Epidural Steroid Injections (ESIs)

Though chronic back pain is a relatively rare phenomenon, and most patients are treated successfully with conservative therapies, there are some cases that require more invasive treatments. Some patients simply require more aggressive treatments in order to be able to complete their rehabilitation exercises, or simply to live their life without disability due to severe pain. For this reason, narcotic pain medications or Epidural Steroid Injections (ESIs) may be necessary in some cases.

Epidural Steroid Injections (ESIs) are commonly used to treat lower back pain and related leg pain associated with sciatica. This treatment has been used since 1952, and it has been perfected over time, with the use of guidance technologies such as Fluoroscopy and the C-Arm X-Ray. These injections involve a needle that delivers saline, a local anesthetic (lidocaine or bupivacaine) and steroid to the injured tissues. These substances have the effect of reducing inflammation to the area and flushing out chemicals produced by injured cells that trigger the body's inflammatory response.

Prognosis: Epidural Steroid Injections (ESIs) do not promote the healing of tissues, nor are they designed to help make the back stronger or more flexible. This treatment is not designed to be a cure for your condition. Ideally, what this treatment should do is provide you with enough pain relief to get you exercising again and completing a physical therapy protocol as designed by your doctor and physical therapist. Hopefully, by the time the effects of the steroid wears off (which could be up to several months) your rehabilitative program should have made your back strong enough that you won't need the injections again, or any other form of treatment.

A patient may have up to three ESIs in a one year period. A higher frequency of injections may lead to damage or even tissue destruction.

Lumbar epidural steroid injections are the most common types of procedures that are performed at back pain management clinics. ESIs are also performed in the cervical spine (neck) and mid thoracic region (middle back).

Pain clinics differ in their procedures used to guide the injection needle into place. Most back experts believe that those clinics that use Fluoroscopy or X-Ray guidance procedures give patients the best probability for success and the lowest complication rates. Ask the spine surgeon performing your injection procedure is her or she uses Fluoroscopy for guidance.

Results/Prognosis: Most studies report that more than 50% of patients who receive this treatment find significant pain relief related to their lower back or sciatica leg pain. While this success rate may seem a little low, remember that most of these patients were in significant pain, and many of them did not respond to any other treatment.



Epidural steroid injections deliver saline and medications at or near the location where the pain signal originates. This procedure involves the delivery of a very small amount of medication to act on a specific area. In contrast, painkillers and oral steroids must get absorbed into the bloodstream, where they have global body effects. Oral painkillers and oral steroids, because they affect the whole body, have many more unacceptable side effects.

The Procedure: an ESI delivers the medications directly into the epidural space of the spine. The saline and anesthetic may have the effect of flushing out inflammatory chemicals that have been produced, and the steroid medication may prevent the proliferation of inflammatory chemicals following its injection.

the dural sac surrounds the spinal cord, nerve roots and cerebrospinal fluid. The epidural space encloses the dural sac and is filled with small blood vessels and fat. It is within this space that the medication is injected.

A Typical medication solution contains the following:
  • A steroid, or cortisone is the most common anti-inflammatory agent used. Due to this precise delivery system, the medication may have its intended effect for several months. Though inflammation is a necessary bodily process required to heal the body, it may prohibit patients from living a normal life when it produces pain levels that are too high to manage. Decreasing inflammation helps to reduce pain levels. Commonly used steroids for this type of procedure are Methylprednisolone acetate, Dexamethasone, and Triamcinolone.
  • Lidocaine (Xylocaine) is a fasting acting anesthetic that provides temporary pain relief. For longer lasting pain relief, the medication Bupivacaine may be used. Though anesthetic's primary purpose is short-term pain relief, it may have the effect of flushing out the chemicals or immunologic agents that promote inflammation.
  • Saline is used to dilute the anesthetic. Saline may also have the effect of flushing out inflammatory chemicals in and around the epidural space.
Other types of injections include Selective Nerve Root Blocks (SNRB), Facet Joint Blocks, Facet Rhizotomy and Sacroiliac Joint Block Injections.