All About Epidural Steroid Injections

What Is an Epidural Steroid Injection?

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.

“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,” says Leonardo Kapural, MD, PhD.

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 or cause of pain is healing.

“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,” says Gerard Malanga, MD. “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.”

“Epidural injections can be done at any level of the spine: cervical (neck), thoracic (mid-back), lumbar (low back), and sacral (tailbone area),” says Steven Richeimer, MD. “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.”

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 shows many spinal structures including, the third and fourth lumbar (low back) vertebrae, spinal cord, subarachnoid space, and epidural space. Photo Source: 123RF.com.

Types of Epidural Injections

The three types of epidural steroid injections (ESIs) are Interlaminar Epidural Steroid Injection, Transforaminal Epidural Steroid Injection, and Caudal Epidural Steroid Injection. Let’s take a moment to explore each one.

• Interlaminar Epidural Steroid Injection: This injection happens with a person lying face down. Using fluoroscopic X-ray, the surgeon will inject a solution into the epidural space that is causing pain. This procedure is especially useful in the treatment of spinal disorders that affect the entire spine, like spinal stenosis.

• Transforaminal Epidural Steroid Injection: Similar to the Interlaminar Epidural Steroid Injection, the patient is lying face down and the surgeon will use fluoroscopic X-ray to guide the injection. This is a more complicated, but more precise technique than Interlaminar Epidural Steroid Injection. It delivers a small volume of medication to the site of the problem in the spine.

• Caudal Epidural Steroid Injection: This approach, which also uses fluoroscopic X-ray, typically targets the tailbone. It’s therefore often chosen for pain in the lower spine.

Risk of ESIs

Although ESIs have low rates of major risks, there are some potential complications that can occur during the procedure. These include:

• Bone demineralization: Corticosteroids are associated with loss of bone density and future fractures.

• Suppression of the hypothalamic‐pituitary‐adrenal (HPA) axis: This can lead to chronic fatigue syndrome symptoms and, in some cases, Cushing’s Syndrome. High blood pressure, bone loss, and type 2 diabetes can result.

• Suppression of the immune system: This can put you more at risk for infections.

• Elevated glucose levels: This is of particular concern to people with diabetes.

Other complications that can arise from epidural steroid injections include an infection at the injection site, an allergic reaction to the injected solution, nerve injury, numbness in the legs, bleeding, back pain, and, in rare cases, paralysis.

The most important thing you can do throughout the process is to ask questions and communicate honestly and openly about any concerns with your surgeon.

What Happens Before an Epidural?

Although you will be given a local anesthetic during an epidural, some people may receive a mild sedative to help alleviate anxiety about the procedure.

Perhaps the most important preparation you can take is to be mentally ready for the procedure. This means having a thorough discussion with your surgeon about the process, risks, complications. Don’t hesitate to discuss your fears and expectations. The following questions may be helpful in preparing for your ESI:

• Why is the procedure needed?

• What are the alternatives to this procedure? Are there other treatment choices available based on my current medical condition?

• What are the benefits of the surgery, and how long will they last?

• What are the risks and possible complications of having the operation?

• What could happen if I don’t have the operation?

• Should I get a second opinion?

• What is the health care provider’s experience in doing this procedure?

• Where will the surgery be performed?

• What type of anesthesia will be administered?

• What can I expect during recovery?

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 before 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 before 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/warfarin (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 before 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.

What Happens During a Spinal Epidural 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).

An 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: SpineUniverse.com.

The skin on the patient’s back is scrubbed using two 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.

Pictured 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 an Epidural Injection?

The patient is returned to the recovery area where they are monitored by medical staff for 30-60 minutes. Before 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 two 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.

Patients may return to their normal activities the day after the procedure, including returning to work.

Effectiveness of Epidural Steroid Injections

Epidural steroid injections are a common non-surgical treatment for several spinal disorders. A wealth of research exists on ESIs, but two specific studies may be of interest.

The first study, 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 two 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 in Seattle.

The second study, 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.

These injections have been shown to provide excellent pain relief in many patients (particularly those who have had symptoms for less than three months, not had a previous spine surgery, are younger than 60, 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.

“In my experience, 60% of patients require only one injection and only 10-20% will require three injections,” says Dr. Malanga. “Certainly, if there is little or no pain relief after trying two injections, it is unlikely that the third injection will be of benefit.”

Who is a Candidate For an Epidural Steroid Injection?

These injections do not help every patient.

“For leg pain greater than the back pain, guidelines from a respected source suggest that patients who had full pain relief from the first epidural injection should not receive another one but to be re-evaluated in four weeks and followed thereafter,” says Dr. Kapural.

“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 patients with the diagnosis of lumbar canal stenosis, improvement after such injections may be longer lasting than it was initially thought,” he says.

