Alternatives to Epidural Steroid Injections | Why epidural did not work for you

Danielle.Steilen.ProlotherapistDanielle R. Steilen-Matias, MMS, PA-C

In this article back pain treated with epidural steroid injections and Prolotherapy are compared. We will answer common patient questions such as:

If you have questions about Epidural Steroid Injections for back pain, send them in by emailing us

Here is a new study. Let’s look at the list of leading universities who participated in this study: University of Washington, Oregon Health and Science University, Brigham and Women’s Hospital and Spine Unit, Harvard Vanguard Medical Associates, University of Texas, Stanford University Medical Center, University of Colorado, the University of Pittsburgh, Columbia University Medical Center, New York, and let’s add the Mayo Clinic, Henry Ford Hospital in Detroit, and Kaiser Permanente Center for Health Research. Clearly there is a lot of knowledge behind this research.

Published in the journal Archives of physical medicine and rehabilitation, August 2017, these researchers came up with these conclusions concerning the overall long-term effectiveness of treatment with epidural corticosteroid injections for lumbar central spinal stenosis and the effect of repeat injections, including crossover injections of lidocaine alone, on outcomes through 12 months.

“For lumbar spinal stenosis symptoms, epidural injections of corticosteroid plus lidocaine offered no benefits from 6 weeks to 12 months beyond that of injections of lidocaine alone.”

Here is the result of this research:

It is very likely if you are reading this research article, epidurals were not helpful for you and you are debating continued use of opioids, surgery, or are researching alternatives. I am glad you are here.

Epidurals, sometimes referred to as epidural nerve blocks or epidural blocks, can be delivered as:

The goal of this injection is pain relief through a reduction of inflammation and swelling in the epidural space.

Numerous research studies have found it challenging to determine whether one technique is superior to the other, especially when considering multi-level disc related pain.

In the medical journal Neurosurgery, a review of 1931 patients who either received spinal surgery or epidural steroid injections for back pain were compared to see which treatment was superior.

After years of collecting data from thousands of patients and condensing the results down to 161 patients who met the criteria for comparison, the doctors found that for various problems of the spine, surgery is superior to epidural steroid injections for improving quality of life and pain.

This difference does not hold for disability level 1 year after treatment, however. What does this mean?

For some patients who had either epidural steroid injections or spinal surgery, two mainstays of conservative care – one year later there was no improvement in disability levels.(2)

Ineffectiveness of surgery or epidural steroid injections starts at the diagnosis

In a recent study, German doctors made a significant discovery. Chronic lumbar pain syndromes without neurological (nerve and muscle) deficits can be caused by many problems not just what shows up on an MRI scan looking for back pain. In many cases a diseased intervertebral disc is found on radiological examination but the clinical relevance of these findings is not clear.

But there is a problem of inflammation.

This study from German published in the medical journal Schmerz (Pain) A transforaminal epidural injection (the injection near the nerve root inflammation) into the lumbar region can reduce inflammation and therefore improve temporary treatment outcome, but it does not repair damage and long-term clinical improvement is lacking. (3This agrees with the above research on the lack of  long-term effectiveness.

The only best use of epidural steroid injection is to provide pain relief until spinal surgery can be performed

In a study published in the Hong Kong medical journal, doctors suggest that the only best use of epidural steroid injection is to provide pain relief until spinal surgery can be performed. What do they base this on?

Conclusions: The immediate response to transforaminal epidural steroid injection was approximately 80%. Transforaminal epidural steroid injection is a useful diagnostic, prognostic, and short-term therapeutic tool for lumbar radiculopathy.

Although transforaminal epidural steroid injection cannot alter the need for surgery in the long term, it is a reasonably safe procedure to provide short-term pain relief and as a preoperative assessment tool.(4)

Concern: Epidural stopgap until surgery

“Unnecessary multiple epidural steroid injections delay surgery for massive lumbar disc herniation”

There are numerous research papers that suggest that the use of epidural steroid injection subjects patients to complications by withholding surgery and that spinal surgeons should actively take back patients who could benefit more from surgery. So here the recommendation is to forget the epidural steroid injections all together – go right for the surgery.

In the Spine Journal, doctors from Massachusetts General Hospital, Northwestern School of Medicine, Johns Hopkins University School of Medicine / Walter Reed National Military Medical Center, suggested that Epidural steroid injections may provide a small surgery sparing effect in the short term compared to control injections, and reduce the need for surgery in some patients who would otherwise proceed to surgery.(5)

Dr. Nancy Epstein writing in the journal Surgical neurology international:

This brings us to another interesting point: Delay of treatment, any treatment.

