Epidural Steroid Injection (ESI)

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Overview

Back pain affects nearly everyone at some point in their adult life. Often times the exact cause of pain is not readily apparent, as there are many factors which may contribute to a patient’s back pain, including disc disease, referred pain, as well as psychological factors. This can make the exact site and level responsible for the back pain more challenging to localize and diagnose. Unfortunately, while imaging studies (X-RAYs, MRI and CT scans) are helpful in screening the spine for potential causes of low back pain, sometimes they don’t demonstrate an exact cause for a patient’s pain.

Back pain may arise from any anatomic structure within or around the spine which has nerve endings and is capable of transmitting pain. These structures include discs, facet joints, muscle, nerves, ligaments and dura (the membrane lining of spinal canal). All of these structures are either directly touching or in close proximity to the epidural space. Pain may be either within the spine itself (‘axial’), or radiating from the spine (‘radicular’). Both of these types of pain are ideally alleviated with the ESI.

The Epidural Injection (ESI) is a procedure that anesthetizes the space around the spinal sac (dural sac). This procedure may be performed at any level of the spine, although is most commonly performed in the lumbar spine or cervical spine. As opposed to a selective nerve root block, or a facet injection, which target a specific nerve or joint on one side of the spine, the ESI treats several consecutive levels on both sides of the spine.

The ESI procedure delivers a low volume of concentrated medication directly into a portion of the epidural space. The ESI typically covers the epidural space of about 3 vertebral body levels.

What Does ESI Stand For?

ESI stands for epidural steroid injection — a procedure that places corticosteroid medication into the epidural space surrounding an irritated spinal nerve root. Depending on which part of the spine is treated, you may see it written as a cervical ESI (neck), a thoracic ESI (mid-back), or a lumbar ESI (lower back). The lumbar ESI is the most common.

You may also encounter ESI as an abbreviation for the Emergency Severity Index, the five-level triage scale used in hospital emergency departments. The two are unrelated. Everything on this page refers to the injection.

Related abbreviations you may see on a referral or an operative note

ILESI — interlaminar epidural steroid injection
TFESI — transforaminal epidural steroid injection
SNRB — selective nerve root block, a closely related injection used more for diagnosis than for treatment
ESI series — more than one injection performed over several weeks, when repeat treatment is genuinely indicated

What Is The Epidural Space?

The membrane that covers the spinal cord and nerve roots in your spine is called the dura membrane. The space surrounding the dura is the epidural space. Nerves travel through the epidural space to your back and into your legs. Inflammation of these nerve roots may cause pain in these regions due to irritation from a damaged disc or from contact in some way with the bony structure of the spine.

What Is An Epidural And Why Is It Helpful?

An epidural injection places anti-inflammatory medicine into the epidural space to decrease inflammation of the nerve roots, hopefully reducing the pain in your back or legs. The epidural injection may help the injury to heal by reducing inflammation. It may provide permanent relief or provide a period of pain relief for several months while the injury/cause of your pain is healing. Depending on the location of your pain, the spinal steroid injection can be given in the neck (cervical), middle back (thoracic) or lower back (lumbar).

What Will Happen To Me During The Epidural Procedure?

An IV may be started so that relaxation medication can be given. You will be placed lying on your stomach on the x-ray table and positioned in such a way that your doctor can best visualize your back using x-ray guidance. The skin on your back will be scrubbed using 2 types of sterile scrub (soap). Next, the physician will numb a small area of skin on your low back with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, your doctor will direct a small needle using x-ray guidance into the tiny bony opening (sacral hiatus) just above the crease in your buttocks. A small amount of contrast (dye) is then injected to insure proper needle position in the epidural space. If the medicine does not travel high enough to reach the affected area, a small catheter will be placed into the epidural space and advance up to the area of abnormality.

Interlaminar, Transforaminal and Caudal: The Three Epidural Approaches

“Epidural steroid injection” describes where the medication goes — not how the needle gets there. There are three established routes into the epidural space, and the right one depends on your anatomy, which nerve root is involved, and whether you have had previous spine surgery. All three are performed under fluoroscopic (live X-ray) guidance with contrast dye, so placement is confirmed before any steroid is delivered.

Interlaminar (ILESI)

The needle enters in the midline, between the laminae of two adjacent vertebrae, and delivers medication into the posterior epidural space. The medication tends to spread across several spinal levels, which suits a central disc herniation or symptoms affecting both legs.

Transforaminal (TFESI)

The needle travels through the neural foramen — the bony opening where the nerve root exits the spine — placing medication directly alongside the affected root. This is the most targeted of the three. Because it treats one specific root, it also carries diagnostic value: how you respond helps confirm which nerve root is actually generating your pain.

Caudal

The needle enters through the sacral hiatus at the very base of the spine and fills the lowest portion of the epidural space. Because it approaches from below rather than through a previous surgical field, it is often chosen when prior lumbar surgery or epidural scarring makes the other routes difficult.

For a fuller explanation of what the steroid actually does once it reaches an inflamed nerve root — and what it cannot do — see why an inflamed nerve root burns, and what an epidural steroid injection actually does.

What Will Happen After The Epidural Procedure?

You will go back to a recovery area or may be recovered in the procedure room where you will be monitored for 15-30 minutes. You will then record the relief you experience during the next week. You will also be given a follow-up appointment for a repeat block if indicated. The number of injections you need is based on your own clinical response, not a fixed schedule — there is no particular magic in a series of three. If a repeat block is indicated, it is usually spaced one to three weeks apart, and we reassess after each one. You may not be able to drive on the day of your epidural steroid injection procedure. Your legs may feel weak or numb for a few hours, but your weakness should quickly resolve. If it does not, please go to the nearest ER.

