Back pain is the number-one reason people visit their doctors, and epidural steroid injections have been a mainstay of treatment for short-term pain relief for decades. The injections seem to be most effective for people who have "radicular" pain, or pain that radiates from the spine to a leg or an arm, caused by a herniated disk. Even so, relief is often only temporary, and injections should be limited to no more than two or three a year.
Experts aren't quite sure how worthwhile the injections are for other conditions since research findings from clinical trials are inconsistent. Because of the small number of high-quality scientific studies on epidural steroid injections, strong recommendations for their use are lacking.
The American Academy of Neurology's (AAN’s) guidelines state that "epidural steroid injections play a limited role in providing short-term pain relief for lower back pain that radiates down a leg and do not provide long-term pain relief." Specifically, they say that the average amount of relief is small and lasts only two to six weeks after injection. And, says the AAN, the injections don't "buy time: to avoid surgery.
Similarly, the American Pain Society suggests that epidural steroid injections may be used for radicular pain caused by a herniated lumbar disk, but the group falls short of strongly recommending them.
In April 2014, the U.S. Food and Drug Administration (FDA) issued a warning that the "injection of corticosteroids into the epidural space of the spine may result in rare but serious adverse events, including loss of vision, stroke, paralysis, and death." According to the FDA, drug labels of injectable corticosteroids are required to carry a warning describing these risks.
Not effective for sciatica?
New doubt has also been cast on the effectiveness of epidural steroid injections when treating sciatica, a common condition caused by irritation of the sciatic nerve leaving the spinal canal in the lumbar (lower) region of the back. (A herniated lumbar disk is the most common cause of sciatica.)
Some past studies have suggested that the injections do little to relieve sciatic pain, including tingling and numbness, which can radiate into the buttocks, down the thighs, to below the knees and into the calves and feet. A recent study (Annals of Internal Medicine, Nov. 13, 2012) concluded the injections provided only slight, short-term (less than one year) improvement in leg pain and disabilitybut no back-pain benefit.
The study authors don't rule out epidurals for sciatica but recommend patients first try more conservative treatments, such as pain medications, whenever possible. If you suffer from sciatica and are considering injections because noninvasive approaches haven't worked for you, discuss their benefits and risks with your doctor before agreeing to the procedure.
Gauging the risks
Despite the fungal meningitis outbreak, epidural steroid injections are generally safe and complications are rare. The injections can occasionally cause
- "steroid flush," a flushing of the face and chest with a feeling of warmth and increase of temperature over several days
- sleeping difficulties
- water retention
- a temporary increase in pain for a few days
Serious adverse effects are rare but can include an allergic reaction, bleeding, nerve damage, infection and paralysis, along with the small risk of meningitis or other infection. Because they are at increased risk of complications, some people should avoid the injections, including those who:
- Have uncontrolled diabetes or blood pressure
- Take blood-thinning drugs or have a bleeding disorder
- Have unstable angina or congestive heart failure
- Have an active infection
- Are allergic to steroids, anesthetics or contrast dye
Long-term use of oral steroids is a known risk factor for osteoporosis, a condition in which bones weaken and fracture easily, but little is known about the effects epidural steroids have on bone health. Findings reported in a new study (Spine, Dec. 3, 2012) suggest that postmenopausal women who undergo an epidural steroid injection may be at risk for a slight decrease of bone density in the hip, but the study couldn't establish a direct link between injections and bone loss.
The study was small in scopeonly 28 women treated with injections were trackedmaking it difficult to draw definitive conclusions, but it lays the groundwork for larger studies investigating whether injected steroids are a risk factor for bone loss.
If you're already at risk for bone loss, you should discuss the potential benefits and harms of injections with your doctor. You may also want to take preventive measures against low bone density such as increasing calcium intake, taking vitamin D supplements and doing weight-bearing exercises.
The bottom line
If you're suffering from back pain that hasn't improved from conservative methods, take a judicious approach when considering epidural steroid injections and understand that their benefits may be limited. Ask your doctor about their relative merits in your particular case and find out how long you should expect any relief to last.
Lee Hunter Riley, MD, Associate Professor, Orthopaedic Surgery & Neurological Surgery Johns Hopkins Medicine
For many people, back pain goes away on its own or with nonsurgical treatments. Epidural steroid injections shouldn't typically be used as a first-line therapy for back pain relief, but that doesn't mean they can't play a role in treating pain. But injections won't cure the underlying cause of back pain, and they provide only temporary relief. Unfortunately, in many cases, chronic back pain can't be cured, but must instead be managed, like other chronic conditionsand patients must have realistic expectations of what epidurals can do.
Source: Prepared by the Editors of The Johns Hopkins Medical Letter: Health After 50; Updated by Remedy Health Media