Perhaps there is no source of confusion, contention, obfuscation, and general misunderstandings primarily among patients but also doctors as there is in regard to epidural steroid injections. This chapter is devoted to trying to dispel some of the more common myths.

Epidural steroid injections do not correct any anatomical or biomechanical problems leading to a radiculopathy. Epidural steroid injections, however, do not mask pain or “put a Band-Aid” on the problem. Epidural steroid injections work by serving to reduce the swelling and inflammation around an inflamed nerve root. When used in isolation, epidural steroid injections have not been shown to provide good, consistent long-term relief. When used as a tool to enable patients to participate with structured therapeutic exercises, they have been shown to have good efficacy. However, in the end the data as it stands is mixed and a large part of the resulting confusion lies in the fact that prospective, double-blind placebo-controlled studies in an effort to evaluate only the injection have not included structured physical therapy as part of the study design. As a result, in many of these studies only short-term benefit is seen from the injection. Short-term benefit should be the norm to be expected from most steroid injections for a variety of musculoskeletal pathologies as they address inflammation, not biomechanics. Prospective cohort outcome studies and retrospective studies, by contrast, follow patients through a normal treatment paradigm which does or at least should include therapeutic exercises, and these studies have tended to show good longer-term efficacy for epidural steroid injections [1–3]. Of course, it should be emphasized and reemphasized that these studies do not show good long-term effect of the injection alone but rather as it is used as part of a more comprehensive treatment paradigm. What is clearly needed are double-blind placebo-controlled studies that incorporate physical therapy as well as the injection procedures and that also look at this paradigm as it relates to patients with herniated discs causing radiculopathy as well as multifactorial spinal stenosis causing radiculopathy.

The number and frequency of epidural steroid injections remains a topic that lacks data and consensus in equal parts. Many doctors tell each other and their patients that there should be a limit of three epidural steroid injections in a six-month time frame or sometimes even in a year. However, this is based in dogma, not research. Three injections is a fine number, but why not four or seven or two or even one? As there is no data, there really is no good answer. What is established is that steroid injections may locally degrade cartilage and will weaken tendons and so are and should be used sparingly in joint and tendon injections. There is some systemic absorption of the medication and systemic steroids are known to have many different and serious side effects. The amount of systemic absorption is small but there is at least some suggestion that it may increase fracture risk in elderly patients (see below) and so the potential for problems from systemic absorption should not be completely discounted. However, with regard to the epidural space, it is not known whether there is a local risk of repeated injections. No local risk from repeated epidural steroid injections (other than the risk of any singular injection of infection, bleeding, nerve trauma, and infarction which will be discussed below) has been effectively documented. Some spine surgeons feel that repeated epidural steroid injections performed over the course of years and decades may predispose to an increased complication of dural tearing during a potential spine surgery. However, this conjecture has not been scientifically validated, and the same spine surgeons tend to report that even if that were the case it would not necessarily be a reason to not perform the injections if they are helpful. Insurance companies tend to restrict the number of epidural steroid injections a patient may receive in a year, and this sometimes plays a practical role in decision-making depending on the specific circumstance. However, if the decision of how many injections to perform is based on insurance rather than medical science, this should be effectively communicated to the patient. Insurance denial or restriction does not equate to sound medicine – in this case it merely serves to help perpetuate the dogma.