To the Editor:—

In their letter to the editor, Mchaourab and Hamill-Ruth 1ask, ‘should imaging studies be routinely performed prior to epidural steroid injections?” The answer is yes, emphatically. The authors describe a patient on long-term steroid therapy for asthma who developed epidural lipomatosis that constricted the lumbar dural sac to the point of producing low back pain. There were no signs of radiculopathy, and although the L5–S1 intervertebral disc was protruding slightly, the indication for epidural steroids was doubtful at best; the MRI demonstrated the imperative need to have a precise and objective diagnosis, before initiating an invasive procedure on the spine.

Other reasons can be named to further support performing imaging studies before any pain-related invasive procedure, in which case if the caudal approach would have been attempted for an epidural steroid injection a dural puncture may have occurred. The list can go on and on. 2 

Abrams, in an earlier letter, 3raised the issue of cost; this may be answered not only by the fact that a more effective treatment may be attained if an accurate diagnosis is known, but as importantly, by defining the occurrence of surgically-related complications. 4A precise diagnosis can prevent a falsely attributed complication to the epidural steroid injection, placing the blame instead, on the spinal operation. An extra safety is the selection of the optimal epidural space for epidural steroid injection treatment.

Mchaurab AS, Hamill-Ruth R: Should imaging studies be routinely performed prior to epidural steroid injections? A nesthesiology 2001: 95: 1539–40
Aldrete JA: Need for precise diagnosis prior to epidural steroids. A nesthesiology 2000; 93: 565–6
Fitzgibbon DR: Liability arising from anesthesiology based pain management in the non-operative setting. ASA News 2001; 61:No.6, 122–15
Abrams SE: In reply. A nesthesiology 2000; 93: 566–7