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Steroid Injections for Back Pain: A Costly Shot in the Dark?
Megan Brooks
February 17, 2025
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Epidural steroid injections (ESIs) offer limited effectiveness in reducing back pain and disability, an updated review by the American Academy of Neurology (AAN) suggested.
“They may modestly reduce pain in some situations for up to 3 months and may reduce disability for up to 6 months or more. The limited available evidence was insufficient to create practice recommendations,” lead author Carmel Armon, MD, of Loma Linda University School of Medicine in Loma Linda, California, told
Medscape Medical News.
The review was
published online on February 12 in
Neurology.
Key Findings
ESIs are commonly used to manage back pain but their efficacy remains debatable.
Armon and an expert panel reviewed the latest evidence on the efficacy of ESIs for cervical and lumbar spinal stenosis and radiculopathies. They focused on 90 randomized controlled trials published between 2005 and 2021 assessing pain and disability outcomes in the short-term (≤ 3 months) and long-term (≥ 6 months).
The panel noted that owing to “great variability” in efficacy measures used in the studies, they report differences based on any measure of success: The success rate difference (SRD).
For cervical and lumbar radiculopathies, ESIs “probably” reduce pain (SRD, −24.0%; number needed to treat [NNT], 4) and disability (SRD, −16.0%; NNT, 6) and “possibly” decrease long-term disability (SRD, −11.1%; NNT, 9), the authors reported. However, there is “insufficient” evidence to determine whether ESIs reduce long-term pain in radiculopathies (SRD, −10.3%).
For lumbar spinal stenosis, ESIs possibly reduce both short-term disability (SRD, −26.2%; NNT, 4) and long-term disability (SRD, −11.8%; NNT, 8) but not short-term pain (SRD, −3.5%) and there is insufficient evidence to gauge whether ESIs reduce long-term pain (SRD, −6.5%).
For cervical spinal stenosis, the effectiveness of ESIs remains unclear due to insufficient data.
“Most of the studies looked at epidural steroid injections for radiculopathy or spinal stenosis in the lower back, so it is unknown how effective they may be for these conditions in the neck,” Armon told
Medscape Medical News.
The role of ESIs in preventing surgery is also unclear. The available data show no significant difference in surgical rates between ESI and control groups (risk difference, 10.5%).
This updated review “affirms the limited effectiveness of ESIs in the short-term for some forms of chronic back pain,” author Pushpa Narayanaswami, MD, of Beth Israel Deaconess Medical Center in Boston, said in a news release.
“We found no studies looking at whether repeated treatments are effective or examining the effect of treatment on daily living and returning to work. Future studies should address these gaps,” Narayanaswami added.
A Costly Shot in the Dark?
Reached for comment, Shaheen Lakhan, MD, neurologist and researcher based in Miami, said the updated AAN data review “reinforces what many in pain management have observed — ESIs offer limited long-term benefit and come with significant financial burden.”
“ESIs may be effective as a short-term bridge for acute radicular pain, particularly in those with clear inflammatory markers and no signs of central sensitization, allowing patients to participate in rehabilitation and return to daily activities. However, if pain has already chronified in the brain, an ESI is just a costly shot in the dark,” Lakhan told
Medscape Medical News.
“Rather than a one-size-fits-all approach, we should refine patient selection using multi-modal biomarker data — including genomics, imaging, biochemical markers, and functional assessments — to predict who is most likely to benefit,” Lakhan said.
“As machine learning models evolve, integrating biomarkers and patient-specific factors will allow for precision-guided ESI use, reducing unnecessary interventions while ensuring those most likely to benefit receive them. The future of pain management should focus on data-driven, personalized care, prioritizing sustainable, cost-effective strategies that prevent chronic pain rather than merely suppressing symptoms temporarily,” Lakhan added.
This research was supported by the AAN. Author disclosures are available with the original article. Lakhan had no relevant disclosures.
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