Comparative effectiveness and safety of varying corticosteroid doses for lumbar epidural steroid injections: a systematic review and narrative synthesis.

OBJECTIVE

Lumbar epidural steroid injections (ESIs) are widely used to treat chronic low back pain. We conducted a systematic review and narrative synthesis to evaluate the effectiveness and safety of varying lumbar ESI corticosteroid doses.

METHODS

We searched PubMed, Embase, and Web of Science for English-language studies in humans comparing corticosteroid doses for lumbar ESI, published through August 12, 2025. Of 1553 records, 14 studies were included. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool for randomized controlled trials and the Risk of Bias in Non-randomized Studies-of Interventions tool for non-randomized studies.

RESULTS

Methylprednisolone was most frequently used (7 of 14 studies), followed by dexamethasone and triamcinolone (3 studies each), and betamethasone (1 study). Across studies, higher corticosteroid doses did not yield significantly greater improvements in pain relief or function than lower doses but were linked to greater risks of adverse effects, particularly endocrine complications such as hyperglycemia and hypothalamic-pituitary-adrenal axis suppression.

CONCLUSIONS

Pain relief and functional outcomes after lumbar ESI do not improve linearly with corticosteroid dose, whereas adverse effects tend to increase with higher doses. These findings support using the lowest effective corticosteroid dose. The lowest reported doses with efficacy not statistically different from higher doses in lumbar ESI include dexamethasone 4 mg, methylprednisolone 20 mg, triamcinolone 10 mg, and betamethasone 3 mg. Our review is expected to help develop standardized protocols for comparing corticosteroid doses in lumbar ESIs and to identify the lowest effective dose.