Chronic Back Pain

Back pain is a widespread, debilitating disorder that results in an enormous socioeconomic burden. The lifetime prevalence of low back pain ranges from 60 to 90%, and the annual incidence is ~5%1,2. The annual cost to treat chronic back pain has been estimated to exceed $100 billion, of which up to $50 billion is due to lost productivity3.

A specific type of back pain in the distribution of lumbosacral nerves is known as lumbosacral radicular pain, which is frequently referred to as sciatica. It is a common condition with a lifetime incidence varying from 13% to 40% 4. The corresponding annual incidence of an episode of lumbosacral radicular pain ranges from 1% to 5%1,2. It is rarely diagnosed before the age of 20, peaks in incidence in the fifth decade and declines thereafter2.

Lumbosacral radiculopathy is believed to result most commonly from prolapsed disc material causing pain secondary to mechanical impingement and/or inflammation of the anterior primary rami of lumbar nerve roots5. Approximately 90% of cases of lumbosacral radicular pain are caused by a herniated disc with nerve root compression, with various other etiologies accounting for the remaining 10% of the cases4,6.

Lumbar Radiculopathy is a subtype of Low Back Pain characterized by debilitating pain usually requiring medical intervention

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There are several conservative treatments for lumbosacral radicular pain, each with varying levels of effectiveness. These therapeutic approaches include bed rest, staying active (in contrast to bed rest), analgesic or non-steroidal anti-inflammatory drugs (specifically opioids and benzodiazepines), acupuncture, spinal manipulations, traction therapy, physical therapy, behavioral treatment, and epidural steroid injections2,7,6.

The initial phase of sciatica frequently responds to conservative management. In some cases, when these more conservative treatments for lumbosacral radicular pain are ineffective, surgical intervention has been explored as a treatment option. The comparative effectiveness of the various treatment modalities has been a topic frequently addressed in the literature, but there is currently no FDA-approved epidural steroid treatment for lumbosacral radicular pain.

Recent trends in non-narcotic approaches to pain management

Increasing evidence has shown the limitations and risks of the use of opioids in the management of low back pain, which may favor the use of alternative treatments, such as epidural steroid injections.

Research shows that opioids do not provide clinically meaningful pain relief in patients with low back pain8. Further, the risk of prescription opioid abuse and misuse has risen to epidemic proportions in the U.S.9

This has contributed to multiple medical organizations recommending multi-modal analgesia for chronic pain management, including the American Society of Anesthesiologists, American Society of Regional Anesthesia & the American Academy of Orthopedic Surgeons. Multi-modal analgesia is the use of two or more analgesic agents or techniques to improve pain management while minimizing risk of adverse events.

Specifically, guidelines have concluded that “Consultants, ASA members, and ASRA members strongly agree that epidural steroid injections with or without local anesthetics should be used for radicular pain or radiculopathy.”10
back-pain
Lumbosacral radicular pain is a progressive disease – often leading to treatment with multiple prescription medications. Patients typically use chronic medications, such as opioid analgesics and eventually expensive back surgery.

There is no currently approved injectable product for epidural administration. There are an estimated 10 million epidural steroid administrations per year in the US alone.11


  1. Frymoyer 1988.
  2. Frymoyer 1992.
  3. Crow & Willis 2009.
  4. Stafford et al. 2007.
  5. Lindahl & Rexed 1951.
  6. Valat et al. 2010.
  7. Koes et al. 2007.
  8. Efficacy, Tolerability and Dose Effects of Opioid Analgesics for Low Back Pain. JAMA Internal Medicine. 2016 Jul 1; 176.
  9. Rudd et al. Center for Disease Control and Prevention. Increases in Drug and Opioid Overdose Deaths 2000-2014. MMWR 2015; 64; 1378-1382.
  10. Practice Guidelines for Chronic Pain Management. Anesthesiology. 2010; 112: No 4 Apr 2010.
  11. NEJM July 3, 2014 Editorial: Epidural Glucocorticoid Injections in Patients with Lumbar Spinal Stenosis; Gunnar B.J. Andersson, M.D., Ph.D.