Frequently Asked Questions:

Epidural Steroid Injections

Dr. Craig Best

Epidural steroid injections (ESI) are very commonly used to help treat radicular neck or low back pain (pain that radiates from the neck down the arm or low back down the leg). It is probably the most common spine-related injection I perform. Prior to the procedure, I often get similar questions from patients, so I thought I’d put together a list of frequently asked questions AND answers.

Frequently Asked Questions

1) How well do cervical and lumbar epidural steroid injections work?

 

A recent systematic review demonstrated high quality evidence for use of ESI for management of lumbar radicular pain (sciatica). Using the criterion of greater than 50% reduction in pain, use of lumbar transforaminal ESI for patients with lumbar radicular pain due to disc herniation provided significant improvement in 63% of patients at 1 month, 74% of patients at three months, 64% of patients at six months, and 64% of patients at one year. Use of lumbar transforaminal epidural steroid injections for patients with lumbar radicular pain due to spinal stenosis provided greater than 50% reduction in pain in 49% of patients at one month, 48% of patients at three months, 43% of patients at six months, and 59% of patients at one year. 

Similarly, a systematic review evaluating use of ESI for cervical radicular pain demonstrated significant improvement in pain (greater than 50%) in the majority of patients for up to 1-2 years. 

2) Does a higher dose of steroid provide an increased benefit?

 

While it is not intuitive, studies do not demonstrate any added benefit with a higher dose of steroid. Use of lower dose steroid with ESI has been shown to be just as effective as moderate and high dose steroid.

3) How many ESI can I get in a year? How many ESI can I get in a lifetime?

 

As it stands right now, there is no conclusive evidence regarding the number of ESI that can be performed in a year or a lifetime. However, appropriate spacing between injections and close monitoring of cumulative steroid dosing is important.

4) How quickly will the steroid kick in after the injection is performed? If I need another ESI, how long do we have to wait between injections?

 

The beneficial effects of ESI usually take effect in 1-14 days after the injection. As such, I usually wait at least 3 weeks to 3 months within a six-month time frame if additional ESI is/are required. 

5) Are there any potential side effects from the steroid?

 

In my experience, the large majority of patients do not experience significant side effects from ESI; however, short-term and generally short-lived side effects may include increase blood sugar (glucose) levels, flushing, insomnia (difficulty sleeping), and gastritis. Long-term side effects of excessive use of steroid may include hypothalamic-pituitary-axis suppression and Cushing’s disease.

 6) Can the steroids administered with ESI cause osteopenia/osteoporosis (decreased bone mineral density)?

 

Studies demonstrate that cumulative doses of methylprednisolone of 200mg over a one-year period and 400mg over a three-year period can significantly decrease bone mineral density and potentially contribute to development of osteoporotic compression fractures. Conversely, cumulative doses of less than 200mg methylprednisolone in post-menopausal women or 3g in healthy men did not significantly decrease bone mineral density. 

7) I have a seafood/shellfish/iodine/contrast dye allergy. Can I still get an ESI?

 

The Spine Intervention Society recommends use of contrast dye for nearly all spine injections. The main allergen in seafood that causes allergic reactions is tropomyosin and not iodine/iodide, though seafood can contain iodine/iodide; however, those persons with seafood allergies may be more prone to allergic reaction in general. The type of contrast used with ESI and other spine injections has a 0.7-3.1% chance of mild immediate reaction. In patients with known contrast dye allergy or concern about allergic reaction, pre-medication with prednisone and diphenhydramine (Benadryl) can help to blunt/avoid any reaction. 

8) Do ESI increase blood glucose levels? Is it safe for patients with diabetes to undergo ESI?

 

Steroids administered with ESI have the potential to increase blood sugar (glucose) levels. On average, blood glucose levels may be increased for one day in non-diabetics and 2 days for diabetics; however, blood glucose levels may be increased for 7-14 days in diabetics. As such, patients with diabetes must do their best to obtain good glucose control prior to ESI (ideally HbA1C less than 7%), monitor their blood glucose levels very closely after undergoing ESI, and the blood glucose level must be 200mg/dL or less when checking blood glucose level prior to the injection. 

9) Can I take a shower or bath after my injection? Can I go swimming after my injection? 

 

Currently, there is no significant evidence that avoidance of bathing or swimming decreases risk of infection after spine injections. 

References

  1. Premedication for contrast medium allergies. SIS Fact Finders. March 2014. 
  2. Smith et al. Epidural steroid injections and hyperglycemia. SIS Fact Finders. April 2015. 
  3. Manchikanti et al. Do cervical epidural steroid injections provide long-term relief in neck and upper extremity pain? A systematic review. Pain Physician. 2015. 
  4. Mattie et al. Annual maximum dose of epidural steroid injection. SIS Fact Finders. June 2019. 
  5. Schneider et al. Cumulative lifetime steroid exposure via epidural administration. SIS Fact Finders. July 2019. 
  6. Smith et al. The effectiveness of lumbar transforaminal injection of steroid for the treatment of radicular pain: a comprehensive review of the published data. Pain Medicine. 2019.

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