Someone with chronic back pain will contact our office and ask us about Epidural steroid injections. Typically they will ask one of two questions: “Do Epidural steroid injections work?” Or question two: “Why didn’t Epidural steroid injection(s) work for me?” In response to the second question we will ask, “Did the injection help at all?” The usual response? “It worked for a couple of weeks.” Epidural Spinal Injections as we will see in the research below are not a substitute for the eventual need for spinal surgery. They are a stop gap to hold you over until you can get the surgery.
Epidural spinal injections do not prevent the need for subsequent spinal surgery or provide long-term relief for many
Epidural steroid injection is not a curative treatment. As an anti-inflammatory treatment it may help for a short while in reducing pain causing pressure on the spinal nerves, but, for many, it is not long-lasting. This is why research tells us that it is not a spinal surgery preventative.
Our research journey will begin here in 2013 and we will bring this research current to 2020.
In a 2013 study in the International journal of technology (1) assessment in health care, investigators wrote:
“Epidural steroid injection did not improve back-specific disability more than a placebo. . . “
“Epidural steroid injection did not significantly decrease the number of patients who underwent subsequent surgery compared with a placebo. . . “
” A long-term benefit of epidural steroid injections for low back pain was not suggested at 6 months or longer.”
Five years later, in June 2018, a study from Stanford University School of Medicine published in the Spine Journal (2) said this right at the top of the paper:
“Lumbosacral epidural steroid injections have increased dramatically despite a narrowing of the clinical indications for use.”
It can be challenging to make sense of that statement to a patient with back pain. The research evidence to support the use of Epidural steroid injections is weakening, but doctors are giving more of them. At least in 2018 they were.
Let’s continue with the Stanford research
Within 6 months, 12.5% of Epidural steroid injection patients underwent lumbar surgery.
By 1 year, 16.9% had surgery
By 5 years, 26.1% had surgery
Patients with herniation had surgery at rates of up to five times to seven times higher, with the highest rates of surgery in younger patients and those with both herniation and stenosis.
“In the long term, more than one out of every four patients undergoing Epidural steroid injection for lumbar herniation or stenosis subsequently had surgery, and nearly one of six had surgery within the first year.”
A December 2019 study, (3) citing this research in its findings also found that use of Epidural steroid injection before surgery offered greater risk of complication in the form of incidental durotomy,damage to the dura mater, the membrane covering the spinal cord.
An 2018 study from Stanford made these observations in patients 5 years after an initial transforaminal epidural steroid injection(s). This study also appeared the Spine Journal. (4) : “Patients with lumbosacral radiculopathy from an intervertebral disc herniation are frequently treated by transforaminal epidural steroid injections. The long-term outcomes of these patients are poorly described.” A transforaminal epidural steroid injection is given at the foramen where a nerve roots exits the spine.
Despite a high success rate at 6 months, the majority of (patients) experienced a recurrence of symptoms
“Despite a high success rate at 6 months, the majority of (patients) experienced a recurrence of symptoms at some time during the subsequent 5 years. Fortunately, few reported current symptoms, and a small minority required additional injections, surgery, or opioid pain medications. Lumbar disc herniation is a disease that can be effectively treated in the short-term by transforaminal epidural steroid injections or surgery, but long-term recurrence rates are high regardless of treatment received.”
Do Epidural spinal injections really provide any benefit? Are they worth the risks?
Dr. Nancy Epstein of the The Albert Einstein College of Medicine wrote in the journal Surgical neurology international (5) of the risks of epidural and transforaminal steroid injections in the spine. That in fact was the title of her research study.
In this research Dr. Epstein suggests:
For many patients with spinal pain alone and no surgical lesions, the “success” of epidural injections may simply reflect the self-limited course of the disease.
Alternatively, although those with surgical pathology may experience transient or no pain relief, undergoing these injections (typically administered in a series of three) unnecessarily exposes them to the inherent risks, while also delaying surgery and potentially exposing them to more severe/permanent neurological deficits.
The suggestion here is that the back pain would have gone away on its own without the need for the epidural. Secondly, some people do require spinal surgery, especially in some instance of failed back surgery where there can be elevated risk for neurological damage. The concern is that epidurals are offered to patients who should be sent to surgical consultation.
In conclusion, Dr. Epstein writes: “Although the benefits for epidural steroid injections may include transient pain relief for those with/without surgical disease, the multitude of risks attributed to these injections outweighs the benefits.”
In 2020, a paper published in the journal Pain Medicine (6) noted two “myths” concerning Epidural steroid injections
Myth # 1 Epidural steroid injections (ESIs) can be repeated without concern regarding the duration of time between injections.
Myth # 2: A “series” of ESIs is sometimes required regardless of the clinical response to a single ESI.
