Alternatives to Epidural Steroid Injections
Ross Hauser, MD., Danielle R. Steilen-Matias, MMS, PA-C.
Comparing injections for back pain.
While you are waiting for spinal surgery, your doctor may be offering you a pain management program to help you until the surgery date. One option is the use of epidural injections.
In this article, we are going to look at three types of patients:
1. The people who already had the epidural injection(s) and you have been told that the next step is surgery because the epidural injections have limited effect and you will need something else to help you.
2. You have tried the epidural and it did not help as much as you thought it would but your doctor is confident the next injection will help. Still, you are exploring whether to try it again or find something else. OR,
3. You have been newly suggested to get the injection and you were advised of the benefits and risks and you are looking up information on the Epidural Steroid Injections. You still have hope that you will not need surgery and this may be your answer.
The challenge is finding a suitable alternative.
Typically we will get an email or a patient will tell us in the office that they were recommended to get an epidural, and, doing what most people do, they went right to internet to look up what an epidural steroid injection is, what are the side-effects of an epidural steroid injection, and how much does it really help? It does not take long for someone to discover enough information about epidural steroid injections to want to explore an alternative. The challenge is finding a suitable alternative. Below are some of the types of emails we receive.
Epidurals and physical therapy
I have had four epidural injections over the last 36 months. I get great results initially, but after a few months the pain returns. I am grateful however for the time I do get relief, even if the pain comes back. My doctor told me the epidural injections are not the long-term plan, I need to find alternatives. One alternative was physical therapy. I went twice a week but started to have worsening pain. (Please see our article Why physical therapy and yoga did not help your low back pain.) Now I don’t know what to do, get a surgery or take a lot of pills.
Successful surgery turned into non-successful surgery, epidurals are not helping
I had a lumbar laminectomy at two levels. For over a year I had great results. Then I started having pain that went into my hips. I was sent to physical therapy and given pain medications. Since these treatments did not help me the next step was the epidural injections. I had two of them. The pain has now moved down my leg and it is making it very difficult to walk. My doctors are debating whether this is a hip or a problem in my low back.
Some people have had great success with epidural steroid injection. Some people even had a few of them. These are the people we typically do not see in our office. We see the ones who had the less than desired results or failure of the treatment. This is the group of patients this article is for.
Epidurals, sometimes referred to as epidural nerve blocks or epidural blocks, can be delivered as:
A very brief description of the goal of this injection is pain relief through a reduction of inflammation and swelling in the epidural space. The injection can be given as:
- interlaminar epidural injections (which delivers the injection over a wider area of the back),
- transforaminal epidural injections, (more targeted to a specific nerve – some call this an epidural nerve block or epidural block injection),
- and caudal techniques (delivery into the extreme lumbar spine).
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.
Overall long-term effectiveness of treatment with epidural corticosteroid injections
In May 2020, the journal Pain Medicine,(1) published a section of the journal titled: “Fact Finders for Patient Safety.” In this section came the findings of the Spine Intervention Society’s Patient Safety Committee. What were these findings? The identification of “Two Myths.”
- Myth #1: Epidural steroid injections can be repeated without concern regarding the duration of time between injections.
- Myth #2: A “series” of epidural steroid injections are sometimes required regardless of the clinical response to a single epidural steroid injection.
What was published as “fact,” was:
- Fact: After an epidural steroid injection, a period of up to 14 days may be needed to assess the clinical response. Systemic effects on the hypothalamic-pituitary-adrenal (HPA) axis may last three weeks or longer. (These are the well-known side effects of epidurals, they include Cushing’s syndrome where a fatty hump may develop between the shoulders, a rounded face (moon face), and pink or purple stretch marks.) These factors must be considered when determining if or when another Epidural steroid injection is indicated. There is no evidence to support the routine performance of a “series” of repeat injections without regard to the clinical response.”
The effect of repeat injections
Here is a recent 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, research lead by the University of Washington’s Comparative Effectiveness, Cost and Outcomes Research Center, doctors made these observations (2) 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.”
