Steroids for Back Pain: Your Questions Answered

When we talk about steroid injections for back pain, it’s important to note that we aren’t talking about the kind of steroids the muscle-bound jock you knew in high school kept in his gym bag. We’re talking about corticosteroids, man-made drugs similar to cortisol, a hormone naturally produced by your adrenal glands (1). In this section, we’ll take a look at the science behind how steroids provide pain relief as well as some commonly prescribed steroid medications.

Corticosteroids and Pain Relief

Epidural steroid injections are one of the most widely used nonsurgical treatments prescribed for low back pain and leg pain. Many studies have shown their effectiveness in managing symptoms of lower back pain (2). But why are they so effective?

When cells in your body are injured or infected, they release proteins called cytokines. Those cytokines cause inflammation and swelling, which places pressure on nerves and nerve roots, leading to a pain sensation (3).

Corticosteroid medications mimic the potent anti-inflammatory hormones made by your body. When administered in therapeutic doses – meaning in amounts larger than your body would make on its own – steroids inhibit the release of cytokines, thereby reducing inflammation and providing pain relief.

Because steroids work as immunosuppressants, they can also treat joint pain associated with certain autoimmune diseases, such as lupus and rheumatoid arthritis (4).

Epidural steroid injections can be further augmented with local anesthetics, such as lidocaine (5).

It’s important to note that steroids treat symptoms – in this case, back pain – but not underlying causes.

Types of Corticosteroids

Steroids come in all different forms – topical creams, tablets, and inhalers to name a few– but in this article, our focus is on epidural steroid injections. Depending on the cause of your back pain and your medical history, your doctor may choose to prescribe any one of a number of corticosteroids, including:

• Cortisone
• Prednisone
• Prednisolone
• Methylprednisolone
• Triamcinolone
• Dexamethasone
• Betamethasone

For people suffering from chronic back pain, corticosteroid injections can offer significant pain relief and improvement in function. In this section, we’ll cover the different circumstances under which your doctor might recommend steroids for back pain.

Nerve-Related Pain

Steroid injections are most commonly used to treat back pain associated with sciatica, spinal stenosis, herniated disc, degenerative disc disease, and spondylolisthesis (6).

What do these conditions all have in common? They all involve inflammation which puts pressure on the spinal nerves. That’s why steroid injections – with their anti-inflammatory properties – are such an effective treatment method.

Joint Pain Caused by Arthritis

Corticosteroid injections are often recommended for treating persistent joint pain associated with certain types of inflammatory arthritis. Patients with rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, systemic lupus erythematosus (lupus), and juvenile idiopathic arthritis may experience pain relief from steroid injections.

In addition to alleviating pain from arthritis, steroid injections can also halt inflammation that threatens joints or other structures in the body (7).

Corticosteroid injections typically aren’t the first line of treatment for arthritis-related pain. In many cases, they’re used to provide quick, short-term pain relief while patients wait for disease-modifying antirheumatic drugs (DMARDs) or biologics to start working (4).

Physical Therapy and Nonsteroidal Anti-Inflammatory Drugs Aren't Cutting It

In many cases, steroid injections are the middle ground between conservative care and surgery.

For patients who are unable to find relief through nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen, steroid injections can provide short-term pain relief that meaningfully improves their quality of life.

Steroid injections also provide relief much more rapidly than other methods of conservative care, such as physical therapy. While some studies have shown physical therapy and corticosteroid injections to be similarly effective in treating chronic back pain, other studies indicate that patients experience a higher degree of pain relief more quickly with steroids (8).

Steroids treat the symptoms (not the root causes) of musculoskeletal disorders, but that in and of itself can have benefits that far outlast the relatively short-lived effects of the injection. Corticosteroid injections help “break the cycle of pain and inflammation and allow the body to compensate for the condition” (9).

As a Diagnostic Tool

Epidural steroid injections can also be used to assess the role of certain nerves or joints in musculoskeletal pain.

Physicians use selective nerve root blocks to diagnose cervical or lumbar radiculopathy – pinched nerves in the neck or lower back. If injecting steroid medication into a specific nerve root causes the symptoms to go away, that tells your doctor which nerve is causing your pain (10, 11).

Steroid injections can also be used to diagnose pain caused by inflammation in the sacroiliac joint (in the lower spine, right above the tailbone), facet joints (the joints between the vertebrae of the spine), and the medial nerves (the nerves that go from the facet joints to the brain) (12).

