Epidural Steroid Injection

Epidural Steroid Injection is actually the direct administration of an anti-inflammatory drug (corticosteroid) to specific points in the spine. The purpose is to suppress inflammatory processes around the nerve roots emerging from the spinal cord and thus relieve pain.

What Is an Epidural Steroid Injection and How Does It Work?

An epidural steroid injection is a treatment method consisting of corticosteroids injected into the epidural space of the spine (i.e., the area outside the membrane surrounding the spinal cord). We can liken this injection to pouring a chemical drain cleaner into a clogged sink. Just as chemicals break down the materials causing the clog to reduce blockage and overflow, corticosteroids suppress the edema and inflammation around the nerve root to relieve the “blockage” sensation, i.e., pain.

• Primary Mechanism of Action: In response to injury or compression, the body initiates an inflammatory process. Inflammation is a defense mechanism but, if prolonged, can damage tissues and cause pain and sensitivity. Epidural steroids target the chemicals involved in this inflammatory process to address the source of pain.
• Short‑ and Mid‑Term Effect: Some patients feel a significant reduction in pain within a few days after the injection. This effect generally lasts weeks to a few months. Although durations vary individually, the main goal is to reduce pain enough for the patient to participate more comfortably in physical therapy or daily activities.
• Drug Delivery Pathway: Unlike oral medications, corticosteroids are delivered directly to the target area. This results in relatively fewer systemic side effects. However, it is not entirely risk‑free; these issues will be discussed in detail later.

Why Are Epidural Steroid Injections Used for Pain Management?

Pain is a common problem that can diminish quality of life and sometimes become chronic. Regional pains such as in the lower back, neck, or upper back are among the most frequently encountered issues in daily life. In some cases, pain cannot be controlled with simple painkillers, severely limiting mobility. This is where epidural steroid injections come into play.

• Targeted Treatment Approach: When oral medications mix into the bloodstream, delivering high doses to the target tissue can be difficult. With an epidural injection, the drug is sent directly to the problem area, achieving high local effect without excessive systemic circulation.
• Control of Inflammation: In cases such as lumbar disc herniation or cervical disc herniation, nerves become compressed, and a “fire” of inflammation ignites around the site. Steroids extinguish or significantly reduce the flames of this “fire.” One of the most important steps in pain management is controlling the fire at its source.
• Preparation for Rehabilitation: When pain is unbearable, patients cannot participate in physical therapy or exercise, stalling the treatment process. Epidural injections calm the pain, increasing mobility and facilitating participation in physical therapy. This makes it possible to strengthen muscles and improve spinal stability in the long term.
• Alternative to Surgery: Surgery often offers a permanent solution for structural issues in the back or neck. However, not every patient is a surgical candidate or ready for surgery. Epidural steroid injections can be considered an alternative, sometimes delaying or eliminating the need for surgery. Of course, this is not true for every case; proper patient selection is crucial.

Which Conditions Can Be Treated with Epidural Steroid Injections?

Spinal problems arise from various mechanisms, and each case has its own story. Epidural steroid injections are most commonly used for conditions related to nerve root inflammation or compression. Let’s look at a few examples of these conditions:

• Herniated Disc (Lumbar Disc Herniation)

The term “herniated disc” refers to the rupture of the cartilage discs between the vertebrae, causing the disc material to press on the nerve root. The herniated disc tissue exerts pressure on the nerve root, leading to pain, numbness, and even weakness. Steroid injections can calm the inflammation around the nerve root and alleviate symptoms.

• Cervical Disc Herniation (Neck Hernia)

The same mechanism can occur in the neck region. Pain, numbness, and tingling radiating from the neck to the arm are common symptoms. Epidural injections in this area similarly aim to reduce edema around the nerve root.

• Spinal Stenosis

When the spinal canal narrows, nerve tissue is compressed as if in a narrow tunnel. This condition especially causes leg pain, numbness, and fatigue when walking. Epidural steroid injections can temporarily relieve symptoms by reducing inflammation around the nerve.

• Degenerative Disc Disease

Over time, the discs between vertebrae wear down, thin, or lose flexibility. This process can sometimes cause nerve compression or inflammatory reactions. Injections can be effective for radicular pain caused by disc degeneration.

