Epidural Steroid Injection (ESI): A Proven Effective, Safe Treatment for Back Pain
Recently, I read an opinion article arguing that epidural steroid injections (ESI) are being used “too often” to treat back pain. This claim piqued my interest, because I’ve been administering ESI in my practice to treat frequent or chronic lower back pain and sciatica for many years now, and my patients report excellent results. In addition, I’ve personally experienced the benefits of this treatment, so, when I read the claims of the critic, I definitely had some questions.
In this article, I will:
Define epidural steroid injections
Explain how they work and when they should be used
Address the claims made by critics of epidural steroid injections
And review why ESI may be the best option for a person experiencing frequent or chronic lower back pain or sciatica
ESI By the Numbers
Epidural steroid injections (ESI) deliver strong, targeted, anti-inflammatory medicine into the epidural space around the spinal cord. The purpose of this treatment is to reduce inflammation and swelling, relieving the pressure on spinal nerves and nerve roots which can cause back pain and sciatica.
Approximately 9 million ESI treatments are administered every year in the United States. On one hand, that sounds like a lot. And it’s true that those numbers give us a tremendous body of data to draw from regarding safety and efficacy. However, the specific allegation was that epidural steroid injections are performed too frequently, so let’s look at that “9 million” number in context.
There are roughly 331 million people in the United States. Based on those numbers, even if we performed one million additional procedures each year, that’s still only 1 in every 331 Americans receiving a single epidural steroid injection over an entire year. Consider that number in relation to the percentage of Americans living with back pain. Nearly half of all working Americans — so 5 out of 10 — report occasional or frequent back pain. That’s nearly 80 million people living with back pain, compared to 9 million ESI treatments administered. That means the vast majority of people are finding back pain relief in some other way. But are those methods as safe or as effective as ESI?
A Safe, Effective Treatment for Back Pain Because of the similarity in name, people sometimes ask if epidural steroid injections are the same as the epidurals often administered prior to childbirth. No, they are not. An epidural corticosteroid injection is not the same as the epidural analgesic administered to expectant mothers.
Epidural steroid injections reduce inflammation, offering relief of lower back pain and sciatica that usually lasts about three months. In many cases, this is enough time for the underlying cause of the pain to heal. In other cases, the pain relief delivered by ESI gives patients time to try non-invasive treatments that address the underlying cause of the pain.
Critics who wish to limit or dismiss ESI as a treatment argue that epidural steroid injections are often prescribed because “the system” is set up to exploit patients for the financial benefit of physicians. I would like to submit a much more practical reason for prescribing ESI: Epidural steroid injections are administered because ESI is safe and ESI works.
As an interventionist, having treated patients in pain for more than three decades, I’ve administered countless epidural steroid injections. But, when I suffered acute sciatica from a herniated disc, I experienced how effective ESI can be firsthand. After my injury, I went from living a healthy, active, and pain-free life to struggling with severe pain that drastically reduced my quality of life. I couldn’t even stand for more than 20 minutes at a time. The things I loved to do, all the activities that brought my joy? Forget it. Out of the question. Like countless patients before me, I found ESI to be an effective treatment that allowed me to get back to doing all the things I enjoy with the people I love.
That experience gave me a clearer perspective on what my patients are going through and proved beyond a shadow of a doubt what I already knew medically: epidural steroid injection can change the lives of people living with lower back pain. Yet, I know so many people are still living with frequent or chronic back pain, struggling needlessly because they are not aware of all their treatment options or because of unfounded fears caused by people who unfairly criticize this proven effective back pain treatment.
What About the Risks? As with any medical procedure, there are some risks, which should be discussed with your doctor prior to receiving treatment. Serious side-effects are very rare. Despite this, some critics allege that patients are risking “permanent damage” if they receive too many ESI treatments. On this point, I am in partial agreement with the critics. Too many injections can cause medical problems for the patient. Of course, there are risks associated with the overuse of any medical treatment, even common over-the-counter medications such as aspirin or acetaminophen. But, when it comes to epidural steroid injections, how much is too much? The article I referenced above quotes Dr. Forest Tennant, a California-based pain management specialist who says he has treated patients who claim to have received up to 36 epidural steroid injections in a single year. That’s three injections per MONTH, when the usual number of ESI patients get a year are around three. So, yes, Dr. Tennant is correct: Administering TWELVE TIMES the usual dosage is far too much.
