After rest, exercise, chiropractic and physical therapy, and treatment with non-steroidal anti-inflammatory drugs (NSAIDs), steroid injections are one of the most commonly performed treatments for back pain. While generally considered safe, epidural steroid injection side effects can occur. Knowing what the side effects of epidural steroid injections are is the first way to reduce the risk, but there are other ways to protect yourself.
Most common epidural steroid injection side effects
While still relatively rare, the most common epidural steroid injection side effects include the following (from most to least common):
- Temporarily increased pain
- Infection and bleeding at the injection site
- Sleeplessness, especially in the days following injections
- Fever, especially the night after the injection
- Facial flushing
- Temporary decrease in immune system functioning
- High blood sugar
- Stomach ulcers
- Worse outcomes for some conditions
- Significant bone loss in post-menopausal women, along with increased risk of bone fractures
We’ll talk more about the recent research into epidural steroid injection side effects, especially rarer complications. Also check out the comments on this post to learn about other side effects other patients have experienced after an injection.
What’s the research on epidural steroid injections?
While these more common side effects are something to be aware of and work with your doctor to avoid, there are immense benefits of using epidural steroid injections for pain management. In medical school, doctors learn the Hippocratic oath: “first do no harm.” By that measure, epidural steroid injections hit the mark. In a recent study of 4,265 epidural steroid injections procedures in 1,857 patients, researchers found no major complications. Minor complications, such as localized increased pain or pain at the injection site, occurred in 2.4% of cases. More serious complications, including nerve injury, infection, or death have been reported, but represent a tiny fraction of those receiving this procedure.
Pain doctors have been studying epidural steroid injections for decades and there are over 45 placebo-controlled, scientific studies assessing thousands of patients to test their efficacy. Most of these studies found that epidural steroid injections were effective in relieving pain. You can review a list of these studies here in the Clinical Trials section of this page.
Additionally, some studies in which epidural steroid injections performed similarly to the control treatment delivered other potentially beneficial injections to the control group. Thus, the evidence from these studies does not necessarily contradict a therapeutic effect of epidural steroid injections — both groups may have received a helpful treatment. Like any medical treatment, there is a right and wrong time to any intervention.
The following video gives a great overview of how a balanced approach to epidural steroid injections can help you find relief, while avoiding common side effects.
Less common epidural steroid injection side effects
More research in the last five years looks at less common, but more serious side effects. These risks affect different populations at varying rates, so talk to your doctor about ways to prevent these side effects. Again, avoiding risks is part of a balanced approach to this pain management technique. Epidural steroid injections do work, and well, for many patients. Before using them, however, it’s important to know as much as you can about how they work and various risk factors.
1. Worse outcomes for some conditions
For patients with spinal stenosis, a major side effect of steroid injections may be worse outcomes and an increased chance of surgical intervention. Dr. Kris E. Radcliff and his colleagues at Thomas Jefferson University in Philadelphia had another finding. They found that patients who opted for epidural steroid injections (ESI), a common treatment protocol, were worse off, noting:
“Despite the common treatment practice of incorporating one or more ESI in the initial non-operative management of patients with spinal stenosis, these results suggest that ESI is associated with worse outcome in the treatment of spinal stenosis.”
2. Significant bone loss in postmenopausal women
Side effects of steroid injections may cause significant bone loss to the injection area in postmenopausal women, a Henry Ford Hospital study found. Shlomo Mandel, M.D., Henry Ford orthopedic physician and the study’s lead author, pointed out that:
“The findings of our study suggest that epidural steroid injections for back pain relief should be approached cautiously in patients at risk for bone fragility. Physicians who do prescribe them should consider measures that optimize bone health such as calcium and vitamin D supplements and exercise as part of their patient’s treatment plan.”
3. Risk of contamination
A side effect of steroid injections is infection at the injection site. In 2012, however, the U.S. Centers for Disease Control and Prevention began receiving reports of fungal meningitis in patients receiving steroid injections. Fifty-eight of the 745 reported cases resulted in fatality, prompting a warning for all doctors and patients utilizing steroid injections.
However, this tragic and devastating outbreak was isolated to one pharmacy. An event like this is unprecedented in the 60-year history of this treatment, given that over eight million epidural steroid injections are done in the U.S. each year. Thankfully, even in the year of this tragic outbreak, fewer than one in 10,000 epidural steroid injections led to fungal infection and fewer than one in 150,000 injections led to a fatal fungal infection.
As with all medicines, the possibility for contamination exists. Because of the area in which steroid injections are administered epidural steroid injection side effects due to this can be more serious. Read on to learn strategies for avoiding this risk.
