If you are asking which injection is best for your lower back pain, you are asking the right question — and the honest answer is that it depends on what is actually generating your pain. There are at least six evidence-based interventional procedures used for lower back pain in 2026, and they are not interchangeable. Picking the wrong one wastes time, money, and your willingness to try again. This guide is how a board-certified interventional pain physician thinks through the decision, written in plain language so you can have an informed conversation with your own doctor.
A quick note on framing. The right question is rarely “which shot will fix my back?” It is “what is causing my pain, and which procedure best matches that source?” Inflammation around a nerve root from a herniated disc behaves differently from arthritis in a facet joint, which behaves differently from sacroiliac joint dysfunction, which behaves differently from a trigger point in the paraspinal muscles. The procedure follows the diagnosis — not the other way around.
How a Pain Specialist Actually Picks the Right Injection
Before recommending any injection, a thoughtful interventional pain physician answers three questions:
Where is the pain coming from? Radicular pain that shoots into the leg suggests nerve-root inflammation. Pain that worsens with backward bending and is localized over the spine suggests facet joints, though no history or exam finding reliably identifies facet pain on its own (Cohen 2007). One-sided low-back pain near the dimple of Venus that worsens with sitting suggests the sacroiliac joint, which is the source in an estimated 15% to 30% of chronic low back pain without leg symptoms (Cohen 2013). Diffuse muscle pain with palpable tender knots suggests a myofascial source.
What does the imaging show? An MRI shows which structures are compressed or arthritic, but many of those findings also appear in people without pain. The best procedures align an imaging finding with a matching exam finding.
What is the goal of this specific procedure? Some procedures are diagnostic — designed to test whether a structure is the pain source. Others are therapeutic — designed to provide weeks to months of relief. A few do both. Knowing the goal up front sets honest expectations.
With that framework, here are the six injections most commonly used for lower back pain, in the order a specialist typically considers them.
1. Lumbar Epidural Steroid Injection (ESI)
Best for: Radicular pain — sciatica, shooting leg pain, pain from a herniated disc, lumbar spinal stenosis, foraminal stenosis. Pain that follows a nerve-root pattern (L4, L5, or S1) into the buttock, thigh, calf, or foot.
How it works: Under fluoroscopic X-ray guidance, a needle is advanced into the epidural space around the spinal nerve roots. A corticosteroid (typically dexamethasone or methylprednisolone) plus local anesthetic is injected to reduce inflammation around the affected nerve root. Three approaches exist — interlaminar, transforaminal, and caudal — and the choice depends on your imaging.
Evidence and duration: It depends on the diagnosis and on timing. For leg pain from an irritated lumbar nerve root, a blinded trial of transforaminal injections found that 54% of patients given steroid had at least half their pain relieved at one month, against 7% to 21% in the control groups, and fewer kept that relief over the following year (Ghahreman 2010). Averaged across placebo-controlled trials, the benefit is smaller and mostly short-term (Chou 2015, Oliveira 2020). The American Society of Interventional Pain Physicians, whose members perform these injections, rates the evidence for disc herniation more favorably (Manchikanti 2021). For central spinal stenosis, a 400-patient trial found steroid plus lidocaine no better than lidocaine alone at six weeks (Friedly 2014). For leg pain that has lasted three months or longer, a 2025 BMJ guideline panel recommended against epidural injections (Busse 2025). The best candidates have recent nerve-root pain that matches the MRI.
What comes next: Pair with structured physical therapy. A repeat injection makes sense when the first one gave real relief that has since worn off. Repeating an injection that did nothing rarely helps. In a trial of 400 older adults with spinal stenosis, further injections added nothing long-term when the first six weeks had not helped (Friedly 2017).
Read more: Epidural steroid injections at Modal Pain Management.
2. Medial Branch Block
Best for: Axial low-back pain (no leg radiation) that worsens with backward bending, twisting, or transitioning from sitting to standing. Pain that is reproducible over a specific spinal segment on exam. The medial branch block is primarily a diagnostic procedure — it answers the question “is your pain coming from your facet joints?”
How it works: A small volume of local anesthetic (about 0.5 mL) is placed under fluoroscopic guidance onto the medial branch nerves at two adjacent levels. You then complete a structured pain diary over the next 4–8 hours. If your usual pain drops by at least 80%, the facet joints at those levels become the likely source. At Modal Pain Management the block is done twice, lidocaine first and bupivacaine second, and both must clear that bar.
