Spine, pain & sports medicine
Epidural steroid injections
An epidural steroid injection places a small amount of corticosteroid, usually with local anesthetic, into the epidural space around irritated spinal nerve roots. We use it most often for radicular pain, including sciatica, and for selected cases of spinal stenosis, as one part of a plan that still includes diagnosis and physical therapy. Dr. Adam Nessim, an interventional spine physician, and Dr. Fernando Martinez, a pain medicine physician on the team, perform these procedures with fluoroscopy when the anatomy and the story match.
What the epidural space is
The spinal cord and the nerve roots travel inside the spinal canal, wrapped in a membrane called the dura. The epidural space is the thin corridor outside that membrane and inside the bony canal. Fat, vessels, and the exiting nerve roots occupy it. Medication placed there can bathe the nerve roots and the adjacent dura at a chosen level. That is a different target from a medial branch block, which is aimed at the small nerves that supply the facet joints, and a different target from an injection into a peripheral joint.
People hear the word epidural and think of labor analgesia, which also uses this space. The family resemblance is real. The purpose here is different: a modest dose of steroid directed at inflamed or mechanically irritated nerve roots, in a person whose pain has a radicular quality or whose stenosis is producing neurogenic symptoms, with imaging that can plausibly explain those symptoms.
The epidural space can be reached from the back of the canal (an interlaminar approach) or along the nerve as it leaves the foramen (a transforaminal approach). A caudal approach through the sacral hiatus is sometimes used in the low back. Which route we choose depends on the level, the anatomy, prior surgery, and the question the injection is meant to answer.
Who this is for
We consider an epidural steroid injection when the dominant problem is radicular pain: pain, often with numbness, tingling, or a sense of electrical travel, that follows a nerve-root pattern into the arm or the leg. Lumbar radiculopathy is the pattern most people call sciatica. Cervical radiculopathy can send similar symptoms into the shoulder, the scapula, or the hand. Imaging may show a disc herniation, foraminal narrowing, or stenosis that lines up with the examination. Alignment between the story, the neurologic findings, and the picture is what makes the injection a reasonable tool.
Selected spinal stenosis belongs in this conversation when standing and walking bring on leg heaviness, pain, or numbness that eases with sitting or leaning forward, and when the canal or the foramina are narrowed in a way that matches. An injection does not widen the canal. It may calm the inflamed roots enough that walking and rehabilitation become more possible for a period of time.
Isolated axial back or neck pain, without nerve symptoms and without a radicular examination, is a setting in which epidural steroid injections are less useful. In that situation we look more carefully at the facet joints, the sacroiliac joint, and the disc as pain sources, and we may discuss a medial branch block when the pattern looks facet-mediated. People with progressive weakness, bowel or bladder change, fever, cancer history with new pain, or a recent major trauma need a workup that is not an elective epidural.
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Transforaminal and interlaminar, in patient language
An interlaminar injection approaches the epidural space from the back of the spine, between two laminae, and spreads medication more centrally in the canal. It is a familiar, well-practiced route at the lumbar and cervical levels, and it can cover more than one root when the problem is a bit broader. Contrast under fluoroscopy shows us how the medication is likely to travel before we commit to the steroid.
A transforaminal injection approaches along the nerve as it exits the spine, through the foramen. The needle is aimed so that a smaller volume of medication is delivered closer to a specific root. When one root is the clear culprit, this route can be more selective. It also has a different risk profile, particularly in the neck, which is why cervical transforaminal injections, when they are used at all, are planned with extra attention to technique, contrast, and the type of steroid.
Neither approach is a personality preference. The choice is anatomic: where the compression or the inflammation sits, whether prior surgery has changed the canal, and how we can place medication where it can reach the irritated root while keeping the known risks in view. We explain the route we intend to use before the day of the procedure.
Cervical epidural steroid injections
Cervical epidurals are considered for selected people with neck pain that is accompanied by radicular symptoms in the arm, scapula, or hand, when imaging and the examination point to a cervical root. The canal is smaller than in the lumbar spine, and the spinal cord is present at these levels, so the procedure is planned with that anatomy in mind. Interlaminar cervical injections are typically performed at a level where the ligamentum flavum and the canal dimensions make access more predictable. Transforaminal cervical injections, if discussed, carry a rare risk of serious neurologic injury, including stroke and spinal cord injury, which is why many physicians are selective about that route and about using non-particulate steroid when a transforaminal approach is chosen.