4. Risk of bone fracture increases
Especially in vulnerable populations, the risk of spinal bone fracture increases by 29% with each steroid injection. Shlomo Mandel, M.D., a Henry Ford orthopedic physician and the study’s lead author (and author of the more recent study on postmenopausal women) notes:
“For a patient population already at risk for bone fractures, steroid injections carry a greater risk than previously thought and actually pose a hazard to the bone.”
When are epidural steroid injections the right treatment?
While there are risks, the evidence is also clear that epidural steroid injections can provide short-term benefits (lasting several months) for many patients that include reduced pain, and the ability to return to work and resume normal life. The long-term benefits, over the course of years, appear to be smaller but some patients continue to find relief and are able to avoid more extreme treatments because of these injections.
Epidural steroid injections are most useful for certain types of back pain. Some patients’ back pain is the result of one or more bulging spinal discs. When the disc protrudes to the side, it can put pressure on the nerve roots that pass through the spine. Often, this occurs in the lower back and causes pain that radiates from the lower back down the legs. This is often called sciatica or lumbar radiculitis. The research is clear that epidural steroid injections can help reduce pain for such patients, in part because these injections reduce the inflammation, relieving pressure on the nerve roots.
Watch a live procedure in the epidural steroid injection video below.
How to prevent epidural steroid injection side effects
With the potential for such serious side effects, it might be easy to dismiss steroid injections as a pain management option. However, steroid injections can be a very effective way to manage debilitating pain. Here are five ways to prevent or avoid side effects of epidural steroid injections.
1. Work with a highly-skilled, experienced pain management specialist
For such a delicate procedure, you want a skilled pain doctor with extensive experience. Ask friends and family for referrals if they have experience in this area. You can also search the licensing boards of your state to see if your pain management specialist has been commended (or censured). Using a locator tool online can help.
2. Understand your level of risk
Certain groups are more vulnerable to serious side effects of steroid injections. Postmenopausal women who are already experiencing bone loss may not want to receive steroid injections. Other risk factors for serious side effects include:
- Underlying health conditions
- Compromised immune system
- Smoking or alcohol consumption
- Overall health
3. Know what location of injection works best
There are three locations or types of steroid injection: transforaminal, interlaminar, and caudal. Caudal injections allow the most medicine to flood the entire spinal column but are often associated with the most serious side effects. Of the three, caudal injections also seem to offer the least pain relief in both the short- and long-term. Talk to your doctor about the type of injection she or he is proposing.
4. Do your research and ask questions
One of the best ways to minimize steroid injection side effects is to do your research and ask your doctor questions about the procedure. There is a lot of conflicting research on steroids. A comprehensive review of the studies can help you learn more about this treatment.
Also, you must actively involve yourself in decisions about your care. A patients’ ability to make informed choices depends on their understanding of their condition and the treatment options available. You can find out more about epidural steroid injections and news about them by subscribing to the blog on PainDoctor.com or reading through our posts on this topic.
5. Reduce your risk factors
As much as possible, take steps to reduce the factors that put you at risk for more serious side effects. Quit smoking, begin exercising as you can, and eat healthy. It can be difficult to make these changes when struggling with back pain. Exercise can be especially challenging. Work with a physical therapist to design a program of exercises that you can do safely.
Other pain management options
Like any tool, once it is found useful there is a risk that it will be overused. Responsible pain doctors rely on many tools for comprehensive pain management, of which epidural steroid injections are just one. The best pain doctors will first pursue conservative care for their patients. This means:
- Chiropractic care
- Physical therapy
- Behavioral therapy
- Holistic treatments
- Over-the-counter medications
If those treatments are not successful in alleviating your pain, your pain doctor should then move on to low risk medications, such as non-steroidal anti-inflammatory and neuropathic medications. Surgery and other interventional treatments should generally be a last approach to treating pain.
Unfortunately, interventional treatments all carry risks. This is why these treatments are used only for patients who continue to suffer from moderate to severe pain even after conservative care. Many surgical treatments have much greater risks and side effects than injection therapy. Opioids not only carry a significant risk of addiction, but also cause over 16,500 deaths each year. When epidural steroid injections are compared to the risks of surgery or the use of opioids, the potential risks and benefits can be well-justified.
Finding a balanced approach
Not every patient in pain needs an epidural steroid injection, but the right patient will likely benefit from its effects. When it comes down to it, you may decide that the side effects of steroid injections just aren’t worth risking for your particular case.
While some people find immediate, long-lasting relief from this type of pain management, if you are worried about epidural steroid injection side effects and not convinced they will work, choosing another pain management strategy is okay. You have the final say in the treatment of your pain. Pain management specialists have a number of different options for treating pain. A caring and compassionate doctor will work with you to find a pain management strategy that works for you.
If you want to learn more about this treatment approach, click the button below to find a pain specialist in your area.