Epidural Steroid Injection, ESI, spine injections, steroid shots in spine, back pain injections, back pain shots (2022)

Overview

An epidural steroid injection (ESI) is a minimally invasive procedure that can help relieve neck, arm, back, and leg pain caused by inflamed spinal nerves due to spinal stenosis or disc herniation. Medicines are delivered to the epidural space, which is a fat-filled area between the bone and the protective sac of the spinal nerves. Pain relief may last for several days or even years. The goal is to reduce pain so that you may resume normal activities and a physical therapy program.

What is an epidural steroid injection (ESI)?

A steroid injection includes both a corticosteroid (e.g., triamcinolone, methyl-prednisolone, dexamethasone) and an anesthetic numbing agent (e.g., lidocaine or bupivacaine). The drugs are delivered into the epidural space of the spine, which is the area between the bony vertebra and the protective dura sac surrounding the spinal nerves and cord (Fig. 1).

Epidural Steroid Injection, ESI, spine injections, steroid shots in spine, back pain injections, back pain shots (1)

Corticosteroid injections can reduce inflammation and can be effective when delivered directly into the painful area. Unfortunately, the injection does not make a herniated disc smaller; it only works on the spinal nerves by flushing away the proteins that cause swelling. The pain relief can last from days to years, allowing your spinal condition to improve with physical therapy and an exercise program.

Who is a candidate?

Patients with pain in the neck, arm, low back, or leg (sciatica) may benefit from ESI. Specifically, those with the following conditions:

  • Spinal stenosis: A narrowing of the spinal canal and nerve root canal can cause back and leg pain, especially when walking.
  • Spondylolisthesis: A weakness or fracture between the upper and lower facets of a vertebra. If the vertebra slips forward, it can compress the nerve roots causing pain.
  • Herniated disc: The gel-like material within the disc can bulge or rupture through a weak area in the surrounding wall (annulus). Irritation, pain, and swelling occur when this material squeezes out and comes in contact with a spinal nerve.
  • Degenerative disc: A breakdown or aging of the intervertebral disc causing collapse of the disc space, tears in the annulus, and growth of bone spurs.
  • Sciatica: Pain that courses along the sciatic nerve in the buttocks and down the legs. It is usually caused by compression of the 5th lumbar or 1st sacral spinal nerve.

ESI has proven helpful for some patients in the treatment of painful inflammatory conditions. ESI can also help determine whether surgery might be beneficial for pain associated with a herniated disc. When symptoms interfere with rehabilitative exercises, epidurals can ease the pain enough so that patients can continue their physical therapy.

ESI should NOT be performed on people who have an infection or have bleeding problems. The injection may slightly elevate the blood sugar levels in patients with diabetes. It may also temporarily elevate blood pressure and eye pressure for patients with glaucoma. You should discuss this with your physician.

If you think you may be pregnant, tell the doctor. Fluoroscopy x- rays may be harmful to the baby.

(Video) Epidural Steroid Injections

Who performs the procedure?

Physicians who perform epidural steroid injections include physiatrists (PM&R), radiologists, anesthesiologists, neurologists, and surgeons.

What happens before treatment?

The doctor who will perform the procedure reviews your medical history and previous imaging studies to plan the best approach for the injections. Be prepared to ask any questions at this appointment.

Patients who take take blood thinning medication (Coumadin, Plavix, etc.) may need to stop taking it several days before the ESI. Discuss any medications with your doctors, including the one who prescribed the medication and the doctor who will perform the injection.

The procedure is usually performed in an outpatient center using x-ray fluoroscopy. Make arrangements to have someone drive you to and from the center the day of the injection.

What happens during treatment?

At the time of the procedure, you will be asked to sign consent forms, list medications you are presently taking, and if you have any allergies to medication. The procedure may last 15-45 minutes, followed by a recovery period.

The goal is to inject the medication as close to the painful nerve as possible. The type of injection depends on your condition and if you have metal rods or screws from previous surgery. The doctor will decide which type is likely to produce the best results.

