Lumbar Epidural Injection

Spinal epidural injections are a non-surgical treatment to help relieve low back and leg pain. A pain management doctor explains the injection procedure.

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What Is the Spine's Epidural Space?

The membrane that covers the spinal cord and nerve roots in the spine is called the dura mater, a protective type of tissue. The space surrounding the dura mater is the epidural space. Nerves travel through the epidural space to the back and into the legs. Inflammation of these nerve roots may cause pain in these regions due to irritation from a damaged disc or from contract in some way with the bony structure of the spine.
Illustration of epidural anesthesia with catheter.Illustration shows many spinal structures including, the third and fourth lumbar (low back) vertebrae, spinal cord, subarachnoid space, and epidural space. Photo Source:

What Is an Epidural Spinal Injection, and How May It Help Reduce Back or Leg Pain?

A spinal epidural injection places anti-inflammatory medicine into a specific region of the spine's epidural space. The medication helps decrease inflammation of the nerve roots, hopefully reducing the pain in the back or legs. The epidural injection may help the injury heal by reducing inflammation. It may provide permanent relief or provide a period of pain relief for several months while the injury/cause of pain is healing.

What Happens During a Spinal Epidural Injection Procedure?

An intravenous line (IV) is started so that relaxation medication can be given. The patient is placed lying on their side on the x-ray table and positioned in such a way that the physician can best visualize the low back using x-ray guidance (sometimes called fluoroscopy).

fluoroscopic real time x-ray view of the lumbar spine during a procedureAn image of fluoroscopy (real time x-ray) shows what the doctor saw while performing a low back procedure, such as a spinal injection. Photo Source:

The skin on the patient's back is scrubbed using 2 types of sterile scrub (soap). Next, the physician injects a numbing medication into the skin area where the epidural injection will be administered (eg, L3-L4). This medicine stings for several seconds. After the numbing medicine has been given time to be effective, the physician directs a small needle, using x-ray guidance into the spine's epidural space. A small amount of contrast (dye) is injected to ensure the needle is properly positioned in the epidural space. A mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) is injected.
spinal injection with fluroroscopic guidancePictured is a patient laying face down on their stomach on the treatment table. Pillows help keep the patient comfortable. In the background, is the monitor the physician will view to precisely guide needle placement during the injection procedure. Photo Source: Shutterstock.

What Happens After a Lumbar Epidural Injection?

The patient is returned to the recovery area where they are monitored by medical staff for 30-60 minutes. Prior to discharge, the patient is asked to record their levels of pain relief during the next week using a post-injection evaluation sheet ("pain diary").

A follow-up appointment will be made for a repeat injection pain block, if indicated.

Depending on the patient’s level of pain relief, another injection may be administered in 2 weeks. The patient’s back or legs may feel weak or numb for a few hours. This is to be expected, but it does not always happen.

General Pre- and Post-injection Instructions for Lumbar Epidural Injections

A few hours before the procedure, the patient may be allowed to eat a light meal. If the patient has type 1 diabetes, they must not change their normal eating pattern prior to the procedure. Patients may take their routine medications (eg, high blood pressure, diabetic medications).

Patients should not take pain medications or anti-inflammatory medications the day of their procedure. Patients should be in pain prior to this procedure, so it’s important not to take medications relieve or lessen pain. These medicines can be restarted after the procedure, if they are needed.

If a patient is on coumadin (blood thinner) or glucophage (Metformin, a diabetes medicine), they must notify their treating physician so the timing of these medications can be explained.

In general, the patient is asked to be at the outpatient facility one hour prior to the procedure and can expect to be at that facility approximately 2-3 hours. A driver must accompany the patient and be responsible for getting them home. No driving is allowed the day of the procedure. Patients may return to their normal activities the day after the procedure, including returning to work.

SpineUniverse News/Research Comment:
Current Evidence on the Effectiveness of Epidural Steroid Injections

Epidural steroid injections are a common non-surgical treatment for several spinal disorders, and research is continuously refining the medical community’s understanding of this treatment. The more clinicians know about these injections, the better equipped they are to improve patient care and treatment outcomes.

A wealth of recent research exists on epidural steroid injections, but we’d like to highlight 2 specific studies that may be of interest to our readers.

The first study, which was published in 2015, focused on the effectiveness of epidural steroid injections on lumbar spinal stenosis symptoms (spinal stenosis affecting the low back is a common cause of back and leg pain).

