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Cost effectiveness of epidural steroid injections to manage chronic lower back pain

David K Whynes1*, Robert A McCahon2, Andrew Ravenscroft3 and Jonathan Hardman4

Author Affiliations

1 School of Economics, University of Nottingham, Nottingham, NG7 2RD, UK

2 Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre, Nottingham, NG7 2UH, UK

3 Department of Anaesthesia, Nottingham University Hospitals NHS, Nottingham City Hospital, Nottingham, NG5 1PB, UK

4 Division of Anaesthesia and Intensive Care, University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH, UK

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BMC Anesthesiology 2012, 12:26  doi:10.1186/1471-2253-12-26

Published: 27 September 2012



The efficacy of epidural steroid injections in the management of chronic low back pain is disputed, yet the technique remains popular amongst physicians and patients alike. This study assesses the cost effectiveness of injections administered in a routine outpatient setting in England.


Patients attending the Nottingham University Hospitals’ Pain Clinic received two injections of methylprednisolone plus levobupivacaine at different dosages, separated by at least 12 weeks. Prior to each injection, and every week thereafter for 12 weeks, participants completed the EQ-5D health-related quality of life instrument. For each patient for each injection, total health state utility gain relative to baseline was calculated. The cost of the procedure was modelled from observed clinical practice. Cost effectiveness was calculated as procedure cost relative to utility gain.


39 patients provided records. Over a 13-week period commencing with injection, mean quality adjusted life year (QALY) gains per patient for the two dosages were 0.028 (SD 0.063) and 0.021 (SD 0.057). The difference in QALYs gained by dosage was insignificant (paired t-test, CIs -0.019 – 0.033). Based on modelled resource use and data from other studies, the mean cost of an injection was estimated at £219 (SD 83). The cost utility ratio of the two injections amounted to £8,975 per QALY gained (CIs 5,480 – 22,915). However, at costs equivalent to the tariff price typically paid to providers by health care purchasers, the ratio increased to £27,459 (CIs 16,779 – 70,091).


When provided in an outpatient setting, epidural steroid injections are a short term, but nevertheless cost effective, means of managing chronic low back pain. However, designation of the procedure as a day case requires the National Health Service to reimburse providers at a price which pushes the procedure to the margin of cost effectiveness.

Trial registration

ISRCTN 43299460