Of course, that extreme example is nowhere near the norm.
The reasons for not exceeding the usual number of injections are medical and practical. We all know the definition of insanity: “Doing the same thing over and over, expecting a different result.” That seems to be what was happening in the case of the patient Dr. Tennant mentioned.
Medically speaking, I hope Dr. Tennant reported that case to the state medical board, because that number of injections far exceeds usual treatments protocols, for several very good reasons. Over-using steroids can cause muscles and bones to weaken, which, in addition to the direct results, can also indirectly worsen pain and inflammation. Medically, the proper course when a patient is not responding to one treatment is to move them up the treatment ladder to another minimally invasive procedure, or, if absolutely necessary, traditional surgery.
Practically speaking, why would any responsible physician keep trying the same treatment, especially with such frequency, when it clearly wasn’t helping? And why would any patient just keep going back for more, especially considering the risks associated with frequent steroid use? That makes no sense.
In the same article, a patient, claiming to be suffering from a serious medical condition called arachnoiditis, blames ESI for their condition. Arachnoiditis is caused when one or more of the membranes surrounding the nerves of the spinal cord becomes inflamed. This can happen for many reasons: injury, infection, irritation, chemical intrusion, compression of spinal nerves, or one of the many different possible complications from invasive spinal surgery. Arachnoiditis, while serious, is extremely rare. Further, it is most often seen after traditional spinal surgery. I have never seen a single case of arachnoiditis caused by ESI in my practice.
Risks of Alternative Treatments Critics of ESI over-emphasize the risks of epidural steroid injections while ignoring what all of us recognize is a serious, ongoing health issue: opioid addiction. Some doctors rely heavily on prescription medication to help their patients “manage” their pain. They may suggest physical therapy or moderate exercise which is also done prior to ESI therapy, but the decision to shift treatment to addictive drugs is made too soon in far too many cases and with far too little consideration of the long-term effects of addiction to prescription narcotics.
Most pain medication, including over-the-counter NSAIDs (ibuprofen and aspirin) and acetaminophen, can cause side-effects when misused. However, some of the most significant risks are associated with opioid drugs including morphine, hydrocodone, oxycodone, and codeine. In addition to the more common side-effects such as constipation and respiratory depression, misuse of opioids can lead to cognitive impairment and even increased sensitivity to pain. When used appropriately, pain medications, including opioid drugs, can offer effective short-term pain relief. However, these medications should not be considered the only option prior to surgical intervention. And yet, far too often, they are.
The numbers are staggering. In the year 2017 alone, more than 191 million narcotic prescriptions were written in the United States. That’s 58 prescriptions per 100 people. Of those cases, about 11 million narcotic prescriptions were misused, and 17,000 people died due to narcotic prescription misuse. In addition to the tragic human cost, the financial burden of the opioid epidemic costs the United States more than $77 million per year. Thousands of people dead, tens of millions wasted… Given these serious repercussions, looking for alternatives to opioids, when possible, is a reasonable response.
I want to be absolutely clear here. I’m not against using pain medication. Medical science has given us tremendously beneficial medications that I prescribe to patients on a regular basis. However, there is no doubt over-prescribing narcotics is a serious health concern. In far too many cases, patients trade chronic pain for addiction. They go to their doctor seeking medical help and a better quality of life. They end up addicted to medication that robs them of the quality of life it was supposed to provide. In contrast to highly-addictive opioid medication, epidural steroid injections, when used appropriately, are safe, effective, and non-habit-forming. ESI is not a miracle cure, and it is not the best treatment option for everyone. However, the success rate is very high, and patients who respond positively to this treatment regularly go from barely able to function to resuming normal daily life.
Is ESI Right for Me? Every person’s lifestyle, health situation, expectations, and pain tolerance are different. Determining if epidural steroid injection is the right treatment for you requires a one-on-one consultation and an independent evaluation. In most cases, though, a person may be a good candidate for ESI if