Lasting Relief With Epidural Steroid Injections

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General Pre/Post Instructions

You should eat a light meal within a few hours before your procedure. If you are an insulin dependent diabetic, do not change your normal eating pattern prior to the procedure. Please take your routine medications (i.e. high blood pressure and diabetic medications). If you are on Coumadin, Heparin, Plavix or any other blood thinners (including Aspirin), or the diabetic medication Glucophage you must notify this office so the timing of these medications can be explained. We do not use sedation, so most patients drive themselves home; if your legs feel weak or numb, wait until that has resolved before driving. You may return to your normal activities within two to four hours of the procedure, including returning to work. The discomfort generated during the epidural procedure may take several days to subside, and your physician may prescribe pain medication. During the healing process it is important to treat your back with care. Your physician will provide you with activity and physical rehabilitation guidelines. You will be required to do a special physical therapy and rehabilitation program for several weeks after your procedure. A special back support may be necessary as well as electrical stimulation to lessen spasms. You should be able to resume regular activity within two to four hours after your procedure. You may have to undergo a nerve conduction study and EMG to help determine the severity and duration of back injury. You may experience an increase in your usual pain including muscle soreness in your back where the needles were inserted neck pain after epidural. Use ice packs three or four times a day and take your usual pain medications.

Duration of Relief

Most patients will have 2-3 months of relief of some of their complaints. This can range from no relief to near absolute relief with the duration being from days to many months. Some patients may not get any relief with the first injection but after one or two more done over the following weeks. Many physicians will do these injections in cycles (series) where they will do one, two or three epidural injections over a couple of weeks. The interval between these cycles should be somewhere between two to three months. More frequent administration of steroids could lead to more serious spinal epidural side effects. Transforaminal epidural steroid injection series will often last for 4-6 months or even longer.

Insurance, Cost and Getting Back to Normal

What it costs

An epidural steroid injection is a covered medical procedure under most plans when it is medically indicated, but what you personally pay depends on your own policy. As a courtesy, we submit insurance claims on your behalf; you remain responsible for your co-pays, co-insurance and deductibles. Some plans deny a specific procedure, or pay a reduced rate, even when we believe the care is appropriate for you. If you have a financial hardship, tell us early — individual accommodations can sometimes be made. The full terms are set out in our office policy FAQs.

Getting back to normal

This is an outpatient procedure. You are monitored for 15 to 30 minutes afterward, and most patients resume their normal activities — including work — within two to four hours. We do not use sedation, so you can usually drive yourself home; the exception is temporary leg weakness or numbness, which can last a few hours. Soreness where the needle entered is common and responds to ice and your usual pain medication. The complete pre- and post-procedure instructions, including how to handle blood thinners and diabetes medication, are in the instructions section above — please read them before your visit, because the timing of those medications has to be planned in advance.

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Epidural Steroid Injection FAQs

The skin and deeper tissue are numbed first with local anesthetic, which is the part most patients actually notice. Pressure during the injection itself is common. Most describe the procedure as uncomfortable rather than painful, and it takes only a few minutes once positioning and imaging are set.

The local anesthetic can give relief within hours, but that wears off. The steroid itself takes effect over roughly two to seven days. Duration varies widely, from weeks to several months, and depends on how much of your pain is driven by inflammation around the nerve rather than mechanical compression.

There is no single fixed number, but injections are spaced to limit cumulative steroid exposure and we reassess after each one. If two well-placed injections produce no meaningful benefit, a third is unlikely to, and we would look for a different pain generator rather than repeat. More on what decides how often epidural injections are repeated.

No — we do not use sedation for epidural steroid injections. The skin and deeper tissue are numbed with local anesthetic and you stay awake and responsive throughout. Because there is no sedation, most patients drive themselves home. The exception is temporary leg weakness or numbness, which can last a few hours; if you have that, wait until it has fully resolved before driving. Tell us in advance if you take a blood thinner such as warfarin, clopidogrel, apixaban or rivaroxaban, because the timing has to be coordinated with the prescribing physician.

That is useful diagnostic information rather than a dead end. An epidural that does not relieve your pain suggests the nerve root is not the primary generator, which redirects the work-up toward the facet joints, the sacroiliac joint, or a discogenic source.

They use the same family of medication, but not the same target. A “cortisone shot” usually means corticosteroid placed into a joint or soft tissue — a shoulder, a knee, a bursa. An epidural steroid injection places the medication into the epidural space around an irritated spinal nerve root, under fluoroscopic guidance, to reduce inflammation at the root itself. Same drug class, different anatomy, different problem being solved. More on what the steroid does at the nerve root.

Most are temporary: soreness where the needle entered, a short-lived increase in your usual pain, facial flushing, a night or two of poor sleep, and a transient rise in blood sugar that matters if you are diabetic. Less common risks include a post-dural-puncture headache and, rarely, bleeding, infection or nerve irritation. This is exactly why we review your blood thinners and diabetes medication before scheduling. Side effects and the diabetic question, in more detail.

You are monitored for 15 to 30 minutes and then go home. We do not use sedation, so most patients drive themselves home. Legs can feel weak or numb for a few hours, and that should resolve quickly — if it does not, go to the nearest emergency room. Most patients resume normal activity, including work, within two to four hours. Injection-site soreness can linger for several days and responds to ice. Office policies and what to expect.

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