The learning point of this research is that a mild painkiller, such as lidocaine, works just as well as corticosteroid without corticosteroids well know side-effects.
In research lead by the University of Washington’s Comparative Effectiveness, Cost and Outcomes Research Center, doctors made these observations:
- “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 in terms of self-reported pain and function or reduction in the use of opioids and spine surgery.
Repeated injections of either type offered no additional long-term benefit if injections in the first 6 weeks did not improve pain
- In patients with improved pain and function 6 weeks after the initial injection, these outcomes were maintained at 12 months. However, the trajectories of pain and function outcomes after 3 weeks did not differ by injectate type. Repeated injections of either type offered no additional long-term benefit if injections in the first 6 weeks did not improve pain.”
For some, epidurals did not work beyond 6 weeks or at all, and for those patients, further injections did not offer benefit.
- So for some people, the epidurals worked up to 12 months.
For some, epidurals did not work beyond 6 weeks or at all, and for those patients, further injections did not offer benefit.
- So for some people, the epidurals worked up to 12 months.
There is no significant consensus regarding epidurals effectiveness
In a February 2020 study in the journal Anesthesiology and Pain Medicine, (3) researchers confirmed these findings in their own study. Suggesting: “Epidural steroid injection is a non-operative minimally invasive procedure for pain relief in spinal canal stenosis. However, there is no significant consensus regarding its efficacy.” Further, while the Epidural steroid injection could help people in the short-term, which may be the goal as you are being pain managed until you are ready for surgery, it is not as helpful for people with multi-level spinal problems or people who are fighting weight problems.
Epidural steroid injections “do not repair damage and long-term clinical improvement is lacking”
In a recent study, published in the medical journal Schmerz (Pain), (4) 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.
- What the study says is that an MRI or scan is showing disc problems but it is unclear if that is causing any problems. See our article on MRI for back pain as a risk of failed back surgery syndrome.
But there is a problem of inflammation. 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. This 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? Maybe that is the goal of your treatment now. But there are options for surgery too.
In agreement with the previous study that epidural steroid injection does not repair damage and long-term clinical improvement is lacking, is a 2015 study (5) where 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?
- In this study, the immediate response rate to transforaminal epidural steroid injection was 80.2% in patients with clinically diagnosed lumbar radiculopathy and magnetic resonance imaging of the lumbar spine suggesting nerve root compression.
- Of patients with single-level radiculopathy and multiple-level radiculopathy, 80.3% and 78.6% expressed an immediate response to transforaminal epidural steroid injection, respectively.
- The analgesic effect lasted for 1 to 3 weeks or less in 15% of patients
- for 3 to 12 weeks 15.9% patients,
- and for more than 12 weeks in 92 (39.7%) patients.
- Of the 232 patients in this study, 106 (45.7%) were offered surgery, with 65 (61.3%) undergoing operation, and with 42 (64.6%) requiring spinal fusion in addition to decompression surgery.
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.
Concern: Epidural stopgap until surgery
How about evidence that the epidurals are only masking pain and could be making your situation worse? Research: pain relief was not reflected in a significant immediate improvement in motor performance. Pain relief did not fix your structural problems
For many people, the goal is pain relief. Whatever way this can be achieved is seen as a necessary outcome. But are you only masking a worsening situation?
Here is a piece of research from doctors at the University of Arizona that makes a very good point that the only best use of epidural steroid injection is to provide pain relief until spinal surgery can be performed. It was published in 2016 in the journal Clinical Biomechanics.(6)
The researchers looked at people with degenerative facet arthritis who were treated with medial or intermediate branch nerve block injection.
Then they asked these people about their pain and measured these people with standardized scoring systems for a health condition, disability, objective motor performance measures (gait, balance, and timed-up-and-go) at pre-surgery, immediately after the injection, one-month, three-month, and 12-month follow-ups.
- Results showed that average pain and disability scores improved by 51% and 24%, respectively among patients, only one month after injection.