Researchers at Penn State University writing in the medical journal Clinical spine surgery sought out to determine what factors could or could not predict which patients would benefit most from caudal epidural steroid injections in managing chronic low back pain and radiculopathy.

Among the findings:

The longer the patient waited for treatment, the less likely the caudal epidural steroid injections would work.(7)

The reason comprehensive Prolotherapy is favored in our practice over epidurals is because Prolotherapy injections repair damaged tissue. In the above research, the pain is being caused by spinal tissue that needs repair, epidurals do not repair this tissue. The longer the patient waits for treatment, the more damage occurs and the greater the likelihood of surgical intervention. Prolotherapy can help patients repair damage and avoid surgery.

Epidural Steroid Injections Risks and Concerns

Concern: Spinal pain after epidural shot

It is clear that Epidural Steroid Injections are a cause of concern to patients and doctors. Recent research cites multiple case reports of neurological complications resulting from epidurals have led the Food and Drug Administration (FDA) to issue a warning, requiring label changes, warning of serious neurological events, some resulting in death. The FDA has identified 131 cases of neurological adverse events, including 41 cases of arachnoiditis. A review of the literature reveals an overwhelming proportion of the complications are related to transforaminal epidural injections, of which cervical transforaminal  epidural injections  constituted the majority of neurological complications.(8)

General Concerns:

Italian pain specialists writing in the Polish medical journal Anaesthesiology intensive therapy simply said this:

“We concluded that even if epidural steroid injection is one of the most widely- -used techniques to treat radicular pain, it must be administered cautiously, with careful monitoring for systemic side effects. At the very least, a standardised protocol is necessary.”(9)

But why do patients still get epidurals?

A recent study from John Hopkins suggested that 75% of patients they monitored who were treated with epidural steroids reported 50 percent or greater leg pain relief and felt better overall after one month compared to those who received saline (50 percent) or etanercept (acting as an anti-inflammatory 42 percent).

Patients still get epidurals because they provide pain-relief and as noted below, relief from disability challenges.

Sounds good for the epidural against saline or anti-inflammatory – BUT  after six months, however, slightly more patients in the saline (40 percent) and etanercept (38 percent) groups had a positive outcome than those in the steroid group (29 percent).(10)

This research was cited in a supportive study published by a Chinese research team in the International journal of clinical & experimental medicine. Here, a systematic literature search was conducted to examine studies comparing the effect of local anesthetic with or without steroids. This meta-analysis confirms that epidural injections of local anesthetic with or without steroids have beneficial but similar effects in the treatment of patients with chronic low back and lower extremity pain.(11)

In research from Penn State already cited in this article, doctors found that patients with pain with lumbar extension (most commonly a popular exercise where patients “stretch” their spine by bending backwards) was negatively and significantly related to length of relief duration from the caudal epidural steroid injections. The average length of relief duration is 38.37 weeks for individuals without painful lumbar extension and 14.68 weeks for individuals with painful lumbar extension. The mean length of relief following a caudal injection is reduced by 62% in patients who exhibit pain with lumbar extension.(7)

This research supported a recently published work in the British Medical Journal  that looked at the effectiveness of caudal epidural steroid or saline injections which are often used for chronic lumbar radiculopathy. They looked at the patients’ responses at 6 weeks, 12 weeks, and 52 weeks. It was a multi-centered trial, blinded, randomized and controlled.

They found no statistical or clinical difference between the groups over time.  At the one year follow-up after epidural steroid injection, pain and disability improvement was reported at 36% and 43% of patients respectively. However, this was no different from the natural recovery without treatment.(12)

Side Effect: Epidural steroid injection and bone loss

Research suggests that a single epidural steroid injection in postmenopausal women adversely affects bone mineral density of the hip. Enough so that  doctors should be considering options  when contemplating treatment for radiculopathy.

Writing in the medical journal Spine, doctors noted:

“A single Epidural steroid injection in postmenopausal women adversely affects Bone Mineral Density of the hip.  . . . Our findings show that epidural administration of corticosteroids has a deleterious effect on bone, which should be considered when contemplating treatment options for radiculopathy. The resulting decrease in Bone Mineral Density, while slight, suggests that Epidural steroid injections should be used with caution in those at a risk for fracture.”(13)

In other words, for some women, the temporary relief from back pain can lead to hip fracture.

