Lumbar Epidural Steroid Injections for Low Back Pain and Sciatica

Epidural steroid injections (ESIs) are a common treatment option for many forms of lower back pain and leg pain. They have been used for decades and are considered an integral part of the nonsurgical management of sciatica and lower back pain.

The injection is named an epidural steroid injection because it involves injecting a local anesthetic and a steroid medication directly into the epidural space that surrounds the spinal cord and nerve roots.¹Patel 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/

The Essential Goals of Epidural Steroid Injections for Lower Back Pain Relief

The goals of an epidural steroid injection are to:

• Control pain by reducing inflammation in and around the nerve roots
• Improve mobility and function in the lower back and legs¹Patel 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/
• Allow the patient to participate in and make progress with a comprehensive physical therapy and rehabilitation program

In the course of one’s care program, in most cases, an epidural steroid injection may be recommended after a series of nonsurgical treatments, such as medications and physical therapy,²Knezevic NN, Mandalia S, Raasch J, Knezevic I, Candido KD. Treatment of chronic low back pain - new approaches on the horizon. J Pain Res. 2017;10:1111–1123. Published 2017 May 10. doi:10.2147/JPR.S132769 have been tried, and before surgery is considered.

The role of the injection is typically to provide sufficient pain relief to allow a return to everyday activities and to make progress in physical therapy.

Potential Benefits of Epidural Steroid Injections

Most practitioners will agree that an epidural injection can be beneficial during an acute episode of back and/or leg pain. The main drawbacks of the injections are that they are not always effective, and when effective, the pain relief tends to be temporary, ranging from one week to one year. Typically, if the initial injection is effective, up to 3 injections may be given in one year.

When administered in the lumbar epidural space, steroid injections may have the following benefits:

• Reduce nerve pain and inflammation. Steroids decrease the production of inflammatory chemicals and reduce the sensitivity of nerve fibers to pain, generating fewer pain signals.³Chang, 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 June 26, 2019.^,4Hassan 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/
• Limit oral medication. Pain relief from these injections may help limit or eliminate the need for oral medications,⁴Hassan 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/ some of which may have side effects when taken long-term.
• Continue or re-engage in physical therapy. This injection may provide sufficient pain relief to allow a patient to progress with a rehabilitative physical therapy program.¹Patel 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/
• Postpone surgery. Pain relief experienced from lumbar epidural steroid injections may help postpone surgery, and if physical therapy is effective, it may eliminate the need for surgical intervention.⁴Hassan 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/^,5Bicket MC, Horowitz JM, Benzon HT, Cohen SP. Epidural injections in prevention of surgery for spinal pain: systematic review and meta-analysis of randomized controlled trials. The Spine Journal. 2015;15(2):348-362. doi:10.1016/j.spinee.2014.10.011

Several techniques may be used to administer an epidural injection depending on underlying the condition, the patient’s needs, and the doctor’s preference and experience.

Epidural Injection Approaches

This type of injection can provide acute and significant pain relief because it introduces a steroid medication with strong anti-inflammatory effects directly into the painful area near the spinal nerve(s). An epidural injection may be given using any one of the following approaches:

• Transforaminal route: This technique allows precise administration of the steroid solution into the epidural space, near the area where the nerve is likely to be irritated. This injection technique targets specific nerve roots to control inflammation and pain.¹Patel 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/^,6Bartleson JD, Maus TP. Diagnostic and therapeutic spinal interventions: Epidural injections. Neurol Clin Pract. 2014;4(4):347–352. doi:10.1212/CPJ.0000000000000043
• Interlaminar route: In this technique, the needle is inserted from the back of the spine and the medication is deposited into the epidural space. This method is less precise because it does not deposit the medication near the target nerve root, and the steroid solution is free to spread within the epidural space.¹Patel 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/^,7Pountos 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
• Caudal route: This is a general approach is simple to administer, but medication doesn’t go directly to the source of the pain in the epidural space and around the nerves. The caudal approach may be less effective but is considered safer and easier to perform. This method may help control widespread or diffused pain.³Chang, 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 June 26, 2019.^,7Pountos 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

Effectiveness of Epidural Steroid Injections

Available research indicates generally favorable results, with 70% to 90% of patients experiencing pain relief from these injections, lasting for a week to a year.¹Patel 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/^,8Pandey RA. Efficacy of Epidural Steroid Injection in Management of Lumbar Prolapsed Intervertebral Disc: A Comparison of Caudal, Transforaminal and Interlaminar Routes. J Clin Diagn Res. 2016;10(7):RC05–RC11. doi:10.7860/JCDR/2016/18208.8127 If a good first response is seen, a second injection may be considered when the improvement from the first injection begins to taper off. Typically, up to 3 injections may be given over a 12-month period.¹Patel 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/^,6Bartleson JD, Maus TP. Diagnostic and therapeutic spinal interventions: Epidural injections. Neurol Clin Pract. 2014;4(4):347–352. doi:10.1212/CPJ.0000000000000043

