ACR-ASNR-ASSR-SIR-SNIS Practice Parameter for the Performance of Image-Guided Epidural Steroid Injection

The practice parameter was revised collaboratively by the American College of Radiology (ACR), the American Brachytherapy Society (ABS), the American College of Nuclear Medicine (ACNM), the American Radium Society (ARS), the Society of Interventional Radiology (SIR), and the Society of Nuclear Medicine and Molecular Imaging (SNMMI). Epidural steroid injections (ESI) are widely used procedures for managing spinal pain and radiculopathy in patients who do not respond to conservative therapy. This multidisciplinary practice parameter reviews evidence for the efficacy and safety of ESI and provides best practice recommendations.

This practice parameter was revised according to the process described under the Process for Developing ACR Practice Parameters and Technical Standards on the ACR website (https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Practice-Parameters-and-Technical-Standards) by the Committee on Practice Parameters - Interventional and Cardiovascular Radiology of the ACR Commission on Interventional and Cardiovascular, Committee on Practice Parameters and Technical Standards - Nuclear Medicine and Molecular Imaging of the ACR Commission on Nuclear Medicine and Molecular Imaging and the Committee on Practice Parameters - Radiation Oncology of the ACR Commission on Radiation Oncology in collaboration with the ABS, the ACNM, the ARS, the SIR, and the SNMMI.

Epidural steroid injections can provide meaningful improvements in pain, mobility, function, and quality of life for appropriately selected patients with neck and low back pain, particularly when degenerative changes or radiculopathy are present. This document advises that ESI be performed with image guidance, meticulous technique, and detailed knowledge of spinal anatomy, particularly in light of rare but serious neurologic risks highlighted by the FDA. The parameter specifies absolute and relative contraindications, encourages integrating ESI within a multidisciplinary care pathway rather than as stand-alone therapy, and recommends that only appropriately trained and credentialed physicians who understand the indications, relevant pharmacology, and complication management perform these procedures.

This multidisciplinary practice parameter provides recommendations on indications, contraindications, patient selection, and technical execution to optimize the therapeutic benefit of epidural steroid injections while reducing the risk of serious neurologic and other complications.