Lumbar Epidural Steroid Injection

What is a lumbar epidural steroid injection?

A lumbar epidural steroid injection (lumbar ESI) is an injection of anti-inflammatory medicine — a steroid or corticosteroid — into the epidural space around the spinal nerves in your low back. The main goal of lumbar epidural steroid injections is to manage chronic pain caused by irritation and inflammation of the spinal nerve roots in your low back (the lumbar region of your spine) due to certain conditions or injuries. This type of chronic pain is called lumbar radiculopathy (radicular pain), which can radiate down from your low back to your hips, legs and/or feet.

How does a lumbar epidural steroid injection work?

Healthcare providers may recommend lumbar epidural steroid injections for chronic pain management. Your provider injects a steroid or corticosteroid medication into the epidural space by your spinal cord in your low back.

The lower back region of your spine is called the lumbar spine. This region is made up of five vertebrae, and these vertebrae are the largest of the other vertebrae in your spine. They extend from your lower thoracic spine (chest) to your sacrum (the bottom of your spine).

Your vertebrae are the 33 individual, interlocking bones that form your spinal column, which runs from the base of your brain to your tailbone. These bones help protect your spinal cord from injury while allowing you to twist and turn. Between the vertebral bones are disks that provide cushioning for your vertebrae and flexibility for you.

The five vertebrae in your lumbar spine are named lumbar 1 (L1) through lumbar 5 (L5) from top to bottom. The lumbar vertebrae have several important roles, including:

• Supporting and stabilizing your upper body.
• Allowing twisting and bending movements.
• Protecting your spinal cord and cauda equina (the nerves that descend from the bottom of your spinal cord).

Your spinal cord is a very important bundle of nerves that runs from your brain to your low back. Your spinal cord acts like a highway that connects the nerves located all over your body to your brain so that your brain can communicate with the rest of your body.

Sometimes, nerve roots that are attached to the lumbar region (low back region) of your spinal cord can become pinched or inflamed. This can happen, for example, if you have a herniated disk. The inflamed nerves can cause pain that may radiate down your leg(s).

During a lumbar epidural steroid injection procedure, your provider injects a steroid into the epidural space around your spinal cord. The epidural space surrounds your spinal cord like a sleeve and contains fat, spinal nerves, blood vessels and connective tissue. The steroid acts on the irritated nerve(s) that are causing your pain and reduces swelling and pressure on the nerves.

Lumbar epidural steroid injections most often lead to temporary pain relief that lasts for three months or more, but some people may experience less or no pain relief from the injection.

What are lumbar epidural steroid injections used for?

Healthcare providers use lumbar epidural steroid injections to manage a type of chronic pain known as lumbar radicular pain, which is caused by spinal nerve root inflammation and irritation in your low back. Lumbar radicular pain is often called sciatica. Lumbar radicular pain can cause the following symptoms, which can radiate from your low back down the back of your leg below your knee to your calf and/or foot:

• Pain.
• Numbness.
• Muscle weakness.
• Tingling.

Many conditions can irritate your spinal nerve roots in your low back and cause lumbar radiculopathy (sciatica), including:

• Lumbar herniated disk: This condition is also commonly called a slipped, ruptured or bulging disk. Disks have soft, gel-like centers and a firmer outer layer. Over time or with an injury, the outer layer weakens and can crack. A lumbar herniated disk happens when the inner substance pushes through a crack in one of the disks between two vertebrae in your low back. The leaked material may press on, irritate and/or pinch nearby spinal nerves.
• Lumbar degenerative disk disease: This condition happens when the cushioning in between the vertebrae in your low back begins to wear away. A degenerated disk could cause local inflammation in your spinal nerve roots.
• Lumbar spinal stenosis: This condition is the narrowing of one or more spaces within your lumbar spine. Less space within your spine reduces the amount of space available for your spinal nerve roots. A tightened space can cause the nerves to become irritated or pinched, which can lead to low back pain, especially with repeated activity like walking.
• Lumbar osteoarthritis (lumbar spondylosis): This condition involves changes to the bones, disks and joints in your low back caused by the normal wear-and-tear of aging. Lumbar osteoarthritis can lead to narrowing of the interior of your spinal column in your low back or in the openings where spinal nerves exit, which can cause inflammation and irritation to the nerves.

Other conditions that may be treated with lumbar ESIs include:

• Localized low back pain (axial back pain): Axial low back pain can vary widely and have numerous causes. It can be a sharp or dull pain that you experience constantly or infrequently, and the pain can range from mild to severe.
• Neurogenic claudication: This condition happens from compression of the spinal nerves in your lumbar spine. It can cause pain or tingling in your low back and one or both of your legs, hips and buttocks. These symptoms are especially present when you’re standing upright or walking.

How common are lumbar epidural steroid injections for pain management?