- Similarly, improvement in motor performance was most noticeable in one-month post-injection measurements; most improvements were observed in gait speed (14% normal walking) and hip sway within balance tests, and turning velocity within the timed-up-and-go test.
Interpretations of study:
- Spinal injection can temporarily (one to three months) improve motor performance in degenerative facet osteoarthropathy patients.
- Motor performance showed maximum improvements in one or three months after spinal injections; motor performance deteriorated after these maximum points toward baseline values. (The patient was back where the started from).
The next part the researchers found interesting and so did we.
Patients had a significant pain reduction immediately after injection with a similar reduction of more than 50% observed one month after the injection. This suggests that patients’ perceived pain reduction immediately after spinal injection; however, the pain relief was not reflected in a significant immediate improvement in motor performance.
The epidural masked the back pain but did not improve the degenerative disease condition and can put the patient at risk for hurting themselves because they feel less pain and think their back is getting better. This is not so. This is why some surgeons suggest epidurals should not be given at all, the patient should just go right to 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 altogether – go right for the surgery.
In the Spine Journal (7), 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.
Dr. Nancy Epstein writing in the journal Surgical Neurology International:(8)
- Epidural steroid injections, transforaminal lumbar epidural steroid injections, transforaminal epidural steroid injections, are the most commonly performed procedures in the United States for managing chronic low back pain.
- The procedures are not Food and Drug Administration (FDA) approved for this application and are associated with major risks and complications.
- These steroid injections have been shown to be equally effective as intramuscular steroids, epidural saline or interlaminar saline injections, have no demonstrable long-term benefits, and have not reduced the need for surgery.
- Pain specialists, typically including anesthesiologists, physiatrists, and radiologists, are neither trained in neurology or in spinal surgery but are increasingly performing Epidural steroid injections/variants for patients with surgical spinal lesions.
- Even more recently, and these physicians who are not spine specialists are performing percutaneous diskectomies resulting in major morbidity/mortality.
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 duration of the patient’s symptoms was found to be negatively significantly related to lesser pain improvement.
- For each week of the duration of symptoms, the percentage of improvement decrease.
The longer the patient waited for treatment, the less likely the caudal epidural steroid injections would work.(9)
Epidural Steroid Injections Risks and Concerns
Concern: What is that cortisone doing to your whole body?
Researchers at Vanderbilt University Medical Center published a December 2019 study in the journal Current Physical Medicine and Rehabilitation Reports. (10) What they were questioning is what were the side effects of “systemic absorption of corticosteroids occurs following epidural administration.”
Side-effects group 1:
Central steroid response,
- including sleeplessness,
- non-positional headache,
- and increased radicular pain, represents some of the most common immediate or delayed adverse event related to epidural steroid injections
Side-effects group 2:
The systemic effects of corticosteroids themselves. These include:
- hypothalamic-pituitary-adrenal axis suppression,
- decreased bone mineral density, and others.
Suppression of the hypothalamic-pituitary-adrenal axis can impair digestive functions, the immune system, cause sexual dysfunction, problems of mood and emotional swings, and possible impairment of the body’s energy-producing systems that will lead to excessive fatigue.
Concern: Spinal pain after the 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.(11)
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.”(12)
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.
- Continuing with this cited study, on a pain scale of 0 to 10, with 10 denoting the worst pain, those who received steroids reported, at one month, an average pain score of 2.1 compared with 3.6 in the etanercept group and 3.8 in the group injected with saline.
- Those in the steroid group also reported lower levels of disability (21 percent) than those in the saline group (29 percent) or etanercept group (38 percent).
Sounds good for the epidural against saline or anti-inflammatory. However, after six months, 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).(13)
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.(14)
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 backward) was negatively and significantly related to the 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.(9)
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 the epidural steroid injection, pain and disability improvement were reported at 36% and 43% of patients respectively. However, this was no different from natural recovery without treatment.(15)
Side Effect: Epidural steroid injection and bone loss
- Recent research says epidural steroids for back pain robs postmenopausal women of bone.