• Radiculopathy (Nerve Root Involvement)

Whether in the back or neck, the main symptom of nerve root involvement is pain radiating to the arm or leg, sometimes called “sciatica” or “arm pain.” The cause is pressure on the nerve root, and steroids help break the inflammatory cycle caused by this pressure.

• Post‑Traumatic or Post‑Surgical Inflammation

In some cases, inflammation can develop around the nerve root after a traffic accident, fall, or surgical intervention. If this inflammation becomes chronic, epidural injection may be an appropriate option.

How Is an Epidural Steroid Injection Performed?

Many people approach this procedure with the concern, “I’m afraid of pain when the needle goes into my back.” In fact, when performed in suitable settings and by experienced hands, the procedure is often tolerated at a manageable discomfort level. Let’s examine the process step by step:

Preparation and Positioning

• The patient typically lies prone or, in some cases, sits upright.
• The injection site is sterilized, and local anesthesia is administered to reduce pain at the needle entry point.

Advancing the Needle into the Epidural Space

• Under fluoroscopy (live X‑ray) or ultrasound guidance, the needle is advanced through the appropriate intervertebral space into the epidural space.
• This step is like “fitting a key into a lock.” With imaging guidance, the drug is delivered precisely to the correct location.

Use of Contrast Agent

• Often, contrast agent is administered before the injection to confirm the needle is in the exact right spot. This minimizes the risk of the drug entering a blood vessel or another area.

Injection of Steroid and Local Anesthetic Mixture

• After contrast confirmation, the solution containing corticosteroid and sometimes a small amount of local anesthetic is slowly injected.
• Patients may feel a mild fullness or pressure sensation during this step.

Rest and Observation

• After the procedure, the patient is observed for a short period. Blood pressure, heart rate, and pain level are monitored.
• Typically, the patient can go home the same day. Pain relief may not be immediate; the steroid’s effect becomes noticeable over a few days.

Parasagittal or Transforaminal Approaches

• In some cases, the injection may be performed from the side or near a specific nerve root. This allows for a “targeted strike” at the affected nerve root.
• Different approaches may be required for patients with spinal stenosis or multiple disc problems.

What Are the Benefits of Epidural Steroid Injections?

• Rapid and Effective Pain Relief

Consider someone suffering from a herniated disc or sciatica. Sometimes even taking a step can feel torturous. The injection can control this severe pain within an average of a few days.

• Increased Mobility

During painful days, a person’s greatest desire may be simply to walk comfortably. Pain relief after the injection can make walking, climbing stairs, and even playing with one’s child possible again.

• Preparation for Physical Therapy

Severe pain hinders effective physical therapy, as the patient focuses on pain rather than exercises. The injection reduces pain, paving the way for physical therapy and long‑term recovery.

• Potential to Delay or Avoid Surgery

Some patients seek alternatives because they fear spine surgery. Epidural steroid injections can sometimes delay or eliminate the need for surgery, though this is not guaranteed for every case.

• Local and Targeted Treatment

Oral steroids or painkillers affect the entire body, increasing the risk of side effects. Epidural injection delivers the drug directly to the problem area, reducing systemic exposure.

• Improved Quality of Life

Chronic pain negatively affects psychology, causing insomnia, depression, and irritability. Reducing pain can break this negative cycle.

What Are the Risks or Side Effects Associated with Epidural Steroid Injections?

• Temporary Increase in Pain or Discomfort

Some patients report a slight increase in pain or sensitivity at the injection site within 24 hours post‑procedure. This is usually short‑lived.

• Headache or Nausea

Rarely, headaches or nausea may occur due to the epidural injection. These symptoms typically resolve quickly or with simple measures.

• Dural Puncture (Dura Mater Tear)

If the needle inadvertently pierces the dura mater, a “post‑dural puncture headache” may develop. This is a treatable complication but can be bothersome.

• Infection Risk

If sterile conditions are not strictly maintained, there is a risk of infection such as abscess or meningitis. Though very rare, this possibility must be considered.

• Bleeding or Hematoma

Patients on blood thinners or with clotting disorders may develop bleeding or hematoma at the needle entry site. Pre‑procedure blood tests are important.

• Neurological Complications

Although very rare, nerve damage or temporary sensory loss has been reported. Performing the procedure under imaging guidance by an experienced specialist greatly reduces this risk.