Epidural steroid injections are among the most common type of therapy for managing radicular pain.

In the United States, back pain is the fifth most common reason people seek medical care, and approximately 9% to 25% of people describe having low back pain with leg pain traveling down below their knee (radicular pain) per year.

Who performs a lumbar epidural steroid injection?

Lumbar epidural steroid injections are very precise, so healthcare providers performing the injection must have significant specialized training. Healthcare providers who may perform lumbar ESIs include:

• Physiatrists (Physical Medicine and Rehabilitation providers).
• Radiologists.
• Anesthesiologists.
• Neurologists.
• Surgeons.

How do I prepare for a lumbar epidural steroid injection?

Before your lumbar ESI, it’s important to tell your healthcare provider if you’re pregnant or might be pregnant due to the likely use of fluoroscopy imaging (a type of X-ray imaging) during the procedure. You also need to tell your provider which medications you're taking, including herbs, supplements and other non-prescription drugs.

Your healthcare provider will give you specific instructions about what you need to do to prepare for your ESI injection. Be sure to follow their instructions. Your provider may:

• Limit your eating or drinking (fast) for a certain amount of time before your lumbar ESI.
• Adjust certain medications you’re taking, especially blood thinner medications.
• Request an MRI or CT scan of your back before your lumbar ESI to help determine the exact area that needs to be treated.
• Make sure you have someone with you to drive you home if you’re going to take a sedative for your lumbar ESI.

Questions that may be helpful to ask your healthcare provider before you get a lumbar epidural steroid injection include:

• How often do you perform lumbar ESIs?
• What do I need to do to prepare for my lumbar ESI?
• What are the risks of getting a lumbar ESI?
• What will my lumbar ESI feel like?
• How long will my lumbar ESI last?
• If a lumbar ESI doesn’t relieve my pain, what other options do I have?

What happens during a lumbar epidural steroid injection procedure?

You will likely have your lumbar epidural steroid injection in a hospital or an outpatient clinic. In most cases, a lumbar ESI takes 15 to 30 minutes. It’s important to be very still during this procedure.

There are different ways your healthcare provider can access the epidural space around your spinal cord in your low back, which include:

• Interlaminar ESI (IESI): With this method, the path of the needle is in between two laminae in your spine to get to the epidural space. A lamina is the flat plate of bone that’s part of each vertebra in your spine. The laminae in your spine form the outer wall of the spinal canal and protect your spinal cord. Providers commonly use interlaminar lumbar ESIs to provide temporary pain relief for disk herniation, spinal stenosis with or without radicular pain and localized (axial) low back pain.
• Transforaminal ESI (TFESI): With this method, the path of the needle is through the foramina, which are openings through which nerve roots exit your spine. Providers commonly use transforaminal lumbar ESIs to provide temporary pain relief for radicular pain caused by disk herniation or a specific injury to an individual nerve root.
• Caudal ESI: With this method, the path of the needle is through the sacral hiatus, which is towards the bottom of your sacrum and just above your tailbone, to reach the lowest spinal nerves. Your sacrum is the triangular bone in your low back that’s situated between your hip bones. Providers may use a caudal lumbar ESI to provide temporary pain relief for “failed back” syndrome. Caudal ESIs generally have fewer risks than interlaminar and transforaminal ESIs.

The general steps of a lumbar epidural steroid injection procedure include:

• You will change into a medical gown and lie on a comfortable table on your belly with a pillow under your abdomen. Your healthcare provider may give you medicine to relax, such as a sedative.
• Your provider will thoroughly clean the area of your low back where they’ll insert the epidural to minimize the risk of infection.
• Your provider will use a type of imaging guidance called fluoroscopy (X-ray, or radiology imaging) to help guide the epidural needle to exactly the right position.
• Your provider may inject local anesthesia with a small needle near the area where they’ll insert the epidural. This is so you won’t feel as much pain when they insert the epidural needle, which is larger than a standard needle.
• When the epidural needle is in place in the epidural space around your spinal cord, your provider will inject a contrast material. The contrast material ensures the needle tip is in the epidural space and not inside a blood vessel or other tissue. This helps ensure that the medication will reach the inflamed nerves they are targeting.
• Your provider will then slowly inject the medication, which is usually an anti-inflammatory medication, such as a steroid or corticosteroid. Some providers may inject a mixture of a corticosteroid, normal saline and a local anesthetic.
• When your provider is done with the injection, they’ll apply pressure to the site to prevent bleeding, clean the area again and apply a dressing to the site. You’ll move into a chair or bed to rest for a few minutes to an hour. This is so your provider can make sure you don’t have any reactions to the medication before you go home.

How painful is a lumbar epidural steroid injection?

You’ll likely experience a minor pinch when your provider injects the local anesthetic to numb the area before your lumbar epidural steroid injection.

