Epidural Steroid Injections: Frequently Asked Questions

What are epidural steroid injections?

Epidural steroid injections place corticosteroid medication directly around a pinched nerve as it exits the spine within the epidural space. The epidural space is located where the bones and discs of the spine surround the nerves and spinal cord. This is the space into which disc tissue can herniate and cause pressure and inflammation around spinal nerves.

What are epidural corticosteroid injections used for?

Epidural steroid injections are commonly used to treat back pain caused by a herniated disc (slipped disc), lumbar or cervical radiculopathy, spinal stenosis or sciatica. Corticosteroids are strong anti-inflammatory medications and, when placed into the epidural space, can significantly reduce inflammation around an irritated nerve that is causing back and leg pain and discomfort.

What kind of steroids are used in epidural steroid injections?

The most commonly used steroids in epidural injections are dexamethasone, betamethasone, methylprednisolone, and triamcinolone. The choice of agent and dose is based on patient factors, response to prior injections, the region of the spine being injected, and the epidural approach.

Who can benefit from an epidural steroid injection?

Patients with several common conditions – including lumbar disc herniation, degenerative disc disease, lumbar radiculopathy, sciatica, lumbar spinal stenosis, postherpetic neuralgia and facet/synovial cysts – may benefit from an epidural injection. An epidural steroid injection may be an effective nonsurgical treatment in itself or may aid in surgical planning.

How do epidural corticosteroid injections work?

Epidural steroid injections work by delivering a potent anti-inflammatory to the site of nerve impingement in the spine. Injected medications may include steroids, local anesthetics, and saline, and they can vary in volume and concentration on an individual basis. While epidural injections for other applications may not require image guidance, epidural steroid injections for pain management are routinely performed with fluoroscopic or X-ray guidance to ensure correct, effective, and safe deposition of the injected medications. In select cases, CT or ultrasound guidance may be used as an alternative if indicated.

Cervical and thoracic epidural steroid injections

Epidural steroid injections in the cervical and thoracic spine can be used to treat cervical or thoracic herniated discs, radiculopathy, degenerative disc disease, or spinal stenosis. In the cervical region (neck), these conditions cause pain and neuropathies that radiate to the arm and hand. In the thoracic region (upper back and chest), pain can radiate to the ribs or flank. Injections may be done using an interlaminar or transforaminal technique as described below.

Caudal, interlaminar and transforaminal epidural corticosteroid injections

Three routes may be used for epidural injections in the lumbosacral spine (the vertebrae in the lumbar spine and sacrum of the lower back)

• caudal
• interlaminar (also known as translaminar)
• transforaminal

Your physician will choose which method is right for you based on your diagnosis and if you have had any prior spine surgeries.

• A caudal epidural steroid injection is the least complicated way to access the epidural space but is also the least specific. It can be useful if multiple areas of the spine are involved or if post-surgical changes prevent other approaches.
• An interlaminar or translaminar epidural steroid injection delivers the medication directly into the epidural space at the affected level, can be targeted to one side or the other, and can treat multiple levels or both sides at once.
• A transforaminal epidural steroid injection delivers the medication to the area where the specific affected nerve root exits the spine and is compressed by a disc herniation. It is the usual first choice approach for an epidural injection in the lumbar spine.

How often can you get epidural steroid injections?

Epidural steroid injections are recommended to be administered up to three to six times per year. In the case of a new disc herniation, injections may be only weeks apart with a goal of quick and complete resolution of symptoms. For chronic conditions, three to six months or more between injections is common.

How long do epidural injections last for back pain?

Epidural steroid injections can help resolve pain permanently in patients with a new disc herniation who respond favorably. For patients with chronic pain or recurrent disc herniations, the desired duration of effect is three to six months or more.

What are the risks of epidural steroid injections?

The risks in any procedure involving a needle include bleeding, infection and nerve damage. When performed properly, the risk of any of these is exceedingly low and usually outweighed by the potential benefit of the procedure.

Some contraindications for performing epidural steroid injections include:

• bleeding disorders or anticoagulation
• medication allergies (rare)
• systemic infection or localized infection overlying the area

Risks and benefits of repeated epidural steroid injections should be weighed on a case-by-case basis for patients who have or are at-risk for osteoporosis, as some evidence suggests repeated steroid injections can accelerate bone loss.

What are the side effects of epidural steroid injections?

Common side effects include mild injection site pain, temporary worsening of usual pain, flushing, insomnia, or increased blood sugar. These are usually self-limited and resolve within one to three days. A less common side effect is headache.

Is any preparation required? Can I eat before and after my epidural steroid injection?

Your doctor will give you specific instructions and these will vary by facility and type of epidural (lumbar, thoracic or cervical). Because the procedure is usually performed with local anesthetic rather than sedation, fasting guidelines are not overly prohibitive.

Is any anesthesia used? Are epidural steroid injections painful?

A local anesthetic is injected into the skin, numbing the area where the epidural needle is then placed. Patients may experience mild discomfort but should not experience severe pain during the procedure.

Will I have to lie flat on my stomach for long during or after the procedure?

The procedure can last anywhere from 10 to 20 minutes and requires the patient to lie prone, if possible, to allow for X-ray guidance (fluoroscopy). After the procedure, you can sit, stand, and walk as usual after a short period of monitoring.

What kind of doctor performs epidural steroid injections?

Epidural steroid injections at HSS are performed by several types of doctors – pain management physicians, physiatrists and interventional radiologists – all of whom are trained to safely perform this procedure, often with additional subspecialty fellowship training.

Updated: 6/1/2023

Authors

Anuj Malhotra, MD
Director, Pain Management Division, Hospital for Special Surgery
Assistant Attending Anesthesiologist, Pain Management, Hospital for Special Surgery

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References

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