There is a lot of controversy about the use of epidural steroid injections (ESI’s).  Much like a lot of invasive treatment options there is concern for their overuse, necessity, and risk.  A lot of my fellow chiropractors are completely against the use of ESI’s.  With my moderate philosophy, I believe there is a time and place for most treatment options.  Epidural injections can be beneficial in some, but you should know the risks vs. benefits before you jump on board.

Epidural steroid injections are injections of steroids given to the epidural space near the spinal cord and the involved/inflamed nerve root.  The drugs used for these injections are commonly not recommended for “intrathecal” use.  The penetration depth difference between the epidural and intrathecal space is about the width of a tissue.

According to accepted medical treatment guidelines, epidural steroid injections should only be performed on patients with documented objective evidence of radiculopathy with corroborative imaging (MRI) or electrodiagnostic (NCV) findings.  What this means is that not every patient with low back or neck pain is a candidate for these injections.  There must be evidence of radiculopathy, defined as pain, numbness/tingling, or weakness in the distribution of a nerve root.  ESI’s are far more common than these specific symptoms.  Guidelines also recommend a course of conservative treatment prior to ESI use.  There are many other conditions that could cause irritation of a nerve root or nerve.  An ESI might alleviate the pain for a while, but the pain may come back later because nothing was done for the underlying cause of the nerve irritation.

One of the major concerns in the medical field at the moment is some doctors not having enough training when it comes to various pain management techniques.  Quite a few doctors are learning how to give these shots through weekend courses.  ABIPP/FIPP Board Certified Pain Management Doctors go through years of training to master these procedures.  Possible adverse effects involved with these procedures include arachnoiditis, bowel/bladder dysfunction, headache, meningitis, parapareisis/paraplegia, seizures, and sensory disturbances.  This risk is due to the fact that these injections are given so close to the spinal cord.  Other side effects, although rare, are meningitis, paralysis, and even death.

The issue I have with ESI’s are their efficacy and the risk vs. benefit.  In a March 2013 paper published in Surgical Neurology International, Dr. Nancy Epstein of Winthrop University Hospital in New York, put it more bluntly than any doctor to date: “The multitide of risks attributed to these injections outweighs the benefits,” she wrote.  Epstein went on to say, “These procedures are not FDA approved, and, according to the majority of the literature, are both ineffective and unsafe.”  Further, if the injection does help, then more injections are usually recommended.

As a workers compensation case reviewer I get many cases with requests for ESI’s.  The majority of them are denied due to a lack of evidence of radiculopathy.  These are expensive invasive procedures that are utilized far too often.  Conversely, they may be necessary when the presentation fits the intervention criteria.  If you do decide to go ahead and get an injection then follow these steps I’ve modified from an article on Dr. Oz’s website.

  • Confirm your diagnosis. Make sure that you have the one diagnosis that may respond to ESIs: a pinched or inflammed nerve with radiating pain. This is sometimes called a “herniated” or “bulging” disc with “radiculopathy” or “sciatica.”
  • Give it time. Most back pain resolves on its own with rest and with chiropractic care or physical therapy. Try these for at least 6 weeks, the typical time frame after which patients see improvement. Only get an injection if you are seeing zero progress after this conservative wait-and-see period.
  • Look for an experienced doctor. If you are going to try an epidural steroid injection, choose a doctor who is board certified in a relevant specialty and had extensive ESI training, rather than a weekend course.  Avoid doctors who automatically recommend an entire course of steroid shots rather than trying just one to see if it will help you.
  • X-ray guidance. Most ESIs today are performed under “fluoroscopic guidance,” kind of like a live X-ray, so that the doctor can position the needle correctly in the epidural space before releasing the medication. Insist on this as part of your treatment.
  • Procedure or operating room. Go to a surgery center or hospital with a sterile environment. Your back should be swabbed with sterile solution and draped to lessen the chances of germs from your own skin entering the injection site.  One advantage to getting an ESI at a hospital is that the doctors there do not work on their own. They are overseen by the hospital’s credentialing committee.

My recommendation… why not try conservative therapy options such as chiropractic treatment before choosing any invasive interventions such as injections or surgery?

For more information see the article from Dr. Oz’s website.