Step 1: prepare the patient
The patient lies on an x-ray table. Local anesthetic is used to numb the treatment area so discomfort is minimal throughout the procedure. The patient remains awake and aware during the injection to provide feedback to the physician. A low dose oral sedative, such as Valium or Versed, may be offered depending on the center.

(Video) Ease Chronic Back Pain With Epidural Steroid Injections

Step 2: insert the needle
With the aid of an x-ray fluoroscope, the doctor directs a hollow needle through the skin and between the bony vertebrae into the epidural space. Fluoroscopy allows the doctor to watch the needle in real-time on the x-ray monitor, ensuring that the needle goes to the desired location. Some discomfort occurs, but patients more commonly feel pressure than pain.

There are several types of ESIs:

  • Cervical ESI (neck). The needle entry site is from the side of neck to reach the neural foramen, just above the opening for the nerve root and outside the epidural space (Fig. 2). Contrast dye is injected to confirm where the medication will flow.

Epidural Steroid Injection, ESI, spine injections, steroid shots in spine, back pain injections, back pain shots (2)

  • Lumbar ESI (low back). The needle entry site is slightly off midline of the back to reach the nerve canal (Fig. 3). Contrast dye is injected to confirm where the medication will flow.

Epidural Steroid Injection, ESI, spine injections, steroid shots in spine, back pain injections, back pain shots (3)

  • Caudal ESI (tailbone). The needle is placed in the sacral hiatus above the tailbone to reach the lowest spinal nerves. Contrast dye is injected to confirm where the medication will flow.

Step 3: inject the medication
When the needle is correctly positioned, the anesthetic and corticosteroid medications are injected into the epidural space around the nerve roots. The needle is then re­moved. Depending on your pain location, the procedure may be repeated for left and right sides. One or several spinal levels may be injected.

What happens after treatment?

Most patients can walk around immediately after the procedure. After being monitored for a short time, you usually can leave the center. Rarely temporary leg weakness or numbness can occur; therefore someone should drive you home.

Typically patients resume full activity the next day. Soreness around the injection site may be relieved by using ice and taking a mild analgesic (Tylenol).

(Video) What You Should Know: Lumbar Epidural Steroid Injections

You may want to record your levels of pain during the next couple of weeks in a diary. You may notice a slight increase in pain, numbness, or weakness as the numbing medicine wears off and before the corticosteroid starts to take effect.

Patients should schedule a follow-up appointment with the referring or treating physician after the procedure to document the efficacy and address any concerns the patient may have for future treatments and expectations.

What are the results?

Many patients experience some pain relief benefits from ESI [1,2]. For those who experience only mild pain relief, one to two more injections may be performed, usually in 1-4 week intervals, to achieve full effect. Duration of pain relief varies, lasting for weeks or years. Injections are done in conjunction with a physical therapy and/or home exercise program to strengthen the back muscles and prevent future pain episodes.

What are the risks?

With few risks, ESI is considered an appropriate nonsurgical treatment for some patients. The potential risks associated with inserting the needle include spinal headache from a dural puncture, bleeding, infection, allergic reaction, and nerve damage / paralysis (rare).

Corticosteroid side effects may cause weight gain, water retention, flushing (hot flashes), mood swings or insomnia, and elevated blood sugar levels in people with diabetes. Any numbness or mild muscle weakness usually resolves within 8 hours in the affected arm or leg (similar to the facial numbness experienced after dental work). Patients who are being treated for chronic conditions (e.g., heart disease, diabetes, rheumatoid arthritis) or those who cannot temporarily discontinue anti-clotting medications should consult their personal physician for a risk assessment.

Sources & links

If you have more questions, please contact Mayfield Brain & Spine at 800-325-7787 or 513-221-1100.

Links
Spine-health.com
Spineuniverse.com

Sources

(Video) Epidural Steroid Injections for Chronic Back Pain

  1. Weinstein SM, Herring SA: NASS. Lumbar epidural steroid injections. Spine J 3(3 Suppl):37S-44S, 2003.
  2. Lutz GE, VAd VB, Wisneski RJ: Fluoroscopic transforaminal lumbar epidural steroids: an outcome study. Arch Phys Med Rehabil 79:1362-1366, 1998.

