Effectiveness of epidural steroid injections in the treatment of lumbar radiculopathy: a systematic review and meta-analysis

Abstract

Introduction Epidural steroid injection (ESI) techniques have demonstrated effectiveness in improving short- and intermediate-term pain and disability outcomes; however, their efficacy may vary depending on the specific approach used. This meta-analysis aims to compare disability and pain outcomes among different ESI techniques - transforaminal (TFESI), interlaminar (ILESI), caudal (CESI), and combined approaches - in patients with lumbar radiculopathy. Methods The authors searched PubMed/MEDLINE, Scopus, and Cochrane from inception to December 16, 2025, in accordance with PRISMA guidelines. Studies comparing disability and pain outcomes between different ESIs were assessed. Random-effects meta-analyses were performed to estimate the pooled mean difference between treatment groups at different follow-up timepoints. Sensitivity analyses and publication bias assessments were conducted. Results In total, 31 studies comprising 2,452 patients were included. Compared with ILESI, TFESI demonstrated significantly greater pain reduction at 2 weeks and 1 month of follow-up, as well as superior improvements in both disability and pain at 3 and 6 months. Compared with CESI, TFESI showed superior disability improvements at 2 weeks and 1 month, with pain outcomes remaining superior at 1 and 3 months; however, both disability and pain outcomes plateaued by 6 months. At 12-month follow-up, TFESI demonstrated improved disability scores compared with CESI, with no significant difference in pain outcomes. Across all follow-up timepoints, the combined TFESI + CESI approach was associated with significantly greater improvements in both disability and pain relief compared with TFESI alone. Conclusions TFESI demonstrated superior short- and intermediate-term improvements in disability and pain compared with ILESI, but its advantages over CESI remained inconsistent. Limited evidence suggests that the combined TFESI + CESI approach may offer additional benefits over TFESI alone. Further prospective randomized trials are warranted to better define the efficacy and long-term outcomes of the combined approach. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420261320804