The study’s authors compared 2 types of injections: The first contained corticosteroid plus lidocaine, and the second contained only lidocaine. The authors discovered that corticosteroid injections did not provide significant benefit over the lidocaine-only injections. The results questioned the effectiveness of a corticosteroid on symptom relief.

“These results suggest that although certain patient characteristics are associated with greater likelihood of good outcomes following either type of epidural injection for lumbar spinal stenosis symptoms (and possibly of good outcomes regardless of any treatment), there are no currently identified characteristics that predict a differential benefit from corticosteroid,” said Judith Turner, PhD, Professor of Psychiatry and Behavioral Sciences and Rehabilitation Medicine at the University of Washington, Seattle, WA.

The second study, which was published in 2014, questioned whether epidural steroid injections are effective at delaying or preventing spine surgery. While the authors found that the injections provide a short-term benefit—they may prevent the need for surgery for up to a year—the effectiveness isn’t long-term.

“Epidural steroid injections may provide a small surgery-sparing effect in the short term compared with control injections and reduce the need for surgery in some patients who would otherwise proceed to surgery,” the authors wrote.

So, while the injections may prevent or delay surgery, it’s more of a limited benefit than widely thought.

We note these studies not to discourage you from undergoing epidural steroid injections, but rather to help foster well-rounded discussions with your doctor. These injections have been shown to provide excellent pain relief in many patients (particularly those who have had symptoms for less than 3 months, not had a previous spine surgery, are younger than 60 years, and don’t smoke). However, epidural steroid injections are not magic bullets. Before starting injection therapy, talk to your doctor about the specific risks and benefits for you.

Commentary by Gerard Malanga, MD

Epidural Injections can be a very helpful adjunct in rehabilitation of patient's the spine pain that radiates into an arm or leg or in the thoracic spine around the chest or trunk. They work by placing cortisone (a potent anti-inflammatory medication) close to an inflamed nerve. This allows the patient to be fully able to regain full motion and increase the muscular support of the spine critical in the recovery and prevention of future episodes. They are generally not indicated in spine pain that does NOT radiate from an irritated spinal nerve. Most patients actually respond to just 1-2 injections; therefore, they should not be routinely performed in a "series of three".

In my experience, 60 % of patients require only one injection and only 10-20 % will require 3 injections. Certainly, if there is little or no pain relief after trying 2 injections, it is unlikely that the third injection will be of benefit. In addition, most patients can be treated with a local anesthetic without the need for sedation which requires an IV and a longer recovery immediately after the procedure.

Commentary by Leonardo Kapural, MD, PhD

Epidural glucocorticoid injections are commonly given to relieve pain and improve mobility without surgery, buying time for healing to occur or as an attempt to avoid surgery after other conservative approaches failed. Those injections have a good theoretical rationale, but they do not help every patient. Who then should receive an epidural glucocorticoid injection and how many? For leg pain greater than the back pain, guidelines from a respected source (Abram SE. Treatment of Lumbosacral Radiculopathy with Epidural Steroids. Anesthesiology. 1999:12(91):1937) suggest that patients who had full pain relief from the first epidural injection should not receive another one but to be re-evaluated in 4 weeks and followed thereafter.

Those patients who still have some residual pain after the first injection should receive a second and third injection and patients who did not get any benefit from the first injection should not receive another one. Patient selection is very important in deciding on the type of injections patients should receive. Transforaminal injections (different approach to the epidural space) may produce longer pain relief and may also predict whether a patient might benefit from surgery or not (for details, see McLain RF, Kapural L, Mekhail NA. Epidural steroid therapy for back and leg pain: mechanisms of action and efficacy. Spine. 2005;5(2):191-201). For patients with the diagnosis of lumbar canal stenosis, improvement after such injections may be longer lasting than it was initially thought.

Commentary by Steven Richeimer, MD

Epidural injections can be done at any level of the spine: cervical (neck), thoracic (mid-back), lumbar (low back), and sacral (tailbone area). The thoracic epidural may be a valuable tool in the treatment of mid-back and chest wall pains. These problems might be caused by disc problems, arthritis of the spine, or even shingles.

Updated on: 03/25/19
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Epidural Corticosteroid Injections and Low Back Pain
Gerard Malanga, MD
New Jersey Sports Medicine, LLC
New Jersey Regenerative Institute
Leonardo Kapural, MD, PhD
Pain Physician
Carolinas Pain Institute
Steven Richeimer, MD
Chief, Division of Pain Medicine
Keck School of Medicine
University of Southern California
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