Glossary

anesthetic: an agent that causes loss of sensation with or without the loss of consciousness.

chronic: a condition of slow progression that continues over a long period of time, opposite of acute.

corticosteroid: a hormone produced by the adrenal gland or synthetically made. Regulates salt and water balance and reduces inflammation.

epidural space: the area between the membrane surrounding the spinal cord and the vertebral wall that is filled with fat and small blood vessels.

fluoroscopy: an imaging device that uses x-ray or other radiation to view structures in the body in real time, or "live." Also called a C-arm.

sciatica: pain that courses along the sciatic nerve in the buttocks and down the legs. Usually caused by compression of the 5th lumbar or 1st sacral spinal nerves.

updated > 7.2018
reviewed by > Marc Orlando, MD, Mayfield Clinic, Cincinnati, Ohio

Epidural Steroid Injection, ESI, spine injections, steroid shots in spine, back pain injections, back pain shots (4)Mayfield Certified Health Info materials are written and developed by the Mayfield Clinic. This information is not intended to replace the medical advice of your health care provider.

(Video) Epidural Steroid Injections for Chronic Back Pain

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FAQs

What is the success rate of epidural steroid injections? ›

An analysis of several large clinical trials indicated that 40% to 80% of patients experienced over 50% improvement in sciatica pain and functional outcome from 3 months up to 1 year when 1 to 4 injections were given in that year.

What is the recovery time for epidural steroid injection? ›

Usually, you'll be able to return to normal activities on the next day. The steroids usually begin working within 1 to 3 days. In some cases, you might need up to a week to feel the benefits.

How painful is an epidural steroid injection? ›

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.

How many injections are usually given for epidural injection for lower back pain? ›

In general, you will receive a series of up to 3 injections, given at least two weeks to achieve maximum pain relief. If the injections are successful, most patients will experience at least 6 months of pain relief after the initial series of injections.

What is the next step if epidural injections don't work? ›

An alternative to ESIs, or an option to consider if injections are no longer providing relief, is the mild® Procedure. mild® stands for minimally invasive lumbar decompression. It's a short outpatient procedure that relieves pressure on the spine through an incision smaller than the size of a baby aspirin (5.1 mm).

What should you not do after an epidural steroid injection? ›

Do not drive within 12 hours of receiving your epidural injection. Do not apply heat right to the injection site for at least three days following the epidural. This includes steam rooms, saunas, and hot packs, but your regular shower is safe.

Do they put you to sleep for epidural injections? ›

The injection is performed under local anesthesia and, on occasion, with intravenous sedation. Patients are not deeply sedated or completely asleep for this procedure because it is unnecessary and unsafe to do so.

Are back injections worth it? ›

1) Spinal injections do nothing to correct the problem that is the root cause of your pain. The injection is simply blocking the mechanism that delivers the pain message to your brain or temporarily reducing inflammation. But it is doing nothing to fix the problem that is actually causing the pain and inflammation.

How much does an epidural steroid injection cost? ›

Most patients seeking epidural steroid injection treatment should expect to spend around $4,000.00 at a minimum in 2021-2022. The sessions themselves can become more costly depending on how many injection sites are on the body. Each epidural steroid injection is billed as a separate cost.

What are the long term side effects of epidural steroid injections? ›

While it's very rare, receiving a lumbar epidural steroid injection can lead to some long-term complications, including: Permanent neurologic deficit due to spinal cord or nerve root damage from the epidural injection. Chronic pain due to spinal cord or nerve root damage from the epidural injection.

How long does it take for an epidural to work for back pain? ›

These injections don't always work. When they do, it takes 1 to 5 days. This pain relief can last for several days to a few months or longer. You may want to do less than normal for a few days.

Why does my back hurt worse after epidural steroid injection? ›

You may have an increase in pain levels for two to three days after an epidural steroid injection. This is because of irritation of the nerves in the area the steroid was injected. You should begin feeling pain relief within a few days of the epidural steroid injection.