Who Should Avoid Steroid Injections?

As with every medical procedure, steroid injections come with side effects and aren’t appropriate for every case. Make sure to let your doctor know if you have any of the following conditions:

• Infection
• Bleeding issues
• Diabetes
• Glaucoma
• Pregnancy

At this point, you’re probably wondering what it’s like to get a steroid injection and what to expect if you choose this treatment option. In this section, we’ll give you the tools you need to be prepared for your spinal injection.

What to Expect During Your Appointment

Epidural steroid injections can either be done at an outpatient clinic or at the hospital. The procedure itself can take between 15 - 45 minutes; afterward, you’ll be monitored for up to 40 minutes before being discharged.

During the procedure, you’ll lie on your stomach on an X-ray table. The area of your back where the needle will be inserted will be cleaned, and a local anesthetic will be used to numb the treatment area. You’ll be awake and aware during the procedure.

Under the guidance of an X-ray fluoroscope, your doctor will insert a hollow needle into the epidural space, which is the space inside your spinal canal, right outside the membrane that protects your spinal cord. You’ll likely feel a pinch and some pressure when the needle goes in. In most cases the doctor will first inject you with X-ray dye, also known as contrast, to ensure proper placement of the needle. Then they’ll inject a mixture of the corticosteroid medication and a numbing agent as close to the nerve as possible.

Most patients can resume normal activity the day after their procedure. Many people experience immediate pain relief after their injection, which can be attributed to the numbing medication. This relief is temporary and usually wears off a few hours after the procedure. The steroids themselves can take between two to three days to fully kick in, so it’s normal for your pain to return (and even temporarily worsen) before improving (13, 14).

If you experience pain at the site of the injection, use ice and over-the-counter painkillers for relief. Don’t use heating pads, bathtubs, hot tubs, or whirlpools (15).

What About Oral Steroids?

If you’re nervous about getting an epidural steroid injection, you may wonder if you can take oral steroids instead. In some cases, oral steroids can be an option, but they’re generally not as helpful as injected steroids.

There’s some evidence that shows oral steroids can be effective in treating low back pain. One study showed that oral steroids caused a dramatic improvement in patients with lumbar radiating pain (16); however, the authors of that study admit that there’s not currently a large body of scientific evidence supporting the use of oral corticosteroids for treating lower back pain. In addition, there’s also evidence in the opposite direction which indicates that while oral steroids can improve function in patients with low back pain, they don’t provide a measurable amount of pain relief (17).

Because they target the entire body and not just one specific nerve or joint, oral steroids may be a better option for patients whose pain arises from inflammatory arthritis as opposed to nerve issues.

Oral steroids also exhibit more severe side effect profiles than local steroid injections. Side effects of oral steroids can include weight gain, irritability and mood swings, insomnia, stomach irritation and bleeding, high blood pressure, muscle weakness, and worsening of diabetes (18, 19).

We’ve examined the benefits of epidural steroid injections for chronic back pain, but they aren’t a perfect solution. In this section, we’ll take a look at the risks and side effects of corticosteroid injections as well as their limitations.

Risks and Side Effects

The most common side effects of epidural steroid injections are headaches and short-term increases in pain before pain relief sets in (20). There’s also a chance of infection at the injection site.

Getting steroid injections on a regular basis can lead to its own set of problems. Frequent injections can cause cartilage damage, death of nearby bone, nerve damage, thinning of nearby bone (osteoporosis), and tendon weakening or rupture (15).

Because repeatedly injecting the same joint carries high risks of devastating side effects, doctors typically limit the number of injections to any given joint to four per year.

Limitations

The biggest limitation of steroid injections is that they won’t fix the problem that’s causing your pain. If you have a degenerative condition, steroids won’t change the fact that you may eventually need surgery to correct it (21).

Another limitation of steroid injections is that they’re only effective for so long. The relief provided by steroids for back pain lasts for about 6 months (22, 23). That relatively short-lived relief means that you’ll need to get injections on a regular basis, which increases your likelihood of experiencing negative side effects.

Steroid injections can be a part of a dynamic pain management plan for patients suffering from pain caused both by irritation of the spinal nerves and certain types of arthritis. While they won’t solve the underlying cause of your pain, they can provide much-needed relief when more conservative methods haven’t been successful.