Therapy with glucocorticoids often results in bone loss and glucocorticoid-induced osteoporosis

Other researchers, however, disagree. While they agree that corticosteroids often result in bone loss and corticosteroid-induced osteoporosis, they say it has nothing to do with bone mineral density because no link has been made between epidural steroid injection and bone mineral density. Further smaller doses are okay. Here’s what they say:

[Fortunately these researchers recognized their limitations]: First, this study is limited by the fact that it was retrospective. Second, this study did not consider the use of epidural steroid injection with high-dose corticosteroids. “Third, our study did not include any long-term assessments of the effects of epidural steroid injection on Bone Mineral Density.”(14)

So the findings do not include long-term high dose steroid use. After further review a similar group of researchers came back and said. “Therapy with glucocorticoids often results in bone loss and glucocorticoid-induced osteoporosis. However, the relationship between epidural steroid injection, bone mineral density, and vertebral fracture remains to be determined.” Confused? Read the research, it wasn’t the steroids – it was old age:

Again, the limitations were that this research was not valid for patients who received high-dose corticosteroids, that study group was too small to provide assessment.(15)

An Alternative to Epidural Steroid Injections is Prolotherapy for Back Pain

Temporary pain relief is not what pain patients should be seeking. Permanent healing and pain relief should be the goal. Maybe pain patients don’t believe there is a cure for their pain, so they seek as many pain relief options as possible. The problem is that many pain relief treatments include steroids and anti-inflammatory agents that can make the injury even worse. As the injury gets worse, a person is forced to look for stronger and more complex pain relief. It’s a vicious cycle.

In 2013, doctors at the Hadassah Medical Center in Jerusalem began recruiting patients to test the long-term effects of epidural steroid injection versus Prolotherapy in patients with low back pain. Registered with the US National Institutes of Health US Library of Medicine, the Israeli doctors hypothesis is that in the treatment of low back pain radiating to the leg, the long term results of prolotherapy are more effective than those of the current conventional treatment: epidural steroid injections (ESI). This research is expected to be published in 2019/2020.(16)

Prolotherapy is the opposite of epidural steroid injections.

Prolotherapy creates inflammation to bring blood flow and healing factors to the injured tissue. Any neck or back pain that is related to joint degeneration or ligament injury can be treated effectively with Prolotherapy.

In the Journal of Alternative and Complementary Medicine, doctors said: “Intra-articular prolotherapy provided significant relief of sacroiliac joint pain, and its effects lasted longer than those of steroid injections”(17)

In 2017, research from Prolotherapy doctors including Liza Maniquis-Smigel, MD; Kenneth Dean Reeves MD; Howard Jeffrey Rosen, MD; John Lyftogt,  MD;  and David Rabago, MD; published in the journal Anesthesiology and pain medicine, found that among participants with chronic low back pain and either buttock or leg pain, 10 mL of dextrose injected in the caudal epidural space, compared with injection of 10 mL of normal saline, resulted in substantial, consistent, and significant analgesia within 15 minutes that lasted at least 48 hours.

These findings suggest for the first time that 5% dextrose injected in the caudal space may confer a pain-specific neurogenic effect at the dorsal root level.(18)

There is plenty of research to support the use of Prolotherapy for back pain (especially lumbar pain), here are some of the research summaries.

Citing our own Caring Medical and Rehabilitation Services published research in which we followed 145 patients who had suffered from back pain on average of nearly five years, we examined not only the physical aspect of Prolotherapy, but the mental aspect of treatment as well.

If our study, mentioned above, was solely based on getting 75% of patients off their pain medications, that would be wildly successful in itself. But the fact that Prolotherapy was able to strengthen the patient’s spines and decrease overall disability and return these people to a normal lifestyle. That is not pain management, that is a pain cure.


1 Friedly JL, Comstock BA, Turner JA, Heagerty PJ, Deyo RA, Bauer Z, Avins AL, Nedeljkovic SS, Nerenz DR, Shi XR, Annaswamy T. Long-Term Effects of Repeated Injections of Local Anesthetic With or Without Corticosteroid for Lumbar Spinal Stenosis: A Randomized Trial. Archives of Physical Medicine and Rehabilitation. 2017 Apr 8.

2. Sivaganesan A, Chotai S, Parker SL, McGirt MJ, Devin CJ. 161 Patient-Reported Outcomes After Epidural Steroid Injections vs Surgery for Degenerative Lumbar Disease: A Prospective, Matched Cohort Study. Neurosurgery. 2016 Aug;63 Suppl 1:164-5. doi: 10.1227/01.neu.0000489730.99853.c3.[Google Scholar]

3. Niemier K, Schindler M, Volk T, Baum K, Wolf B, Eberitsch J, Seidel W. Efficacy of epidural steroid injections for chronic lumbar pain syndromes without neurological deficits : A randomized, double blind study as part of a multimodal treatment concept. Schmerz. 2015 Jul;29(3):300-7. [Google Scholar]

4. Leung SM, Chau WW, Law SW, Fung KY. Clinical value of transforaminal epidural steroid injection in lumbar radiculopathy. Hong Kong Med J. 2015 Oct 1;21(5):394-400.[Google Scholar]