What are the dangers of spinal injections? ›

The risks of spinal injections include, but are not limited to: Bleeding. Infection. Nerve injury.

Can I drive after a steroid injection in my back? ›

You may not drive for 12 hours after your injection. It is common to experience mild soreness at the injection site(s) for 24–48 hours. Ice is the best remedy. You may apply ice for 20 minutes at a time several times a day as needed.

What type of doctor gives epidural steroid injections? ›

Physicians who perform epidural steroid injections include physiatrists (PM&R), radiologists, anesthesiologists, neurologists, and surgeons.

How do you sleep after an epidural steroid injection? ›

It is recommended that you lie down and rest at home for at least 2 hours immediately after the procedure. Plan to rest and relax for the first 24 hours after the injection in a reclined position.

What happens next if steroid injection doesn't work? ›

When one (or several) injections fail to fix your problem, often the next recommended step is surgery. The majority of the people we work with are seeking pain relief for their back, knee, neck or shoulder WITHOUT the need for surgery and other procedures.

How many epidurals can you have in a lifetime? ›

How many epidurals can I have? Generally a patient may have up to three epidurals in a row, no earlier than two weeks apart (but it is advisable to have as few epidurals are possible). Epidurals may be repeated every 6-12 months if necessary if pain recurs. Too many epidurals can have significant side effects.

What is the difference between a cortisone shot and an epidural steroid injection? ›

As opposed to a systemic cortisone shot delivered into the bloodstream, an epidural injection is delivered at or near the sources of the nerve pain, providing targeted relief.

Can I drive myself home after an epidural? ›

Driver Required: Numbing medicine injected during your spine procedure can slow your foot pedal reaction time even if your legs and feet don't feel numb. For that reason you must have a driver bring you home after your injection and you should not drive your vehicle for at least 4 hours after the injection.

What should you not take before an epidural? ›

Do not take any anti-inflammatory medications for at least five days prior to an epidural spinal injection. Anti-inflammatory medications include Advil or other ibuprofen products, Aleve, and aspirin. You may eat and drink as usual prior to your scheduled spine steroid injection.

Can you drive after epidural steroid injection? ›

It is not considered safe to drive or operate other heavy machinery after this procedure. You should arrange for an adult to drive you home. When will I be able to eat and take my medications? You should be able to resume eating and taking your medications after the procedure.

How do you prepare for an epidural steroid injection? ›

On the day of your appointment, please refrain from eating or drinking 4 hours prior to your appointment time. You may eat and drink immediately following your injection. If you take routine medications, you may take these on the day of your injection as scheduled with a small sip of water.

How many steroid shots can you get in your back? ›

This can relieve pressure on nerves and nerve roots. The medicine can't fix your back, but it may give you short-term relief from back and leg pain. The medicine may be given as 1 shot or a series of up to 3 shots about a month apart. More than 3 shots in the same spot within 12 months isn't recommended.

What can go wrong during an epidural steroid injection? ›

The most likely causes of spinal cord injury following epidural steroid injection are epidural bleeding, epidural abscess, direct spinal cord trauma, and embolization of particulate matter into the arterial supply of the cord.

What is the best injection for nerve pain? ›

Nerve Block Injections

Lidocaine is the anesthetic most commonly used. After a nerve block injection, you'll quickly have numbness with near-complete pain relief. It wears off after several hours.

How much is a steroid injection cost? ›

How much does a cortisone shot cost? Cortisone shots typically cost roughly $100 to 300 but can be more than $1,000. Your insurance may cover some or all of the cost.

How much does a steroid shot cost? ›

Cortisone injections - a shot containing a corticosteroid - can cost anywhere from $25-$300, depending on your health insurance status, the injection site, and what the injection is being used to treat.

How long does it take for steroid injections in the back to work? ›

The steroid takes two to three days to start to have an effect in most people, and it peaks in about two weeks. Therefore, it may be a while before you feel a change in your pain. Some local tenderness may be experienced for a couple of days after the injection.

