Postlaminectomy Syndrome with Predominantly Radicular Leg Pain: What to Do When Epidural Steroid Injections Have Not Worked

Clinical Scenario

This protocol addresses patients with postlaminectomy syndrome whose pain is predominantly radicular and neuropathic in the lower limbs, with an absence of predominantly axial nociceptive pain. The therapeutic goal is reduction of chronic back and radicular leg pain.

When the Previous Line Has Not Achieved the Target

Epidural injection of steroids under fluoroscopic guidance — with repeated injections when an initial positive response is seen — is the established first approach for predominantly radicular pain in this population. However, when this intervention fails to achieve sufficient radicular leg pain reduction, an escalation to a next-line procedure is indicated.

Distinguishing predominantly radicular from predominantly axial pain is a critical step: for radicular presentations, epidural steroid routes have been explored, but inadequate response to them is well-recognised and prompts the next step described below.

Next-Line Approach (Partial Overview)

When epidural steroid injection has been unsuccessful, a percutaneous procedure targeting the epidural space — particularly suited to cases where adhesions are considered a contributing factor — may be considered as the next step. The specific agents and delivery method are defined in the structured regimen.

Full protocol details, sequencing, and evidence basis available via the link below ↓

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.4103/jcvjs.jcvjs_118_22

When deciding on which procedures may be efficacious in FBSS patients, it is useful to determine if the pain is predominantly axial or radicular.

For those patients with predominantly radicular pain, epidural injection of steroids under fluoroscopic guidance may be achieved through several routes.

If epidural injection is unsuccessful, percutaneous epidural adhesiolysis may be considered especially if adhesions are the cause.

Adhesiolysis is possible either by using an epidural injection of hyaluronidase with saline and steroids.

Percutaneous epidural adhesiolysis has also shown good clinical outcomes but the effect is short-lived and adverse effects are sometimes intolerable.

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