5. Bicket MC, Horowitz J, Benzon H, Cohen SP. Epidural injections in prevention of surgery for spinal pain: systematic review and meta-analysis of randomized controlled trials. Spine J. 2014 Oct 13. pii: S1529-9430(14)01569-1. doi: 10.1016/j.spinee.2014.10.011.[Google Scholar]

6. Epstein NE. Unnecessary multiple epidural steroid injections delay surgery for massive lumbar disc: Case discussion and review. Surg Neurol Int. 2015 Aug 31;6(Suppl 14):S383-7. doi: 10.4103/2152-7806.163958. eCollection 2015. [Google Scholar]

7. Billy GG, Lin J, Gao M, Chow MX. Predictive Factors of the Effectiveness of Caudal Epidural Steroid Injections in Managing Patients With Chronic Low Back Pain and Radiculopathy. Clinical spine surgery. 2017 Jul 1;30(6):E833-8. [Google Scholar]

8. Manchikanti L, Hirsch JA. Neurological complications associated with epidural steroid injections. Curr Pain Headache 1. Rep. 2015 May;19(5):482. doi: 10.1007/s11916-015-0482-3.   [Google Scholar]

9. Bellini M, Barbieri M. Systemic effects of epidural steroid injections. Anaesthesiology intensive therapy. 2013;45(2):93-8. [Google Scholar]

10. Cohen SP, White RL, Kurihara C, Larkin TM, Chang A, Griffith SR, Gilligan C, Larkin R, Morlando B, Pasquina PF, Yaksh TL. Epidural Steroids, Etanercept, or Saline in Subacute SciaticaA Multicenter, Randomized Trial. Annals of internal medicine. 2012 Apr 17;156(8):551-9. [Google Scholar]

11. Zhai J, Zhang L, Li M, Tian Y, Zheng W, Chen J, Huang T, Li X, Tian Z. Epidural injection with or without steroid in managing chronic low back and lower extremity pain: ameta-analysis of ten randomized controlled trials. International journal of clinical and experimental medicine. 2015;8(6):8304. [Google Scholar]

12. Iversen T, Solberg TK, Romner B, Wilsgaard T, Twisk J, Anke A, Nygaard Ø, Hasvold T, Ingebrigtsen T. Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial. Bmj. 2011 Sep 13;343:d5278. [Google Scholar]

13. Al-Shoha A, Rao D, Schilling J, Peterson E, Mandel S. Effect of Epidural Steroid Injection on Bone Mineral Density and Markers of Bone Turnover in Postmenopausal Women. Spine. 37(25):E1567-E1571, December 01, 2012. [Google Scholar]

14. Kang SS, Hwang BM, Son H, Cheong IY, Lee SJ, Chung TY.Changes in bone mineral density in postmenopausal women treated with epidural steroid injections for lower back pain. Pain Physician. 2012 May-Jun;15(3):229-36. [Google Scholar]

15. Yi Y, Hwang BM, Son H, Cheong IY. Low bone mineral density, but not epidural steroid injection, is associated with fracture in postmenopausal women with low back pain. Pain Physician. 2012 Nov;15(6):441-9.[Google Scholar]

16. A Comparison of the Long Term Outcomes of Prolotherapy Versus Interlaminar Epidural Steroid Injections (ESI) for Lumbar Pain Radiating to the Leg [NIH Clinical Trials)

17. Kim WM, Lee HG, Jeong CW, Kim CM, Yoon MH. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. J Altern Complement Med. 2010 Dec;16(12):1285-90. doi: 10.1089/acm.2010.0031. [Google Scholar]

18. Maniquis-Smigel L, Reeves KD, Rosen HJ, Lyftogt J, Graham-Coleman C, Cheng AL, Rabago D. Short term analgesic effects of 5% dextrose epidural injections for chronic low back pain: a randomized controlled trial. Anesthesiology and pain medicine. 2017 Feb;7(1). [Google Scholar]

19. Watson JD, Shay BL. Treatment of chronic low-back pain: a 1-year or greater follow-up. J Altern Complement Med. 2010 Sep;16(9):951-8. doi: 10.1089/acm.2009.0719. [Google Scholar]

20. Wilkinson HA. Injection therapy for enthesopathies causing axial spine pain and the “failed back syndrome”: a single blinded, randomized and cross-over study. Pain Physician. 2005 Apr;8(2):167-73. [Google Scholar]

21. Hauser RA, Hauser MA. Dextrose Prolotherapy for unresolved low back pain: a retrospective case series study. Journal of Prolotherapy. 2009;1:145-155. [JOP/CMRS] [Google Scholar]


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