While many studies have documented the short-term benefits of epidural steroid injections, the data on long-term effectiveness are less convincing. Controversy persists regarding their effectiveness in reducing pain and improving the function. Literature both supporting and opposing them are available.⁶Bartleson JD, Maus TP. Diagnostic and therapeutic spinal interventions: Epidural injections. Neurol Clin Pract. 2014;4(4):347–352. doi:10.1212/CPJ.0000000000000043

In addition, there are several limitations in the research that has been conducted, such as:

• Many studies do not include the use of fluoroscopy or x-ray to verify the proper placement of the medication despite the fact that fluoroscopic guidance is routinely used today.
• Other studies do not classify patients according to diagnosis and tend to 'lump' different types of pain sources together.

These methodological flaws tend to limit the usefulness of the research. More studies are needed to define the role of epidural steroid injections in lower back pain and sciatica.

When Epidural Steroid Injections May be Used

Lumbar epidural injections are typically used in the treatment of conditions that cause irritation and/or inflammation of spinal nerve roots with associated lower back and leg pain. Most common lower back conditions treated include¹Patel 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/:

• Lumbar Herniated disc(s)
• Lumbar Degenerative disc disease
• Lumbar Spinal stenosis

Less commonly, localized back pain (axial back pain) and neurogenic claudication (back pain and leg pain that occurs while walking) may be treated with these injections.³Chang, 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 June 26, 2019.^,6Bartleson JD, Maus TP. Diagnostic and therapeutic spinal interventions: Epidural injections. Neurol Clin Pract. 2014;4(4):347–352. doi:10.1212/CPJ.0000000000000043

Who Performs the Injections

Doctors who administer this type of injection include spine and pain management specialists, such as physiatrists, anesthesiologists, radiologists, neurologists, and spine surgeons. The injection procedure typically takes place in a surgery center, hospital, or a physician's clinic.

Managing Side Effects: Temporary Discomfort and Risks of Epidural Steroid Injections 

Epidural steroid injections are considered a relatively safe and minimally invasive. Temporary side effects may occur in some cases and include (but are not limited to):

• Post-injection pain
• Nausea
• Headache
• Dizziness
• Fainting (vasovagal attack)
• Flushing of the face

These side effects typically resolve in a few minutes to hours. Serious complications, while rare, may include spinal cord damage, dural puncture, and/or stroke.⁹Manchikanti L, Buenaventura RM, Manchikanti KN, et al. Effectiveness of therapeutic lumbar transforaminal epidural steroid injections in managing lumbar spinal pain. Pain Physician. 2012;15(3):E199-245. Available from: https://pubmed.ncbi.nlm.nih.gov/22622912/^,10Ter Meulen BC, Maas ET, Vyas A, et al. Treatment of acute sciatica with transforaminal epidural corticosteroids and local anesthetic: design of a randomized controlled trial. BMC Musculoskelet Disord. 2017;18(1):215. Published 2017 May 25. doi:10.1186/s12891-017-1571-8

See Epidural Steroid Injections: Risks and Side Effects

Lower risk at spinal levels L4 and below

In general, epidural injections administered for spinal levels L4 or lower carry a lesser risk of complication(s) compared to higher levels.¹⁰Ter Meulen BC, Maas ET, Vyas A, et al. Treatment of acute sciatica with transforaminal epidural corticosteroids and local anesthetic: design of a randomized controlled trial. BMC Musculoskelet Disord. 2017;18(1):215. Published 2017 May 25. doi:10.1186/s12891-017-1571-8^,11Schneider B, Varghis N, Kennedy DJ. Ideal Corticosteroid Choice for Epidural Steroid Injections: A Review of Safety and Efficacy. Curr Phys Med Rehabil Rep (2015) 3:151–158 DOI 10.1007/s40141-015-0086-1 The injections are typically performed under fluoroscopy (x-ray guidance) with a contrast dye. Fluoroscopy helps guide the needle to the accurate location and helps prevent nerve and/or artery damage.¹Patel 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/

Specific concomitant medical conditions may raise risk

The injections are typically not given when certain complicating medical conditions are present, such as infections, tumors, or bleeding disorders. Additionally, the injections may not be given in case of uncontrolled diabetes mellitus, certain heart conditions, and pregnancy.¹Patel 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/

Sedatives and/or anesthetics may be used

If necessary, a relaxation medication may be given through an intravenous (IV) line in the patient’s arm, but the patient is usually conscious during this procedure. The treatment area in the lower back is numbed with a local anesthetic injection before the epidural is given, so the epidural injection procedure is usually painless.

An epidural steroid injection procedure may take about 30 minutes to administer. A tingling or mild burning sensation or the feeling of pressure may be experienced as the medication enters the epidural space. When the injection is completed, the irritation and discomfort usually disappear within a few minutes. Patients typically return home after a few hours. Specific post-injection precautions are followed over the next few days.