Evidence and duration: A single facet block is falsely positive in an estimated 17% to 41% of patients (Cohen 2020). A second block lowers that risk but also screens out some people who would have done well with ablation (Cohen 2010). We use two blocks for every patient, the standard the Medicare policy for New York requires. Relief from the block itself lasts only hours by design.
What comes next: A positive result on both blocks opens the door to radiofrequency ablation, which gives months of relief in people who respond.
Read more: Medial branch block at Modal Pain Management.
3. Radiofrequency Ablation (RFA)
Best for: Patients whose facet-joint pain has been tested with positive medial branch blocks. RFA is the longer-lasting treatment that follows the question the block answered.
How it works: Under fluoroscopic guidance, a thin probe is advanced to the medial branch nerve. Radiofrequency energy heats the probe tip, creating a small thermal lesion that interrupts the nerve’s ability to transmit pain signals. No medication is injected.
Evidence and duration: In carefully selected patients, about half to two-thirds report at least 50% less pain six months to two years after lumbar RFA (Conger 2020, Schneider 2020). In people who respond, relief lasts about 9 months on average, sometimes more than a year (Smuck 2012). Not every trial agrees. In the Dutch MINT trial, adding RFA to exercise did no better than exercise alone at 3 months (Juch 2017), and a 2025 BMJ guideline panel recommended against it for chronic back pain (Busse 2025). Relief can fade as the treated nerves recover, and RFA can be repeated.
What comes next: Physical therapy and core strengthening continue alongside it.
Read more: Radiofrequency ablation at Modal Pain Management.
4. Facet Joint Injection (Intra-Articular)
What it is: Under fluoroscopic or CT guidance, a needle is placed directly into the facet joint capsule, and a corticosteroid plus local anesthetic is injected. Some practices use it for suspected facet joint pain.
Why we use medial branch blocks instead: Modal Pain Management does not perform intra-articular facet injections. A 2020 consensus guideline endorsed by multiple pain societies prefers medial branch blocks over intra-articular injections for choosing who goes on to radiofrequency ablation (Cohen 2020). So for suspected facet pain we use a medial branch block, which tests the nerves that carry the joint’s pain and leads to ablation when it works.
5. Sacroiliac Joint Injection
Best for: One-sided low-back pain over the dimple of Venus that worsens with sitting, standing on one leg, climbing stairs, or transitioning from sit to stand. Often seen after pregnancy, a fall onto the buttock, lumbar fusion surgery, or with inflammatory arthritis.
How it works: Under fluoroscopic guidance, a needle is advanced into the SI joint, and a corticosteroid plus local anesthetic is injected. Unlike the medial branch block, which is mainly a test, the SI joint injection is both diagnostic (does the familiar pain drop while the local anesthetic works?) and therapeutic.
Evidence and duration: The published numbers are modest. The 2025 multisociety SI joint guideline found low-certainty evidence that steroid injections relieve pain for at least a month (McCormick 2025). In an uncontrolled series of 39 patients with block-tested SI joint pain, two-thirds had relief lasting more than 6 weeks, averaging about 37 weeks, while the rest got about a month (Liliang 2009). In a small randomized trial of 51 patients with SI joint-related leg pain, the injection succeeded in 50% at 6 to 12 weeks, against 72% for manual therapy (Visser 2013). Repeat injections depend on how well the last one worked and on your plan’s rules. When relief keeps running short, some patients go on to lateral branch radiofrequency ablation.
Read more: Joint and soft-tissue injections at Modal Pain Management.
6. Trigger Point Injection
Best for: Myofascial pain — palpable tender knots in the paraspinal, quadratus lumborum, gluteal, or piriformis muscles. Often co-exists with one of the structural causes above and is missed when only spine imaging is reviewed.
How it works: A small needle is advanced directly into the trigger point, located by feel or with ultrasound depending on the muscle. A local anesthetic is injected, with or without a small dose of corticosteroid.
Evidence and duration: Relief can be quick, but the long-term evidence is limited. A systematic review of 23 trials found the benefit did not depend on what was injected and may come largely from the needle (Cummings 2001), and a review of 15 trials in chronic pain found no clear evidence either way. Adding injections to stretching improved results, but so did ultrasound and laser (Scott 2009).
Read more: Trigger point injections at Modal Pain Management.