The first characteristic doctors look for to determine if a person is a candidate for a lumbar ESI is pain that radiates from the lower back into the legs. This can be a result of the following conditions that put pressure on spinal nerves:

• Herniated discs: Vertebral discs that have lost their shape and pushed through the outer layer of the disc

• Degenerative disc disease: Disc degeneration that results in arthritis, in which spine joints begin to wear out

• Spinal stenosis: A condition that causes a narrowing (stenosis) of the spinal canal

• Non-specific radiculitis: Radiating pain without a specific cause

• Vertebral bone spurs: Bony growths on the vertebrae

• Thickening of ligamentum flavum: A type of degeneration of vertebral ligaments

• Postlaminectomy syndrome: Chronic pain after back surgery

• Facet or nerve root cyst: Growths that are most commonly seen in the sacral (pelvic) area of the back

• Post-herpetic neuralgia: Pain caused by shingles

• Compression fracture with radicular pain: A vertebral fracture

• Scoliosis: The curve and rotation of the spine

Keep in mind that these are general categories that may qualify you for ESI. Your health care provider will perform a thorough history and in-depth diagnostic workup to determine whether you are a candidate.

The following conditions could disqualify you from an ESI:

• Systemic infection or local infection at the site of injection

• Significant bleeding issues

• Significant allergic reaction/hypersensitivity to any of the injected materials

• Local malignancy (cancerous tumor)

Notes: This article was originally published February 20, 2000 and most recently updated November 30, 2022.

Patel, K., Chopra, P., Upadhyayula, S. “Epidural Steroid Injections.” [Updated 2022 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing, 2022, https://www.ncbi.nlm.nih.gov/books/NBK470189/

Katz, J.N., Zimmerman, Z.E., Mass, H., et al. “Diagnosis and Management of Lumbar Spinal Stenosis: A Review.” JAMA, 2022, https://jamanetwork.com/journals/jama/fullarticle/2791689?resultClick=1

“Ligamentum flavum. ” Radiopedia.org, https://radiopaedia.org/articles/ligamentum-flavum?lang=us

Chokshi, F.H, Quencer, R.M., Smoker, W.R.K. “The ‘Thickened’ Ligamentum Flavum: Is It Buckling or Enlargement?” American Journal of Neuroradiology, 2010, http://www.ajnr.org/content/31/10/1813

Oh, Y., Shin, D.A., Kim, D.J., et al. “Effectiveness of and Factors Associated with Balloon Adhesiolysis in Patients with Lumbar Post-Laminectomy Syndrome: A Retrospective Study.” J Clin Med, 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7230941/

“Tarlov Cyst.” American Association of Neurological Surgeons, 2022, https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Tarlov-Cyst

“Questions to Ask Before Surgery.” Johns Hopkins Medicine, 2022, https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/questions-to-ask-before-surgery#:~:text=This%20will%20allow%20you%20to,against%20the%20risks%20before%20surgery.

“Epidural Steroid Injections (Interlaminar, Caudal and Transforaminal). ” Johns Hopkins Medicine, 2022, https://www.hopkinsmedicine.org/sibley-memorial-hospital/patient-care/pain/treatments.html

Van Boxem, K., Rijsdijk, M., Hans, G., et al. “Safe Use of Epidural Corticosteroid Injections: Recommendations of the WIP Benelux Work Group.” Pain Pract, 2019, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7379698/#papr12709-bib-0013

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Epidural – NHS

An epidural is an injection in your back to stop you feeling pain in part of your body.

This page covers epidural anaesthesia, a type of epidural commonly given for pain relief in childbirth and in some types of surgery.

When epidurals are used

Epidurals can be used:

• during labour and childbirth, including caesareans
• during some types of surgery
• after some types of surgery

Steroid medicine can also be given with an epidural injection, to treat pain in your back or leg that’s caused by sciatica, or a slipped (prolapsed) disc.

Preparing for an epidural

If you have any concerns or questions about having an epidural, discuss these with your doctor. Let them know about any medicines you’re taking.

You may be given specific advice about eating, drinking and medicines before the epidural.

You will not be able to drive for 24 hours after having an epidural, so you’ll need to arrange for someone to take you home.

How an epidural is given

Epidurals are given by a specialist doctor called an anaesthetist.

You’re usually awake during an epidural, but for some types of surgery you may have it while under general anaesthetic.

• A drip will be placed in your arm so you can be given fluids while you’re having the epidural.
• You’ll be asked to sit down and lean forwards, or lie on your side with your knees up close your chest.
• You’ll be given an injection of local anaesthetic to numb the skin where the epidural will be inserted.
• A needle is used to insert a fine plastic tube called an epidural catheter into your back (spine) near the nerves that carry pain messages to your brain.
• The needle is then removed, leaving just the catheter in your spine.
• You may feel mild discomfort when the epidural needle is positioned and the catheter is inserted.

The epidural can be inserted at different levels of your spine, depending on the area of your body that needs pain relief.

Pain relief medicines are then given through the catheter. These take about 20 to 30 minutes to take full effect.

Your chest, tummy and legs may feel numb while the epidural medicines are being used, and your legs may not feel as strong as usual.

While the catheter remains in your back, it can be used to top up your pain relief medicines manually or using an automatic pump.