What are the risks of getting an epidural for back pain? ›

Side effects Epidural
  • Low blood pressure. It's normal for your blood pressure to fall a little when you have an epidural. ...
  • Loss of bladder control. ...
  • Itchy skin. ...
  • Feeling sick. ...
  • Inadequate pain relief. ...
  • Headache. ...
  • Slow breathing. ...
  • Temporary nerve damage.

What is the most common side effect of an epidural? ›

Epidural Side Effects are Minimal, at Least In Most Cases

The most common side effect is hypotension, a drop in blood pressure that could affect the baby. This occurs more with higher doses of medication.

How many times can you have an epidural for back pain? ›

Talk to your doctor about your risk for complications. Having these injections too often may weaken the bones of your spine or nearby muscles. Receiving higher doses of the steroids in the injections may also cause these problems. Because of this, most doctors limit people to two or three injections per year.

Is a nerve block the same as an epidural? ›

Differences between these two procedures include:

A selective nerve block targets a specific nerve that needs to be managed by injecting the medication around this structure whereas an epidural injection is injected into the epidural space of the spinal cord to offer symptomatic relief to a larger area of pathology.

How common is nerve damage after epidural? ›

Permanent damage to nerves is very rare. The risk of longer-lasting problems after a spinal or epidural injection is: Permanent harm occurs between 1 in 23,500 and 1 in 50,500 spinal or epidural injections.

Do epidurals help back pain? ›

Epidural injections (Can be done for both acute and chronic spinal conditions causing low back pain. This treatment modality is very effective for short term as well as long term low back pain caused by certain conditions that can irritate the nerves running through the spinal canal and nerve root canal).

Are back injections considered surgery? ›

Spinal injections comprise a less invasive, relatively conservative treatment option for back pain. They are typically considered as an option to treat back pain after a course of medications and/or physiotherapy is completed, but before surgery is considered.

What happens when an epidural hits a nerve? ›

This can occur if the epidural or spinal needle or the epidural catheter damages a single nerve, a group of nerves or the spinal cord. Contact with a nerve may cause 'pins and needles' or a brief shooting pain. This does not mean that the nerve is damaged, but if the needle is not repositioned, damage can occur.

What kind of sedation is used for spinal injections? ›

Conscious sedation—also called moderate sedation or procedural sedation—is a combination of medicines given to help patients relax during a medical procedure by minimizing discomfort and anxiety. It is often used for dental operations, minor surgeries, and other routine medical procedures, such as lumbar ESIs.

What is the recovery time for epidural steroid injection? ›

Usually, you'll be able to return to normal activities on the next day. The steroids usually begin working within 1 to 3 days. In some cases, you might need up to a week to feel the benefits.

How painful is an epidural steroid injection? ›

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.

How long after epidural can you walk? ›

Most of the time, you can walk within a half hour or so of your epidural injection. However, you will not necessarily be walking normally at this point. Most clinics and hospitals monitor you for 15 minutes to an hour after an epidural injection. During this time, they will likely ask how you feel.

What is the next step if epidural injections don't work? ›

An alternative to ESIs, or an option to consider if injections are no longer providing relief, is the mild® Procedure. mild® stands for minimally invasive lumbar decompression. It's a short outpatient procedure that relieves pressure on the spine through an incision smaller than the size of a baby aspirin (5.1 mm).

What should you not do after an epidural steroid injection? ›

Do not drive within 12 hours of receiving your epidural injection. Do not apply heat right to the injection site for at least three days following the epidural. This includes steam rooms, saunas, and hot packs, but your regular shower is safe.

What do you do after a lumbar epidural steroid injection? ›

Lumbar Epidural Steroid Injection
  1. You may resume normal activity as your comfort level allows, but do not engage in any strenuous activity for the first 24 hours after the procedure.
  2. You can return to work 24 hours after your procedure.
  3. You may eat whatever you wish and resume all prior medications.

Why do epidurals not always work? ›

The causes of neuraxial labor analgesia failure include inadequate initial epidural needle placement, suboptimal catheter siting upon threading, catheter migration within the epidural space during labor, problematic neuraxial anatomy of the parturient, or an unpredictably fast labor.