• Systemic Effects of Steroid

Steroids can raise blood sugar and suppress the immune system. Close monitoring is required in diabetic or immunocompromised patients. Frequent steroid injections may increase long‑term osteoporosis risk.

How Long Does the Pain‑Relieving Effect Last After an Epidural Steroid Injection?

• Onset of Effect

The true effect of the steroid usually appears between 2–7 days. Some patients feel relief almost immediately, while others may wait several weeks.

• Duration of Relief

Pain reduction can last from several weeks to several months. Some patients may experience relief for 6 months or longer from a single injection. In others, the effect may be limited to a few days, depending on the severity of the underlying pathology and participation in physical therapy.

• Repeat Injections

If the first injection is partially beneficial but not sufficient, a second or third injection may be considered, usually spaced weeks to months apart. However, frequent steroid use increases side effect risk, and more than 3–4 injections per year is generally not recommended.

• Variability Due to Structural Issues

If the disc tear is very large or nerve compression is chronic, the injection’s effect may be limited and short‑lived, making surgery inevitable in severe cases. Regardless of duration, the relief period provides an opportunity for more active daily living and optimal benefit from physical therapy.

Who Is a Good Candidate for an Epidural Steroid Injection?

• Those with Nerve Root Compression Pain

Patients experiencing “electric shock‑like pain down my leg” or arm pain radiating from the neck—clinical radiculopathy—benefit greatly from epidural steroid injections.

• Those Unresponsive to Conservative Treatments

If physical therapy, painkillers, muscle relaxants, or hot‑cold applications fail to yield significant improvement, injections may be considered as a mid‑level intervention before more invasive options.

• Patients Unsuitable for or Deferring Surgery

Patients with heart disease, advanced age, systemic comorbidities, or personal preference against surgery can consider injections to manage pain and buy time before surgery.

• Those Who Benefited from Similar Treatments Previously

Patients who had good results from one or two prior epidural injections may try again when pain recurs. However, limited efficacy previously suggests limited benefit on repeat.

• Patients Without Active Infection or Significant Coagulopathy

Active infection or clotting disorders are contraindications; these conditions must be treated or controlled first.

What to Expect Before and After an Epidural Steroid Injection?

Before

• Fasting and Medication Adjustment: Often recommended to fast a few hours before the procedure. Blood thinners must be discussed with the physician and may need temporary discontinuation.
• Anxiety and Fear: Many fear “will it hurt when the needle enters the spine?” Local anesthesia usually prevents severe pain; patients feel pressure rather than sharp pain.
• Appropriate Clothing: A hospital gown may be required. Wearing comfortable clothes helps with post‑procedure mobility.

After

• Short‑Term Rest: Patients are observed for 30–60 minutes post‑procedure to monitor vital signs and check for adverse reactions.
• Temporary Findings: Leg numbness or weakness from the local anesthetic may occur for a few hours. Mild soreness at the injection site is common; ice packs can help.
• Pain Changes: As the steroid takes effect over days, initial pain increase or fluctuation is normal. Painkillers and physician guidance ease this period.
• Activity Level: Avoid heavy lifting or strenuous exercise on day one. Light walking or stretching as permitted by the physician is encouraged thereafter.
• Follow‑Up: Monitor pain changes and any new symptoms in the days following. Attend follow‑up appointments to assess treatment success or additional needs. Seek immediate medical attention for severe pain, fever, or persistent weakness.

How Do Epidural Steroid Injections Compare to Other Pain Treatments?

• Oral Medications (Painkillers, NSAIDs, Muscle Relaxants)

• Pros: Easy administration, home use.
• Cons: Gastrointestinal side effects (e.g., ulcer risk), liver and kidney load, short duration, increased side effect risk with high doses.

Compared to epidural injection: oral drugs have higher systemic impact, while injections are directly targeted.

• Physical Therapy and Exercise

• Pros: Strengthens muscles, improves flexibility, long‑term improvement, minimal side effects.
• Cons: Difficult when pain is severe; requires patience and adherence.

Compared to injections: injections provide temporary relief to enable effective physical therapy but are not a standalone permanent solution.

• Traction and Manual Therapy

• Pros: May reduce pressure in mild disc problems.
• Cons: Not suitable for all patients; effects may be temporary and limited clinically.