This can be for several hours (during childbirth) or for a few days (after major surgery).

Mobile epidurals, which use a lower dose of pain relief medicines, are sometimes used in childbirth, allowing you to walk around during labour.

Recovering from an epidural

When the epidural is stopped, the numbness usually lasts for a few hours before its effects begin to wear off.

While the medicine wears off, you’ll probably be advised to rest in a lying or sitting position until the feeling in your legs returns.

This can take a couple of hours, and you may feel a slight tingling sensation in your skin.

Tell the doctor or nurse if you feel any pain. They can give you medicines to help control it.

Do not drive, operate machinery or drink alcohol for 24 hours after having an epidural.

Risks and side effects of an epidural

Epidurals are usually safe, but there’s a small risk of side effects and complications, including:

• low blood pressure, which can make you feel lightheaded or nauseous
• temporary loss of bladder control
• itchy skin
• feeling sick
• headaches
• nerve damage

Read more about the side effects and complications of an epidural

Page last reviewed: 01 February 2023
Next review due: 01 February 2026

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Dear patients!
Multidisciplinary Clinic and Maternity Hospital “Paracelsus” informs you, according to the Letter of the Ministry of Finance of the Russian Federation to the Federal Tax Service dated March 25, 2022. N BS-4-11 / 3605, that subparagraph 3 of paragraph 1 of Article 219 of the Tax Code of the Russian Federation provides for the taxpayer’s right to receive a social tax deduction in the amount paid by him in the tax period for medical services provided by medical organizations engaged in medical activities , him, his spouse, parents, children (including adopted children) under the age of 18, wards under the age of 18 (in accordance with the list of medical services approved by the Government of the Russian Federation).

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How is epidural anesthesia done and how long does it last? – Ropisthesia

The choice of anesthesia method is one of the most pressing issues in preparing for childbirth. Epidural anesthesia is recognized as the most effective method. It allows you to significantly facilitate the course of childbirth, improve the well-being of the woman in labor and save strength to meet the baby. At the same time, epidural anesthesia does not block motor activity, does not affect consciousness: a woman has the opportunity to fully participate in childbirth and follow all the doctor’s recommendations.

Additional benefits of epidural anesthesia:

• The doctor can control the dosage of , the strength and duration of pain relief thanks to the epidural catheter.
• Safety for mother and baby . If the drug is chosen correctly, and the introduction is performed correctly, epidural anesthesia does not harm the woman in labor and the baby.
• Help in labor activity. After the introduction of epidural anesthesia, normalization of uterine contractility, relaxation of the pelvic muscles, and accelerated opening of the cervix are observed.

Given these positive aspects, in the developed world, 60 to 90% of women give birth with an epidural. Therefore, the myth that such a procedure disrupts the birth process should be left in the past. There is no reason to experience pain and stress while giving birth in a modern hospital environment and under the supervision of qualified medical personnel.

How an epidural is done: a description of the procedure

The procedure for performing epidural anesthesia is shrouded in many myths. Therefore, some women find it long, scary and very uncomfortable. It is the fear of this method of anesthesia that often makes women in labor refuse epidural analgesia. But in fact, the technique of epidural anesthesia is understandable and safe. The whole process takes about 10 minutes. You will not experience severe pain during the insertion of the catheter because the skin is pre-treated with a local anesthetic such as lidocaine.

The procedure for epidural anesthesia is as follows:

• The woman should sit down and lean forward or lie on her side in a comfortable position. It is important not to move while inserting the catheter, so keep your body in one position.
• The skin at the catheter insertion site is pre-treated with a local anesthetic to reduce pain during insertion of the epidural needle.
• The anesthesiologist inserts through a thin needle tube (catheter) into the epidural space. This is done in between contractions.
• Pain medication is administered. After 20-30 minutes you will feel the effect of pain relief. Epidural anesthesia can be administered in stages (small doses) or once – the entire drug at the same time. While the catheter is in the epidural space, it can be used to replenish medication manually or with an automatic pump.

After delivery, the doctor removes the catheter from the woman’s back, but it is recommended to remain still for 2-3 hours after the epidural. The catheter may remain in the epidural space for as long as required and may last from a few hours (during labor) to several days.

How long does an epidural last?

Many women in labor worry that the epidural will wear off too quickly and they will continue to experience severe pain. But in fact, such a situation is impossible. Since during childbirth there is an anesthesiologist in the delivery room who constantly monitors the patient’s condition and is ready to take all necessary actions, in particular, to administer another dose of painkillers.

Generally speaking, the effect of the first dose of epidural anesthesia expires no earlier than 2 hours after administration. As we noted above, you can enter a new dose of medication for the entire period of time while the catheter is in the epidural space. Therefore, if you need more pain relief, the anesthetist will take care of it.

Ropisthesia – your comfortable birth

Don’t endure the pain and stress of childbirth. After all, modern medicine offers safe, effective and long-term methods of pain relief that do not harm the mother and baby.