelet Disord. 2012; 13: 48
        • Roland M.
        • Morris R.
        A study of the natural history of back pain. Part I: development of a reliable and sensitive measure of disability in low-back pain.
        Spine (Phila Pa 1976). 1983; 8: 141-144
        • Jordan K.
        • Dunn K.M.
        • Lewis M.
        • Croft P.
        A minimal clinically important difference was derived for the Roland-Morris Disability Questionnaire for low back pain.
        J Clin Epidemiol. 2006; 59: 45-52
        • Lauridsen H.H.
        • Hartvigsen J.
        • Manniche C.
        • Korsholm L.
        • Grunnet-Nilsson N.
        Responsiveness and minimal clinically important difference for pain and disability instruments in low back pain patients.
        BMC Musculoskelet Disord. 2006; 7: 82
        • Martin B.I.
        • Lurie J.D.
        • Tosteson A.N.
        • et al.
        Indications for spine surgery: validation of an administrative coding algorithm to classify degenerative diagnoses.
        Spine (Phila Pa 1976). 2014; 39: 769-779
        • Benoist M.
        The natural history of lumbar degenerative spinal stenosis.
        Joint Bone Spine. 2002; 69: 450-457
        • Micankova Adamova B.
        • Vohanka S.
        • Dusek L.
        • Jarkovsky J.
        • Bednarik J.
        Prediction of long-term clinical outcome in patients with lumbar spinal stenosis.
        Eur Spine J. 2012; 21: 2611-2619
        • Rabinovitch D.L.
        • Peliowski A.
        • Furlan A.D.
        Influence of lumbar epidural injection volume on pain relief for radicular leg pain and/or low back pain.
        Spine J. 2009; 9: 509-517