Easing Back Pain: Understanding Epidural Steroid Injections and Finding the Right Approach for You
"A national survey of Korean pain physicians reveals insights into the use of epidural steroid injections (ESIs) for managing back pain and radiculopathy, highlighting variations and consensus in treatment approaches."
Back pain. It’s a common complaint, and for many, it can be debilitating. One of the go-to procedures for those suffering from lower back pain and radiculopathy (pain that radiates down the leg) is an epidural steroid injection, or ESI. But what exactly constitutes the 'right' way to administer these injections? Is there a consensus among medical professionals?
To answer these questions, a detailed survey was conducted among academic pain centers and select private practices in Korea. The goal was to understand the current practices and identify any common ground in how ESIs are performed.
This article dives into the findings of this survey, shedding light on the different approaches to ESIs and offering valuable insights for anyone considering this treatment option.
Measuring Relief and Reach
About 9 million epidural steroid injections are performed annually in the United States, according to a 2026 report. Reported success rates range from 18% to 90%, depending on the diagnosis, injection approach, and definition of success. Clinical sources commonly define success as at least a 50% reduction in pain with improved daily functioning, while many studies report significant short-term relief in 50% to 80% of appropriately selected patients.
Common Techniques, Uneven Evidence
Epidural steroid injections have been used for decades to manage lumbosacral pain, particularly radiculopathy and chronic low back pain. Common practice includes different injection approaches, and the optimal technique remains debated because physician methods and opinions about effectiveness vary. Multiple systematic reviews support pain relief and functional improvement for up to 6 weeks, although practice patterns continue to vary among interventional pain physicians.
Origins in Paris
Epidural injections for low back pain and sciatica have been used since approximately 1901. The first injections were given around 1900 in Paris by Jean Sicard and Fernand Cathelin, who worked independently. Their early procedures involved injecting small volumes of cocaine into the sacral hiatus, forming an early foundation for the treatment's later evolution.
What the Survey Says: Key Findings on Epidural Steroid Injections
The survey cast a wide net, gathering responses from 122 pain centers out of 173 initially contacted—a solid 70.5% response rate. This included feedback from 39 academic programs and 85 private practices, giving a well-rounded view of ESI practices.
- Steroid Choice: Over half (55%) of the physicians surveyed preferred dexamethasone for ESIs.
- Injection Intervals: A notable difference emerged between academic institutions and private practices regarding the minimum interval between injections. Academic centers averaged 3.1 weeks, while private practices averaged 2.1 weeks (a statistically significant difference with a P value of 0.01).
- Consistency in Approach: Despite some variations, the survey found no significant differences between academic institutions and private practices in terms of the types and single doses of steroids used, the annual steroid doses, or how doses were adjusted for patients with diabetes. The exception, as noted above, was the minimum interval between injections.
Recent Directions in Treatment
A retrospective observational study found that adding paraspinal intramuscular atelocollagen to lumbar epidural steroid injection reduced pain and improved functional capacity in patients with chronic low back pain. A randomized controlled trial in patients with single-level unilateral lumbar disc herniation found that unilateral and bilateral transforaminal injections both reduced pain severity and disability to a similar degree. The bilateral approach was more effective at reducing pain by over 50% in that study.
Limits of Repeated Injections
Evidence on epidural steroid injections is mixed. Multiple studies have identified no sustained positive outcomes for low back pain from multiple spinal injections, and a randomized controlled trial by Iversen et al. found no clinically significant effects from caudal epidural steroid or isotonic saline injections for lumbar radiculopathy. The American Academy of Family Physicians reports that lower-spine injections are not effective for reducing pain and disability, although they may outperform placebo at short-term follow-up.
What Does This Mean for You? Navigating Your ESI Options
The survey highlights that while ESIs are a common procedure, approaches can vary. This underscores the importance of having an open discussion with your doctor about your specific needs and concerns. Don't hesitate to ask about the type of steroid being used, the reasons behind the chosen injection interval, and how the treatment plan will be adjusted if you have diabetes or other health conditions.
Short-Term Benefit, Ongoing Questions
Epidural steroid injections have a moderate short-term effect in managing low back pain with radiculopathy. Severe neurological complications are exceptional, but their possibility has prompted calls for research into alternatives to the foramen and methods for detecting arterial injury. Research on long-term effectiveness remains limited in older adults, despite the high prevalence of back and leg pain in this group.
Value and Low-Value Care
Patients with low back pain are commonly exposed to low-value care despite guideline recommendations to the contrary. Spinal injections for chronic low back pain are identified as a key example of this disconnect. Their persistence illustrates the broader difficulty of removing low-value practices from pain care, even when newer treatments become available.