The New S3 Guideline on “Epidural injections”

Abstract

Background

Epidural injections are frequently performed for radicular pain. The German Society for Spine Surgery (DWG) published an S3 guideline for assessing benefits and performing epidural injections. The goal is to standardize the indication, technique, and medication selection based on evidence.

Material and Methods

The guideline was developed with the participation of ten professional associations and a patient representative using the AGREE II tool. It was based on a systematic literature review with GRADE assessment. Fourteen PICO questions were addressed.

Results

The evidence varies greatly depending on the approach and region. Transforaminal injections are recommended for radicular pain. Interlaminar injections have been shown to have a short-term effect for radicular pain in the lumbar spine. All randomized benefit assessment studies used fluoroscopy for transforaminal injections. CT or ultrasound scanning is also possible. Particulate steroids and preparations containing potentially neurotoxic preservatives should be avoided due to the potential for serious complications. Neurological follow-up and patient feedback are important. Repeat injections are only indicated if there has been a prior response. Series of injections without assessing the efficacy should not be performed.

Conclusion

The new S3 guideline provides practical, evidence-based recommendations for the safe performance of epidural injections. It offers important guidance on indication, technique, and drug selection. Individual medical assessment remains essential.

Key Points

• Periradicular therapy (PRT) is an image-guided transforaminal injection into the epidural space at a defined nerve root.

• The standard is fluoroscopy. The use of CT scanning is also possible.

• Non-particulate steroids (dexamethasone) are preferable due to lower complication rates.

• Neurological examination and monitoring of the patient is important after an intervention.

• A repeat transforaminal injection should only be performed if a positive response was previously found.

Citation Format

• Klessinger S. The New S3 Guideline on “Epidural injections”. Rofo 2025; 10.1055/a-2702-4560

Keywords

spine - interventional procedures - education - technical aspects - treatment effects

Publikationsverlauf

Eingereicht: 04. August 2025

Angenommen nach Revision: 10. September 2025

Artikel online veröffentlicht:
29. September 2025

• References

• 1 Manchikanti L, Knezevic E, Knezevic NN. et al. Epidural Injections for Lumbar Radiculopathy or Sciatica: A Comparative Systematic Review and Meta-Analysis of Cochrane Review. Pain Physician 2021; 24: E539-E554
• 2 Fessl R, Wacker FK, Wilhelm K. et al. Radiologische Schmerztherapien an der Wirbelsäule – Retrospektive Auswertung der DeGIR-Registerdaten 2021. Rofo 2025;
• 3 Klessinger S, Wiechert K. Deutsche Wirbelsäulengesellschaft. S3-Leitlinie Epidurale Injektionen bei degenerativen Erkrankungen. Version 01, 2025. https://register.awmf.org/de/leitlinien/detail/151–005
• 4 Guyatt GH, Oxman AD, Vist GE. et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336: 924-926
• 5 Brouwers MC, Kho ME, Browman GP. et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ 2010; 182: E839-E842
• 6 Guyatt GH, Oxman AD, Kunz R. et al. GRADE guidelines: 2. Framing the question and deciding on important outcomes. J Clin Epidemiol 2011; 64: 395-400
• 7 Lee JH, Lee S-H. Comparison of clinical effectiveness of cervical transforaminal steroid injection according to different radiological guidances (C-arm fluoroscopy vs. computed tomography fluoroscopy). The Spine Journal 2011; 11: 416-423
• 8 Maus T. The Anatomy, Technique, Safety, and Efficacy of Image-Guided Epidural Access. Radiologic Clinics of North America 2024; 62: 199-215
• 9 Derby R, Lee S-H, Date ES. et al. Size and Aggregation of Corticosteroids Used for Epidural Injections. Pain Med 2008; 9: 227-234
• 10 Laredo J-D, Wybier M, Laemmel E. et al. Intra-arterial injection of particulate corticosteroids: mechanism of injury. Skeletal Radiol 2023; 52: 1887-1892
• 11 Dawley JD, Moeller-Bertram T, Wallace MS. et al. Intra-Arterial Injection in the Rat Brain: Evaluation of Steroids Used for Transforaminal Epidurals. Spine 2009; 34: 1638-1643
• 12 Okubadejo GO, Talcott MR, Schmidt RE. et al. Perils of Intravascular Methylprednisolone Injection into the Vertebral Artery: An Animal Study. The Journal of Bone and Joint Surgery-American Volume 2008; 90: 1932-1938
• 13 Kassenärztliche Bundesvereinigung. Einsatz von Kortikoiden bei wirbelsäulennahen Injektionen: Erweiterung der Indikation bei Volon A 40 Kristallsuspension 1 ml und 5 ml. Information der KBV 2014; 211.
• 14 Eworuke E, Crisafi L, Liao J. et al. Risk of serious spinal adverse events associated with epidural corticosteroid injections in the Medicare population. Reg Anesth Pain Med 2021; 46: 203-209