When Do Epidural Steroid Injections Work for Back Pain?

For most people with back pain, surgery is recommended only after all other options have been exhausted.

A common nonsurgical approach to pain relief is epidural steroid injections, which help reduce inflammation around your spinal cord and spinal nerves. They are primarily intended for temporary pain relief, but steroid injections coupled with therapeutic exercise may allow patients to postpone or even avoid surgery altogether.

Read on to learn about how this injection treatment can help alleviate your back pain.

What type of back pain may be treated with epidural steroid injections?

Epidural steroid injections are most often used to treat lower back and leg pain caused by spinal nerves. This pain is commonly referred to as sciatica and/or radiculopathy and occurs when a spinal nerve root in your lower back is pinched or compressed, sending pain and other neurological symptoms down the buttock and thigh, into your leg or foot.

Your spinal nerve roots may be affected by problems related to the bones, discs, and/or soft tissues in your lower back.

Read more about Causes of Lower Back Pain

What are the common medical conditions treated with epidural steroid injections?

Epidural injections may be used to treat sciatica caused by the following common lower back conditions:

• Herniated discs: When the inner soft contents of a disc push through the outer layers.
• Degenerated discs: When a disc loses fluid and shrinks, reducing in height.
• Foraminal spinal stenosis: When the bony openings for spinal nerve roots become narrow, causing compression.
• Spondylolisthesis: When a vertebra slips over the one below it.

These injections may also be used to treat nerve pain caused by spinal cysts (fluid-filled sacs) or vertebral fractures.

What factors can influence the outcome of my injection treatment?

The outcome of your epidural steroid injection may depend on one or more of the following factors:

• Condition being treated: These injections are typically more effective in treating lower back pain with leg pain versus lower back pain alone. ¹ Patel K, Upadhyayula S. Epidural Steroid Injections. [Updated 2019 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470189/ ^{, 2} Hassan KZ, Sherman Al. Epidural Steroids. [Updated 2019 May 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-.Available from: https://www.ncbi.nlm.nih.gov/books/NBK537320/ There are different injection techniques that can be utilized for conditions affecting lower back pain without leg pain (such as facet joint injections or radiofrequency ablation).
• Injection technique: Epidural injections can be administered in several ways. The goal is to reach the epidural space that surrounds the spinal cord. Research indicates that the transforaminal route, where the needle is inserted through the intervertebral foramen on the side of the spinal canal may target the nerve roots more specifically to control pain and inflammation. The other routes include the interlaminar and caudal routes, which are more non-specific. ¹ Patel K, Upadhyayula S. Epidural Steroid Injections. [Updated 2019 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470189/ ^{, 3} Bartleson JD, Maus TP. Diagnostic and therapeutic spinal interventions: Epidural injections. Neurol Clin Pract. 2014;4(4):347–352. doi:10.1212/CPJ.0000000000000043 ^{, 4} Pountos I, Panteli M, Walters G, Bush D, Giannoudis PV. Safety of Epidural Corticosteroid Injections. Drugs R D. 2016;16(1):19–34. doi:10.1007/s40268-015-0119-3

  See Epidural Injection Procedure

• Choice of steroid: The steroids used for epidural injections may be water-soluble (non-particulate) or poorly soluble (particulate) steroids. The poorly soluble steroids usually have a longer-term effect. ² Hassan KZ, Sherman Al. Epidural Steroids. [Updated 2019 May 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-.Available from: https://www.ncbi.nlm.nih.gov/books/NBK537320/ ^{, 5} Knezevic NN, Jovanovic F, Voronov D, Candido KD. Do Corticosteroids Still Have a Place in the Treatment of Chronic Pain?. Front Pharmacol. 2018;9:1229. Published 2018 Nov 1. doi:10.3389/fphar.2018.01229 ^{, 6} Dietrich TJ, Sutter R, Froehlich JM, Pfirrmann CWA. Particulate versus non-particulate steroids for lumbar transforaminal or interlaminar epidural steroid injections: an update. Skeletal Radiology. 2014;44(2):149-155. doi:10.1007/s00256-014-2048-6
• Addition of anesthetics to the steroid: Some injection preparations may contain local anesthetics, which act faster than steroids and help reduce pain signals from inflamed nerves. ⁷ Chang, Douglas, Zlomislic, Vinko. Chapter 273. Lumbar Spinal Injections. In: Chapman, Michael W. Chapman's Orthopaedic Surgery. Philadelphia: Lippincott Williams & Wilkins. https://www.researchgate.net/publication/327034223_Lumbar_spinal_injections_Chapman's_Orthopaedic_Surgery_Chapter_273. Accessed December 23, 2019.

You may have improved pain and functional outcomes when you combine your epidural steroid injection treatment with a comprehensive rehabilitation program. ⁸ van Helvoirt H, Apeldoorn AT, Ostelo RW, et al. Transforaminal Epidural Steroid Injections Followed by Mechanical Diagnosis and Therapy to Prevent Surgery for Lumbar Disc Herniation. Pain Medicine. 2014;15(7):1100-1108. doi:10.1111/pme.12450 Ideally, this combination utilizes the anti-inflammatory effect of the epidural steroid injection to reduce the symptoms, which in turn allows for better progress in the rehabilitation program and consequent long-term improvement.

See Epidural Steroid Injection Pain Relief Success Rates

What should I discuss with my doctor?

If you plan to consider an epidural steroid injection treatment for your back pain, discuss the following points with your doctor:

• How will this treatment benefit my underlying condition?
• What is the typical success rate for this treatment?
• How long will the pain relief last?
• Will I need more than one injection?
• What are the potential side effects and risks?
• Are there any reg-flag symptoms that I need to watch out for?

See Epidural Steroid Injections: Risks and Side Effects

If you are taking any medications, have concomitant medical conditions, or have any other questions regarding this injection treatment, be sure to discuss them with your doctor.

Doctors typically recommend epidural steroid injection treatments after a few weeks of nonsurgical options, such as physical therapy and exercise, have been tried. These injections may help improve lower back and leg pain in the short term and help you participate better in a rehabilitation program.

Learn more:

How Epidural Steroid Injections Work

Indications for Lumbar Epidural Injections