You may not feel anything during your lumbar ESI, or you may feel the following:

• Pressure.
• Tingling.
• A burning sensation.
• Momentary pain.

If you have any discomfort during the injection, it usually goes away once the injection is finished. If you feel intense, sharp pain during or after your lumbar ESI, tell your provider immediately.

What are the side effects of lumbar epidural steroid injections?

Side effects of lumbar ESIs include:

• You may experience a temporary increase in pain before the steroid medication starts working.
• You may have tenderness and/or bruising at the site of your injection.
• If your provider uses fluoroscopy for imaging guidance, there will be minimal low-level radiation exposure due to the X-rays. Fluoroscopy X-rays may be harmful to unborn babies. It’s essential to tell your healthcare provider if you’re pregnant or might be pregnant before you undergo the procedure.
• If you have diabetes, an epidural steroid injection will likely cause high blood sugar (hyperglycemia). This could last for hours or even days.
• If you have glaucoma, an ESI may temporarily increase your blood pressure and eye pressure.

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.

What are the advantages of lumbar epidural steroid injections?

The advantages of lumbar epidural steroid injections include:

• You may experience temporary pain relief.
• You may have enough pain relief to participate in rehabilitation exercises to help treat the cause of your low back pain.
• You may have a better quality of life and an improved ability to do daily activities due to pain relief.
• Lumbar epidural steroid injections may reduce the need for more invasive procedures, such as surgery, for pain management.

What are the risks and possible complications of lumbar epidural steroid injections?

Lumbar epidural steroid injections are usually safe, but there are risks of certain side effects and complications. Although rare, risks and complications that apply to lumbar ESI injections include:

• Low blood pressure, which can make you feel lightheaded.
• Severe headache caused by spinal fluid leakage.
• Infection from the epidural procedure, such as an epidural abscess, discitis, osteomyelitis or meningitis.
• Having a negative reaction to the medications, such as hot flashes or a rash.
• Bleeding if a blood vessel is accidentally damaged during the injection, which could cause a hematoma or a blood clot to form.
• Damage to the nerves at the injection site.
• Temporarily losing control of your bladder and bowels. You might need a catheter (a small tube) in your bladder to help you pee.
• Getting ESI injections too often or receiving higher doses of steroid medication may weaken the bones of your spine or nearby muscles. Because of this, most healthcare providers limit people to two to three ESIs per year.

Can a lumbar epidural steroid injection cause long-term side effects?

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.
• Permanent paralysis from a hematoma that occurs when there’s a buildup of blood between the dura mater and your spinal cord.

What is the outlook (prognosis) for lumbar epidural steroid injection therapy?

Many people experience temporary pain relief from lumbar epidural steroid injections, and some people even experience longer-term relief lasting up to 12 months. However, some people do not experience any pain relief from ESIs.

The goal of lumbar epidural steroid injection is typically to provide adequate short-term pain relief so that you can begin or continue physical therapy or to try to avoid more intensive pain relief procedures. Physical therapy may help promote long-term pain relief by strengthening the muscles that support your spine.

If a lumbar ESI works for you and results in pain relief, your healthcare provider may recommend another injection later on. However, most providers limit people to two to three ESIs per year.

How long do lumbar epidural injections last for back pain?

Studies on lumbar ESIs have revealed that they can provide reliable pain relief for up to 6 months in many cases. However, every person is different and experiences pain differently, so your experience may vary.

Lumbar ESIs are most successful at providing temporary pain relief for radicular pain caused by a lumbar herniated disk and lumbar spinal stenosis. One study revealed that for people with radicular pain secondary to disk herniation who received a lumbar ESI, up to 70% of them felt at least 50% better at one to two months, and 40% of them felt better at 12 months.

It’s important to remember that lumbar ESIs are not intended to cure back pain; their main goal is to provide pain relief.

When should I see my healthcare provider?

If you experience any of the following symptoms after you’ve returned home from your lumbar ESI, be sure to contact your healthcare provider or go to the nearest hospital as soon as possible:

• Experiencing a severe headache while you’re standing up or sitting that feels better after lying down. This could be a sign of a dural puncture.
• Developing a fever, which could be a sign of an infection.
• Having a reduced or complete loss of bladder or bowel control.
• Feeling numbness and/or weakness in your legs, which could be a sign of nerve injury.

A note from Cleveland Clinic

When performed by a skilled healthcare provider, lumbar epidural steroid injections are an often effective and generally safe therapy option for chronic low back pain caused by certain conditions, especially a herniated disk and spinal stenosis. It’s important to remember that a lumbar ESI will most likely not cure your low back pain. Rather, it will provide pain relief so that you can return to your normal activities, improve your quality of life and complete physical therapy. If you’re feeling anxious about receiving a lumbar ESI, don’t be afraid to ask your healthcare provider about it and the procedure. They can answer any questions you may have.