We do not offer a cervical epidural as a first response to neck pain that stays in the midline without nerve features. Facet-mediated neck pain is a different pathway, described on the medial branch block page. After a cervical epidural, a period of observation in the procedure area is routine, and any new arm or leg weakness, unusual headache, or change in coordination is a reason to contact us immediately.
Thoracic epidural steroid injections
Thoracic radicular pain is less common in clinic than lumbar sciatica, and it is easier to miss. People may describe a band of pain around the chest or the abdomen, sometimes mistaken for a visceral problem, when a thoracic root is irritated by a disc, stenosis, or, less often, a synovial cyst. When the history, examination, and imaging support a thoracic radicular source, a thoracic epidural can be considered.
The thoracic canal is narrower than the lumbar canal, and the spinal cord occupies it. Access is planned on fluoroscopy with that constraint in view. We are slower to recommend a thoracic epidural when the pain is poorly localized or when another explanation, including a non-spinal cause of chest or abdominal pain, has not been considered. The injection, when it is done, remains a targeted attempt to calm a specific root, not a general treatment for mid-back aching.
Lumbar epidural steroid injections
Lumbar epidurals are the injections most people mean when they search for this procedure. They are used for sciatica from a herniated disc, for foraminal or lateral recess stenosis that is irritating a root, and for selected central stenosis with neurogenic claudication. The interlaminar route is often chosen when more than one root may be involved or when prior anatomy makes a midline approach more straightforward. The transforaminal route is often chosen when a single root is the target, including after surgery when access to the canal is scarred.
A caudal epidural, entering at the sacral hiatus, can be useful when we want medication to travel up the canal from below, including in some post-surgical lumbar spines. Contrast still matters. Without an image of where the injectate goes, we are guessing.
Lumbar injections are still less useful for isolated low-back aching that does not travel and that has no nerve findings. That pain often lives in the facet joints, the sacroiliac joint, or the disc, and chasing it with an epidural is a mismatch. For facet-pattern axial pain we discuss medial branch blocks. For selected knee and tendon problems that travel with a spine visit, PRP is a separate conversation on the regenerative side of the practice.
What the visit is like
The procedure is done with fluoroscopy. After a review of the plan, medications, allergies, and the target level, you are positioned so that the relevant spine is visible. The skin is cleaned and numbed. A needle is advanced to the epidural space or the foramen, and contrast is injected to confirm that we are in the intended space and that the flow is not intravascular. Only then is the steroid, usually with local anesthetic, placed. Procedure-room time is commonly twenty to forty minutes, plus observation afterward.
Most people are awake. Light sedation can be discussed. Anyone who receives sedation needs a driver. We ask you to pause anticoagulation only when the bleeding risk of the injection and the clotting risk of stopping the medication have both been considered, and that decision is made with your prescribing physician when needed. You should eat a usual light meal unless we have given different instructions because of sedation.
A single visit is sometimes enough to learn whether the root is steroid-responsive. A short series can be considered if the first injection helps and then fades, or if the first injection is a partial answer that still leaves a useful target. There is no automatic package of three. The number is a clinical decision, bounded by how much steroid we are using over time and by whether the diagnosis still holds.
What recovery feels like
Most people go home the same day. The local anesthetic can numb a patch of skin or a portion of the limb for a few hours. That numbness should wear off. A few people feel a temporary increase in their usual pain for a day or two before any steroid effect appears. When steroid helps, the change is often judged over several days to a couple of weeks, not in the procedure room. We would like you walking as comfort allows, and we would like rehabilitation to continue, because an injection that calms a root is more useful when the person is rebuilding motion and capacity with physical therapy.
A post-dural puncture headache, which is a positional headache that worsens upright and eases lying down, is uncommon and is treated if it occurs. Fever, progressive weakness, loss of bowel or bladder control, or a severe headache that is getting worse are reasons to call the same day. Ordinary soreness at the needle site is not.
Risks, including the uncommon serious ones
Common effects include soreness at the injection site, a transient flare of pain, facial flushing, a few nights of lighter sleep, and, in people with diabetes, a temporary rise in blood sugar. These are discussed in advance so they are recognized as expected pharmacology when they happen. Infection, bleeding, and allergic reaction are uncommon and are part of every injection consent. Dural puncture can occur, more often with an interlaminar approach, and can produce a positional headache.
