Why Steroid Injections Don’t Always Help Your Back Pain, and What To Do About It

If you’ve never struggled with back pain… Congratulations! You’re basically a unicorn!

The vast majority of people on this planet will experience back pain at some point in their lifetime. In fact, lower back pain is the most common musculoskeletal problem around the world. 577 million people were living with lower back pain in the year 2017 alone. That’s a lot of people — and a whole lot of pain. And the number would likely stretch into the billions if you included upper and mid-back pain.

If your pain is particularly bad, your healthcare provider may recommend a procedure called an epidural steroid injection (ESI). Pain management specialist Paul Shin, MD, describes ESIs as “a spinal procedure where a mixed solution of local anesthetic and corticosteroid is injected into an epidural space. This is an area where the medicine can block nerves or nerve roots.”

When ESIs work, they can be life-changing.

But they don’t always work. And when they don’t work, it can be incredibly disheartening.

We asked Dr. Shin why ESIs have such unpredictable results and what to do when they don’t make a dent in your discomfort.

What can epidural steroid injections help treat?

ESIs are more likely to provide significant improvement in your back pain if you’re dealing with issues involving your nerves. Examples include:

• Herniated disks — also known as slipped, ruptured or bulging disks.
• Degenerative disk disease.
• Sciatica.

Your pain management specialist isn’t going to inject your back without doing some investigating first. Dr. Shin says you can expect to get a physical exam and imaging studies — like X-rays, CT scans or MRIs — done before there’s any discussion of an ESI.

They’ll also review your medical history and ask about how you’ve responded to previous back pain treatments. With all that information, your physician can make an educated guess about the origin(s) of your pain and how effective an ESI will be.

“Because of the different reasons for back pain, epidural steroids can bring weeks of pain relief to some people, months of relief to others and forever relief to a fortunate few,” Dr. Shin clarifies. If you’re lucky enough to get six or more months of pain relief, Dr. Shin says providers will consider repeating the injection if your pain returns.

But in some cases, ESIs only work for a few days — or worst-case scenario, don’t help at all.

Why epidural steroid injections may not always work

According to Dr. Shin, the outcomes of ESIs are unpredictable for a few reasons. One of them is the complexity of the problem ESIs attempt to solve.

“Back pain can come from multiple areas of the back,” Dr. Shin explains. “The pain may involve the nerves, the nerve roots, the vertebrae, the facet joints, the muscles or a combination.”

ESIs are often successful when used on back pain that involves nerves. But if the primary cause of your pain is a fracture, arthritis or muscle strain, the outcome is more uncertain. The outcome is even hazier if there are several different issues going on at once, as is often the case.

It’s also important to remember that ESIs aren’t usually fixing the underlying cause of your back pain. They can be extremely effective tools for pain relief, but if you have degenerative disk disease, for example, what works one year may not work as effectively — or at all — the next.

Side effects of ESIs

While generally safe and well-tolerated, ESIs — as you can probably imagine — aren’t pain-free procedures. You’re likely to experience some discomfort when you get the injection and may be a bit sore for a day or so afterward.

While rare, side effects can happen. The most common side effects of ESIs are:

• Infection.
• Allergic reactions.
• Local bleeding.
• Rupture of a tendon.
• Prolonged pain.
• Skin discoloration.

It’s more common for an ESI to be ineffective than it is to experience severe side effects.

While failing to relieve your back pain certainly isn’t the goal, it also shouldn’t leave you feeling worse than you did beforehand.

Unless you get too many ESIs. That, it turns out, can do lasting damage.

Risks of ESIs

Epidural steroid injections can do a world of good, but only when they’re used in moderation. Getting ESIs too frequently can put you at risk for:

• Decreased bone density (osteoporosis).
• Weakened bone, ligaments and tendons.
• Thinning of your skin.
• Water retention.
• Immunosuppression.
• High blood sugar (hyperglycemia).

If getting more frequent injections is off the table, what do you do next? Dr. Shin says that if you’re not seeing much in the way of benefits after an ESI, or the benefit doesn’t last for very long (think days or weeks, as opposed to months), it’s time to have a conversation with your provider.

“I recommend talking with your doctor about all the interventional tools available for your specific type of back pain, not just ESIs,” he says.

Alternative treatments for back pain

• Exercise. It may feel like the last thing you want to do when your back is hurting, but building your core muscles and keeping your spine mobile with gentle exercises and stretching will be beneficial in the long run.
• Physical therapy. What you do in physical therapy looks different depending on the cause of your pain. Strength training, stretching, massage and hydrotherapy are just a few of the possible approaches your physical therapist may take to get you feeling better.
• Medication. Pain medication — even the over-the-counter stuff — can cause side effects, so it’s important that you talk to your doctor before you make any changes. Depending on what’s causing your back pain, there may be different pain relief options available to you.
• Heat and cold therapy. Depending on the cause of your back pain, your provider might advise you to apply heat, ice or a combination of the two. Just make sure you’re careful to protect your skin and limit the amount of time you have the heating pad or ice pack on your back.
• (Limited) Bed rest. Some back issues require that you go horizontal for a while, but it’s important to avoid being too sedentary. Not moving for long periods of time can slow down your recovery and, in some cases, actually increase the amount and duration of your pain.  

Getting your back on track

Epidermal steroid injections are a great option to address many causes of back pain. But they aren’t foolproof. They’re less likely to be effective for back issues that don’t have — or only have minor — nerve involvement.

If you’ve had an ESI and found it ineffective, have a conversation with your healthcare provider. It’s dangerous to get the procedure too frequently, and they may be able to suggest alternatives that will provide more relief.