Fact: “After an ESI, a period of up to 14 days may be needed to assess the clinical response. . .There is no evidence to support routine performance of a “series” of repeat injections”
Researchers: Just get the surgery – don’t waste time on epidurals.
People get epidural steroid injections because the alternative is surgery. Many people are not convinced surgery can help them or they do not want to get the surgery because they are a primary care provider or need to work. But are epidural steroid injections any benefit?
An August 2021 paper (7) suggested that doctors not offer multiple epidurals and basically after the first injection, get these patients to surgery. This is what the authors wrote:
“Physicians use a structured decision-making process (an algorithm) to decide how best to treat lumbar spinal stenosis that results from abnormal thickening of the spinal ligaments that run the length of the spinal cord. Early treatments can include one or more epidural steroid injections. This study evaluated a change to the algorithm that involves earlier intervention with a minimally invasive, short outpatient procedure that removes a major root cause of the abnormal thickening (lumbar decompression) and leaves no implants behind. (The surgery does not leave fusion hardware behind because it is not a fusion). Records of patients treated with minimally-invasive lumbar decompression (mild®) after receiving either a single ESI procedure or none at all, were compared with the records of patients who underwent the mild procedure after receiving two or more ESIs (145 total patients). The patients’ pain scores before surgery, at one week post-surgery and at three months post-surgery were reviewed.
The improvements in pain scores following the minimally-invasive lumbar decompression procedure were compared within each group and between the two groups. The improvements in pain scores at both the one-week and three-month follow-up visits indicated that the minimally-invasive lumbar decompression procedure had a positive effect for both groups. Further, there were no significant differences in how much pain scores improved when the two groups were compared. Since neither group experienced significantly more pain relief than the other, there appears to be no benefit to having multiple epidural steroid injections procedures before undergoing the minimally-invasive lumbar decompression procedure. The authors recommend that the algorithm be modified to perform the minimally-invasive lumbar decompression procedure either as soon as lumbar spinal stenosis is diagnosed or after the failure of the first epidural steroid injections procedure.
Another non-surgical treatment option
At the Magaziner Center for Wellness we have seen many patients who suffer from back pain. Not just short-term back pain, but back pain that has challenged the patient for years and decades. These people continue to suffer from back pain while their doctors try to figure out what is wrong with them. Why is it so hard to figure out what is wrong with them? Why have so many treatments, and even possibly surgery, failed them?
Many people we see with chronic, debilitating back pain, have an MRI that shows a disc pressing on the nerves, we do not go in and treat the disc or the area with anti-inflammatories. We treat the supporting structures around it with Prolotherapy, Platelet Rich Plasma injections or stem cell injections.. We treat the ligaments, the tendon attachments, the connective soft tissue. We also treat and strengthen the supporting structures of the pelvis with PRP injections.
If you would like to options for your back pain, please contact our office so we can start a conversation with you.
1 Choi HJ, Hahn S, Kim CH, Jang BH, Park S, Lee SM, Park JY, Chung CK, Park BJ. Epidural steroid injection therapy for low back pain: a meta-analysis. Int J Technol Assess Health Care. 2013 Jul;29(3):244-53. doi: 10.1017/S0266462313000342. Epub 2013 Jun 17.
2 Koltsov JC, Smuck MW, Zagel A, Alamin TF, Wood KB, Cheng I, Hu SS. Lumbar epidural steroid injections for herniation and stenosis: incidence and risk factors of subsequent surgery. The Spine Journal. 2018 Jun 26.
3 Labaran LA, Puvanesarajah V, Rao SS, Chen D, Shen FH, Jain A, Hassanzadeh H. Recent Preoperative Lumbar Epidural Steroid Injection Is an Independent Risk Factor for Incidental Durotomy During Lumbar Discectomy. Global Spine Journal. 2019 Dec;9(8):807-12.
4 Kennedy DJ, Zheng PZ, Smuck M, McCormick ZL, Huynh L, Schneider BJ. A minimum of 5-year follow-up after lumbar transforaminal epidural steroid injections in patients with lumbar radicular pain due to intervertebral disc herniation. The Spine Journal. 2018 Jan 1;18(1):29-35.
5 Epstein NE. The risks of epidural and transforaminal steroid injections in the Spine: Commentary and a comprehensive review of the literature. Surg Neurol Int. 2013;4(Suppl 2):S74-93. Published 2013 Mar 22. doi:10.4103/2152-7806.109446
6. Mattie R, Schneider BJ, Smith C. Frequency of Epidural Steroid Injections. Pain Med. 2020;21(5):1078‐1079. doi:10.1093/pm/pnaa053
7 Pryzbylkowski P, Bux A, Chandwani K, Khemlani V, Puri S, Rosenberg J, Sukumaran H. Minimally invasive direct decompression for lumbar spinal stenosis: impact of multiple prior epidural steroid injections. Pain Management. 2021 Jul(0).