Why is pain worse after epidural steroid injection? ›

You may have an increase in pain levels for two to three days after an epidural steroid injection. This is because of irritation of the nerves in the area the steroid was injected. You should begin feeling pain relief within a few days of the epidural steroid injection.

How effective are epidurals for back pain? ›

Epidural injections (Can be done for both acute and chronic spinal conditions causing low back pain. This treatment modality is very effective for short term as well as long term low back pain caused by certain conditions that can irritate the nerves running through the spinal canal and nerve root canal).

Do steroid injections help bulging discs? ›

Corticosteroid injections can reduce inflammation and can be effective when delivered directly into the painful area. Unfortunately, the injection does not make a herniated disc smaller; it only works on the spinal nerves by flushing away the proteins that cause swelling.

Does epidural take away all pain? ›

Most women experience great pain relief with an epidural, but it won't be 100 percent pain-free. Many women report feeling pretty comfortable after receiving an epidural, but there's also some pressure felt when the contractions occur and you need to push.

How many attempts do you get from an epidural? ›

All residents are allowed two attempts at epidural insertion, after which it is taken over by the fellow or consultant.

Why was my epidural so painful? ›

The proximity of so many nerves also means that the injection is more likely to be painful compared to other procedures. Since the needle will have to pass through several nerve clusters and straight into the spinal column, patients are likely to feel some level of pain and discomfort even if anesthesia is used.

Are back injections worth it? ›

1) Spinal injections do nothing to correct the problem that is the root cause of your pain. The injection is simply blocking the mechanism that delivers the pain message to your brain or temporarily reducing inflammation. But it is doing nothing to fix the problem that is actually causing the pain and inflammation.

What are the dangers of spinal injections? ›

The risks of spinal injections include, but are not limited to: Bleeding. Infection. Nerve injury.

How long does it take for an epidural to work for back pain? ›

How long does a lumbar epidural steroid injection take to work? Your pain may become worse for two or three days after your lumbar ESI before it begins to improve. Epidural steroid injections start working within two to seven days, and the pain relief can last several days to a few months or longer.

Do they put you to sleep for epidural injections? ›

The injection is performed under local anesthesia and, on occasion, with intravenous sedation. Patients are not deeply sedated or completely asleep for this procedure because it is unnecessary and unsafe to do so.

How much does an epidural steroid injection cost? ›

Most patients seeking epidural steroid injection treatment should expect to spend around $4,000.00 at a minimum in 2021-2022. The sessions themselves can become more costly depending on how many injection sites are on the body. Each epidural steroid injection is billed as a separate cost.

What is the difference between a steroid injection and an epidural? ›

As opposed to a systemic cortisone shot delivered into the bloodstream, an epidural injection is delivered at or near the sources of the nerve pain, providing targeted relief.

What should you not take before an epidural? ›

Do not take any anti-inflammatory medications for at least five days prior to an epidural spinal injection. Anti-inflammatory medications include Advil or other ibuprofen products, Aleve, and aspirin. You may eat and drink as usual prior to your scheduled spine steroid injection.

Do you have to rest after a steroid injection? ›

It helps to rest the joint for 24 hours after the injection and avoid heavy exercise. It's safe to take everyday painkillers such as paracetamol or ibuprofen.

What is the best treatment for degeneration of the spine? ›

Physical therapy can help stretch and strengthen the right muscles to help the back heal and reduce the frequency of painful flare-ups. Lifestyle modifications, such as changing your posture, losing weight or giving up smoking, can sometimes help reduce stress on the damaged disc and slow down further degeneration.

Videos

1. Lumbar Epidural Steroid Injection (LESI)
(The Spine & Pain Institute of New York)
2. Back Pain: Before and After Steroid Injections
(RAYUS Radiology™)
3. When Should I get an ESI - Epidural Steroid Injection? | Dr. Sheena Bhuva Explains
(TexasBackInstitute)
4. Epidural Steroid Injections
(ShimSpine)
5. Lumbar Epidural Steroid Injection Animation.
(Alila Medical Media)
6. Steroid Injections for Back Pain
(MountainStar Health)

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