Epidural Corticosteroid Injections and Low Back Pain

Epidural steroid injections are an adjunct treatment, which facilitates participation in an active exercise program and may assist in avoiding the need for surgical intervention.

Written by Gerard Malanga, MD

Although epidural steroid injections (also called epidural corticosteroid injections) may be helpful to confirm a diagnosis, they should be used primarily after a specific presumptive diagnosis has been established. Also, injections should not be used in isolation, but rather in conjunction with a program stressing muscle flexibility, strengthening, and functional restoration.
Proper follow-up after injections to assess the patient's treatment response and ability to progress in the rehabilitation program is essential. A limited number of injections can be tried to reduce pain, but careful monitoring of the response is required prior to a second or third injection.

Epidural steroid injections are an adjunct treatment, which facilitates participation in an active exercise program and may assist in avoiding the need for surgical intervention.

Treatment Rationale
The rationale for the use of epidural corticosteroid injection has improved with the evidence of an inflammatory basis for radicular pain from disc herniation. Epidural steroids have been shown to be effective in pain reduction in patients with radicular pain, although controlled prospective trials are lacking. The efficacy is increased if used in the first weeks following onset.

The goal of these injections is to facilitate an active exercise program and to progress patients through the pain and inflammation stage of recovery as quickly as possible. As with all injections, it should be part of a comprehensive treatment plan involving active exercise.

How the Injection Is Performed

It is not necessary for most patients to undergo a set number or "series" of injections. If minimal to no improvement is found after two injections, then further similar injections are not warranted. The more recent use of a transforaminal approach allows the medication to be delivered in a more targeted fashion to the more ventral aspect of the spinal canal at the level of the presumed site of pathology.

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Use of Epidural Steroid Injections
Epidural injections and intradiscal injections have been used in the treatment of non-radicular degenerative disc disease with limited success.

In addition, epidural steroids have been used in patients with neurogenic claudication from spinal stenosis with mixed results. A limited number of injections can be tried in these patients to reduce pain thought to be at least in part mediated by inflammation.

SpineUniverse News/Research Comment: Important Updates on Epidural Steroid Injections
Epidural steroid injections are often touted for their ability to delay the need for spine surgery in patients who have a range of spinal disorders, including herniated discs, sciatica, and spinal stenosis. But, recent research suggests this benefit has its limitations.

In 2014, research showed that epidural steroid injections have a small effect on preventing or delaying surgery. The authors found that injections reduced the need for surgery in some patients, but this was a short-term effect (up to one year), and may not prevent or delay surgery beyond that.

“The main finding in this study is that there may be a weak surgery-sparing effect for ESI in the short term but not the long term,” the authors wrote.

A second study, published in 2015, focused on the effectiveness of epidural steroid injections in people with lumbar spinal stenosis. Researchers compared injections that contained a corticosteroid and lidocaine to injections that only contained lidocaine—and they found no “meaningful” difference between the two.

“…these results are consistent with the possibility that there is no meaningful benefit for lumbar spinal stenosis symptoms from epidural injections of lidocaine with corticosteroid versus epidural injections of lidocaine only…,” said Judith Turner, PhD, Professor of Psychiatry and Behavioral Sciences and Rehabilitation Medicine at the University of Washington, Seattle, WA.

Epidural steroid injections are among the most common non-surgical treatments for spinal disorders, and much research has been dedicated to better understanding this treatment. Here, we’ve described findings from 2 current studies, but they don’t represent the larger body of evidence on epidural steroid injections.

While these studies question certain aspects of epidural steroid injections’ effectiveness, that does not negate the fact that they can be a safe and effective part of a pain management plan. As with any treatment, setting the right expectations is essential. The best way to do that is to discuss the benefits and drawbacks with your doctor prior to beginning therapy.

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