Compared to injections: injections chemically target inflammation, while traction offers mechanical relief; sometimes used together.

• Radiofrequency or Laser Treatments

• Pros: Can reduce intradiscal pressure and pain in some cases; minimally invasive.
• Cons: Limited availability, high cost, variable efficacy.

Compared to injections: steroids chemically suppress inflammation, whereas radiofrequency targets nerve conduction or tissue structure.

• Surgical Intervention

• Pros: Can directly correct structural issues (large herniation, spinal stenosis), potentially offering permanent relief.
• Cons: Surgical risks (infection, bleeding, anesthesia), long recovery, not guaranteed success.

Compared to injections: injections are less invasive and can be tried before surgery, but surgery may be unavoidable for major structural problems.

Can Epidural Steroid Injections Reduce the Need for Surgery?

• Early Intervention to Control Pain

In some cases, early injection when pain first intensifies can suppress inflammation before it worsens, potentially avoiding surgery.

• Borderline Surgical Candidates

If the size of a disc herniation or degree of nerve compression raises the question “surgery or not?”, successful injection may postpone or cancel surgery plans.

• Quality of Life Improvement and Time Gain

Some patients need time to lose weight, treat heart issues, or strengthen physically before major surgery. Injections provide relief and time for overall health optimization.

• Intermediate Treatment

When conservative treatments fail and surgery is not yet considered, injections serve as an “intermediate” step. Significant improvement may lead to surgery cancellation or postponement.

• Post‑Surgical Recurrence

In some cases, pain recurs after surgery. Instead of another operation, injections may be tried to avoid further surgery.

What Is the Role of Anti‑Inflammatory Drugs in Epidural Steroid Injections?

• Chemical Mechanism

Corticosteroids suppress various chemicals (cytokines, prostaglandins, etc.) involved in inflammation, like pouring water on a blazing fire to limit and extinguish it.

• High Local Concentration

Oral steroids must distribute throughout the body, increasing systemic side effect potential. Injections deliver a “direct hit” to the spinal target area, maximizing local effect.

• Reduced Systemic Effects

Epidural corticosteroids mix less into the bloodstream, limiting effects on blood sugar or immune suppression (though not eliminating them).

• Combination with Local Anesthetics

Sometimes steroids are mixed with a short‑acting local anesthetic. This combination suppresses inflammation while providing immediate relief from the anesthetic, though the lasting effect depends on the steroid.

• Research and Data

Various studies show epidural injections are effective for pain control but may not always provide long‑term relief. Nevertheless, they offer significant comfort increases for many patients in the short to mid term.

How Have Epidural Steroid Injections Evolved from the 1950s to Today?

• Early Applications (1950s)

With the discovery and medical use of corticosteroids, researchers hypothesized their benefit for spinal pain. Early procedures were less refined, and imaging methods like fluoroscopy were not widely available.

• Technical Advances (1960s–1970s)

As radiologic imaging improved, injections became safer and more precise. Increased anatomical knowledge enabled better targeting of drugs to the correct locations.

• Growth of Scientific Research (1980s–1990s)

Randomized controlled trials began evaluating short‑ and mid‑term outcomes. Some studies demonstrated significant pain reduction, while others noted limited long‑term effects, sparking ongoing debate.

• Emergence of Different Approaches (2000s)

Transforaminal, interlaminar, and caudal techniques were developed, improving access to specific nerve roots or spinal segments. Minimally invasive advances increased patient comfort and enabled same‑day discharge.

• Present Day (2010s–Present)

Fluoroscopy and ultrasound guidance are now standard in most centers, improving accuracy and reducing complications. Meta‑analyses and large clinical trials have clarified which patient groups benefit most from this treatment.

Prof. Dr. Özgür KILIÇKESMEZ

Prof. Dr. Özgür Kılıçkesmez graduated from Cerrahpaşa Medical Faculty in 1997. He completed his specialization at Istanbul Education and Research Hospital. He received training in interventional radiology and oncology in London. He founded the interventional radiology department at Istanbul Çam and Sakura City Hospital and became a professor in 2020. He holds many international awards and certificates, has over 150 scientific publications, and has been cited more than 1500 times. He is currently working at Medicana Ataköy Hospital.