pISSN 2005-9159
eISSN 2093-0569

Original Article

Korean J Pain 2015; 28(1): 11-21

Published online January 31, 2015 https://doi.org/10.3344/kjp.2015.28.1.11

Copyright © The Korean Pain Society.

Comparison of the Efficacy of Caudal, Interlaminar, and Transforaminal Epidural Injections in Managing Lumbar Disc Herniation: Is One Method Superior to the Other?

Laxmaiah Manchikanti1,2*, Vijay Singh3, Vidyasagar Pampati1, Frank JE Falco4, and Joshua A. Hirsch5

1Pain Management Center of Paducah, Paducah, KY, USA.

2Pain Management Center of University of Louisville, Louisville, KY, USA.

3Spine Pain Diagnostics Associates, Niagara, WI, USA.

4Mid Atlantic Spine & Pain Physicians, Newark, DE, and Temple University Hospital, Philadelphia, PA, USA.

5Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.

Correspondence to: Laxmaiah Manchikanti. Pain Management Center of Paducah, 2831 Lone Oak Road, Paducah 42003, KY, USA. Tel: +1-280-554-9412, Fax: +1-270-554-5394, drlm@thepainmd.com

Received: September 11, 2014; Revised: October 10, 2014; Accepted: October 11, 2014

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.



Epidural injections are performed utilizing 3 approaches in the lumbar spine: caudal, interlaminar, and transforaminal. The literature on the efficacy of epidural injections has been sporadic. There are few high-quality randomized trials performed under fluoroscopy in managing disc herniation that have a long-term follow-up and appropriate outcome parameters. There is also a lack of literature comparing the efficacy of these 3 approaches.


This manuscript analyzes data from 3 randomized controlled trials that assessed a total of 360 patients with lumbar disc herniation. There were 120 patients per trial either receiving local anesthetic alone (60 patients) or local anesthetic with steroids (60 patients).


Analysis showed similar efficacy for caudal, interlaminar, and transforaminal approaches in managing chronic pain and disability from disc herniation. The analysis of caudal epidural injections showed the potential superiority of steroids compared with local anesthetic alone a 2-year follow-up, based on the average relief per procedure. In the interlaminar group, results were somewhat superior for pain relief in the steroid group at 6 months and functional status at 12 months. Interlaminar epidurals provided improvement in a significantly higher proportion of patients. The proportion of patients nonresponsive to initial injections was also lower in the group for local anesthetic with steroid in the interlaminar trial.


The results of this assessment show significant improvement in patients suffering from chronic lumbar disc herniation with 3 lumbar epidural approaches with local anesthetic alone, or using steroids with long-term follow-up of up to 2 years, in a contemporary interventional pain management setting.

Keywords: Caudal epidural steroids, Disc herniation, Local anesthetic, Lumbar interlaminar steroids, Radiculitis, Transforaminal epidural steroids