Quick Comparators You May Have Searched For
Nerve block vs. epidural for back pain. An epidural treats multiple nerve roots at once via the epidural space — best for radicular pain. A medial branch nerve block targets specific facet-joint nerves to test for a facet source — best for axial pain that worsens with extension. Neither is “better” in the abstract. They answer different anatomic questions.
Cortisone shot vs. epidural. All epidural steroid injections are cortisone shots, because they use a corticosteroid medication. But not every cortisone shot is an epidural. Cortisone is also used in joints, bursae, and trigger points. The clinical difference is the target tissue, not the medication.
Steroid vs. PRP for back pain. Corticosteroids reduce inflammation quickly but do not regenerate tissue. Platelet-rich plasma (PRP) has been studied for facet, sacroiliac, and disc pain, but the trials are few and the results mixed, so it is not a standard spine treatment. It is sometimes considered when steroid responses have plateaued or for patients who want to avoid repeated steroid exposure, and it is usually self-pay because most insurers consider it unproven.
When You Should Not Get an Injection
A spine injection is not the right next step if you have:
- New onset of leg weakness, foot drop, saddle anesthesia (numbness in the groin), or loss of bladder or bowel control. These are surgical red flags: call 911 or go to the nearest emergency room
- Active infection at the injection site or systemic infection
- Unexplained fevers, weight loss, or night pain — these warrant a workup for non-mechanical causes (infection, malignancy, inflammatory arthritis) before injection
- Severely uncontrolled diabetes or anticoagulation issues that have not been addressed with your prescribing physician
- Pain that has not yet been characterized — without a working diagnosis, injecting “somewhere in the back” is poor practice
Any reputable interventional pain physician will defer the injection until these are resolved.
What to Look For in an NYC Pain Specialist
The interventional pain field has wide variability in training and practice quality. When you are choosing where to have a spine injection in New York City, ask:
- Is the physician board-certified in pain medicine (typically through anesthesiology, PM&R, or neurology), not just board-certified in their primary specialty?
- Are procedures performed with fluoroscopic guidance (live X-ray)? Blind injections in the back are not standard of care in 2026.
- Is the physician willing to explain why this specific injection matches your specific pain generator — not just offer the procedure they happen to do?
- Is there a clear next-step plan if the first injection does not work?
- Does the practice work with your insurance, and will they verify benefits before the visit?
If the answer to any of these is unclear, get a second opinion before scheduling.
The Modal Pain Management Approach
At Modal Pain Management in Midtown Manhattan, Dr. Alex Movshis is dual board-certified in anesthesiology and pain medicine, fellowship-trained at the Icahn School of Medicine at Mount Sinai. Spine injections are performed under fluoroscopic guidance in our office-based practice. Before any procedure, Dr. Movshis reviews your imaging, examines the spine, and explains in plain language which injection makes sense for your specific pain pattern — and what we will do if it does not work.
We accept most commercial PPO plans and verify your benefits before your visit at no charge. We do not accept Medicare, Medicaid, HMO plans, or workers’ compensation.
If you have lower back pain and want a clear-headed second opinion on which injection actually fits your situation, call (646) 290-6660 or book a consultation online. You will leave the visit knowing what is most likely causing your pain, how sure we are, and what your options are.
References
This article is reviewed against the peer-reviewed literature. Citations retrieved from PubMed.