Serious neurologic injury is rare and is the reason we use fluoroscopy, contrast, and a slow, deliberate placement. Intravascular injection, spinal cord injury, stroke, epidural hematoma, and epidural abscess are the events we plan to avoid. Cervical transforaminal injections, in particular, have been associated in the literature with rare catastrophic outcomes, which is why technique, steroid choice, and case selection are tighter at that level. We describe these risks in a calm voice because hiding them would be dishonest, and because the absolute frequency is low when the procedure is done for the right indication with image guidance.
Steroid exposure is cumulative. We keep a running awareness of how much has been given over recent months, of bone health, of mood and sleep, and of glycemic control. This page is not a consent form. Consent happens in a visit, with your history, medications, and imaging in front of us.
What the evidence actually supports
Epidural steroid injections are better supported for radicular pain than they are for isolated axial back or neck pain. In people with sciatica from a disc herniation, a well-placed injection can reduce pain for a period of weeks to months and can make it easier to stay in rehabilitation while the natural history of many disc herniations, which is toward improvement, is given time. In spinal stenosis the results are more mixed; some people with neurogenic claudication get a useful window of relief, and some do not. The injection does not reverse the bony narrowing.
An epidural is not a cure. It does not replace the diagnosis, and it does not replace the work of restoring movement. The more honest use is as part of a plan: confirm that a root is the problem, reduce inflammation around that root, and use the calmer interval to progress physical therapy and ordinary activity. Repeating injections without a clear response, or using them as a stand-alone program for axial pain, is a weaker application of the same tool.
We will say in clinic when we think an injection is unlikely to help. That is part of the same standard we apply to medial branch blocks and to regenerative procedures such as PRP: the indication has to be strong enough that the procedure can answer a question or change a trajectory.
How this sits with the rest of the plan
The spine, pain, and sports medicine pathway at the practice is built around evaluation first. An epidural is one option among several, including diagnostic blocks, joint injections, and, when the problem is a knee or a tendon, a conversation about regenerative medicine. The physicians you can read about on the about page are the people who will tell you if the anatomy you have is the anatomy this injection was designed for.
Questions people actually ask
How many epidural injections will I need?
There is no automatic series. Some people have a single injection and a durable enough response, together with rehabilitation, that nothing further is required. Some have a second injection if the first helped and then faded, or if the first was a partial answer. We limit repeat steroid exposure and we stop if the diagnosis is not holding. The number is decided in follow-up, not in a package sold in advance.
How long until I feel better?
Local anesthetic can change sensation for a few hours. The steroid effect, when it happens, is often judged over several days to a couple of weeks. A good day in the recovery area is not the same as a meaningful response, and a sore next morning is not a failure. We time follow-up so we are reading the result after the pharmacology has had a chance to work.
Is a cervical epidural riskier than a lumbar one?
The cervical canal is smaller and contains the spinal cord, so we plan cervical procedures with that anatomy in view. Serious complications are uncommon at every level when image guidance and contrast are used. Cervical transforaminal injections have a particular, rare association with catastrophic injury in the literature, which is why that route is used selectively and with additional technical caution. We will tell you which approach we intend to use and why.
Will this help back pain if I do not have leg pain?
Usually this is a weaker indication. Epidural steroid injections are more useful when there is a radicular pattern or selected stenosis with nerve-related symptoms. Isolated axial back pain without nerve findings often points us toward the facet joints or other structures, and in that setting a medial branch block may be the more coherent test.
Can I drive myself home?
If we use only local anesthetic at the skin and you feel well after observation, many people drive themselves. If sedation is used, you need a driver. If a limb is still numb from the injectate, we will ask you to wait or to have someone else drive. The decision is made before you leave the procedure area.
What if I have diabetes, or I am on a blood thinner?
Steroid can raise blood sugar for a period of days, and we plan monitoring with you and, when needed, with the physician who manages your diabetes. Blood thinners change bleeding risk around the epidural space. Some are continued, some are paused, and that decision is individualized because clotting risk and bleeding risk both matter. Bring a current medication list to the visit.
How does this fit with physical therapy?
An injection that calms a root is more useful when the person is restoring motion, strength, and walking capacity. We treat physical therapy as part of the same plan, including after the procedure, not as an unrelated errand. If therapy has been limited by pain, a helpful epidural can make the next several weeks of work more possible.
Related care
Dr. Adam Nessim is the interventional spine physician at Westport Longevity, Pain & Performance. Dr. Fernando Martinez is a pain medicine physician on the team. These pages do not diagnose and do not replace a visit. Pain and sports medicine visits do not require membership. The Westport location is planned to open in July 2027; an inquiry helps us plan the first conversation.