Research suggests that a single epidural steroid injection in postmenopausal women adversely affects the 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, (16) 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.”
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 researchers from South Korea wrote in the journal Pain Physician.(17)
- “(Our) data suggest that epidural steroid injection using triamcinolone (over 200 mg) for a period of one year will have a negative effect on bone mineral density in postmenopausal women treated for lower back pain. However, ESI therapy using a maximum cumulative triamcinolone dose of 200 mg in one year would be a safe treatment method with no significant impact on Bone Mineral Density.”
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.”
So the findings do not include long-term high dose steroid use. After further review another South Korean group of researchers came back and published in the journal Pain Physician:(18)
“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:
- “Older age and lower bone mineral density were associated with osteoporotic fracture in postmenopausal women treated for low back pain with epidural steroid injection. The epidural steroid injections were not associated with low bone mineral density or fracture.”
Again, the limitations were that this research was not valid for patients who received high-dose corticosteroids, and that study group was too small to provide an assessment.
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 2020.(19)
The reason comprehensive Prolotherapy is favored in our practice over epidurals is that 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 being necessary. Prolotherapy can help patients repair damage and avoid surgery.
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.
The Spinal ligament repair injection treatment option Prolotherapy
In this video Danielle R. Steilen-Matias, MMS, PA-C ., explains and demonstrates a Prolotherapy treatment into the lumbar spine.
Video Summary and Learning Points with Danielle R. Steilen-Matias, MMS, PA-C
- Prolotherapy is multiple injections of simple dextrose into the damaged spinal area.
- Each injection goes down to the bone, where the ligaments meet the bone at the fibro-osseous junction. It is at this junction we want to stimulate repair of the ligament attachment to the bone.
- We treat the whole low back area to include the sacroiliac or SI joint. In this video, the patient’s sacroiliac area in being treated to make sure that we get the ligament insertions and attachments of the SI joint in the low back.
- I’ve marked with a black crayon all down the midline of this patient’s back and then I have a horizontal line drawn where her pain stops. This patient has a curvature of her spine, scoliosis, so it is important to understand where the midpoint (center) of her spine is. In this patient, we are going to go up to the horizontal line into the thoracic area which is usually not typical of all treatments.
- It’s important to note that this particular patient is actually not sedated in any way so even though it is a lot of shots and a lot of injections through the skin which can be painful, patients tend to tolerate it really well the whole procedure goes relatively quickly
- At 2:20 I’m just making sure that I get the sacroiliac or SI ligaments as well as the iliolumbar ligament to help strengthen the low back.
- After treatment we want the patient to take it easy for about 4 days.
- Depending on the severity of the low back pain condition, we may need to offer 3 to 10 treatments every 4 to 6 weeks.
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”(20)
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 the 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.(21)
There is plenty of research to support the use of Prolotherapy for back pain (especially lumbar pain), here are some of the research summaries.
- University of Manitoba, Winnipeg, Manitoba, Canada.The Journal of Alternative and Complementary Medicine
- One hundred and ninety (190) patients were treated between, June 1999-May 2006.
- Both pain and Quality of Life scores were significantly improved at least 1 year after the last treatment.
- This study suggests that prolotherapy using a variety of proliferants can be an effective treatment for low back pain from presumed ligamentous dysfunction for some patients when performed by a skilled practitioner.(22)
- Harold Wilkinson MD, in the journal The Pain Physician
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.
- In our study, 55 patients who were told by their medical doctor(s) that there were no other treatment options for their pain and a subset of 26 patients who were told by their doctor(s) that surgery was their only option.
- In these 145 low backs,
- pain levels decreased from 5.6 to 2.7 after Prolotherapy;
- 89% experienced more than 50% pain relief with Prolotherapy;
- more than 80% showed improvements in walking and exercise ability, anxiety, depression and overall disability
- 75% percent were able to completely stop taking pain medications.(24)
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.
Do you have a question about your back pain?
You can get help and information for our Caring Medical Staff
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