- Chou R, Hashimoto R, Friedly J, et al. Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis. Annals of Internal Medicine. 2015. doi:10.7326/M15-0934 · PubMed
- Manchikanti L, Knezevic NN, Navani A, et al. Epidural Interventions in the Management of Chronic Spinal Pain: American Society of Interventional Pain Physicians (ASIPP) Comprehensive Evidence-Based Guidelines. Pain Physician. 2021. · PubMed
- Cohen SP, Raja SN. Pathogenesis, diagnosis, and treatment of lumbar zygapophysial (facet) joint pain. Anesthesiology. 2007. doi:10.1097/00000542-200703000-00024 · PubMed
- Cohen SP, Williams KA, Kurihara C, et al. Multicenter, randomized, comparative cost-effectiveness study comparing 0, 1, and 2 diagnostic medial branch (facet joint nerve) block treatment paradigms before lumbar facet radiofrequency denervation. Anesthesiology. 2010. doi:10.1097/ALN.0b013e3181e33ae5 · PubMed
- Cohen SP, Bhaskar A, Bhatia A, et al. Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group. Regional Anesthesia and Pain Medicine. 2020. doi:10.1136/rapm-2019-101243 · PubMed
- Cohen SP, Chen Y, Neufeld NJ. Sacroiliac joint pain: a comprehensive review of epidemiology, diagnosis and treatment. Expert Review of Neurotherapeutics. 2013. doi:10.1586/ern.12.148 · PubMed
- Scott NA, Guo B, Barton PM, Gerwin RD. Trigger point injections for chronic non-malignant musculoskeletal pain: a systematic review. Pain Medicine. 2009. doi:10.1111/j.1526-4637.2008.00526.x · PubMed
- Smuck M, Crisostomo RA, Trivedi K, Agrawal D. Success of initial and repeated medial branch neurotomy for zygapophysial joint pain: a systematic review. PM&R. 2012. doi:10.1016/j.pmrj.2012.06.007 · PubMed
- Conger A, Burnham T, Salazar F, et al. The Effectiveness of Radiofrequency Ablation of Medial Branch Nerves for Chronic Lumbar Facet Joint Syndrome in Patients Selected by Guideline-Concordant Dual Comparative Medial Branch Blocks. Pain Medicine. 2020. doi:10.1093/pm/pnz248 · PubMed
- Schneider BJ, Doan L, Maes MK, et al. Systematic Review of the Effectiveness of Lumbar Medial Branch Thermal Radiofrequency Neurotomy, Stratified for Diagnostic Methods and Procedural Technique. Pain Medicine. 2020. doi:10.1093/pm/pnz349 · PubMed
- Juch JNS, Maas ET, Ostelo RWJG, et al. Effect of Radiofrequency Denervation on Pain Intensity Among Patients With Chronic Low Back Pain: The Mint Randomized Clinical Trials. JAMA. 2017. doi:10.1001/jama.2017.7918 · PubMed
- Busse JW, Genevay S, Agarwal A, et al. Commonly used interventional procedures for non-cancer chronic spine pain: a clinical practice guideline. BMJ. 2025. doi:10.1136/bmj-2024-079970 · PubMed
- Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Medicine. 2010. doi:10.1111/j.1526-4637.2010.00908.x · PubMed
- Oliveira CB, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database of Systematic Reviews. 2020. doi:10.1002/14651858.CD013577 · PubMed
- Friedly JL, Comstock BA, Turner JA, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. New England Journal of Medicine. 2014. doi:10.1056/NEJMoa1313265 · PubMed
- Friedly JL, Comstock BA, Turner JA, et al. Long-term effects of repeated injections of local anesthetic with or without corticosteroid for lumbar spinal stenosis: a randomized trial. Archives of Physical Medicine and Rehabilitation. 2017. doi:10.1016/j.apmr.2017.02.029 · PubMed
- Vroomen PC, de Krom MC, Wilmink JT, et al. Lack of effectiveness of bed rest for sciatica. New England Journal of Medicine. 1999. doi:10.1056/NEJM199902113400602 · PubMed
- Liliang PC, Lu K, Weng HC, et al. The therapeutic efficacy of sacroiliac joint blocks with triamcinolone acetonide in the treatment of sacroiliac joint dysfunction without spondyloarthropathy. Spine. 2009. doi:10.1097/BRS.0b013e31819e2c78 · PubMed
- Visser LH, Woudenberg NP, de Bont J, et al. Treatment of the sacroiliac joint in patients with leg pain: a randomized-controlled trial. European Spine Journal. 2013. doi:10.1007/s00586-013-2833-2 · PubMed
- McCormick ZL, Hurley RW, Anitescu M, et al. Consensus practice guidelines on sacroiliac joint complex pain from a multispecialty, international working group. Pain Medicine. 2025. · PubMed
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Frequently Asked Questions
There is no single 'best' injection. The right choice depends on what is generating your pain. For radicular pain (sciatica from a herniated disc or spinal stenosis), a lumbar epidural steroid injection is typically first-line. For axial low-back pain that worsens with backward bending, a medial branch block tests whether the facet joint is the source and, when positive, opens the door to radiofrequency ablation, which gives months of relief in people who respond. For one-sided pain near the dimple of Venus that worsens with sitting or standing on one leg, a sacroiliac joint injection fits better. A good pain specialist will explain that reasoning in plain English before any procedure.
Less than most people expect. A thin needle numbs the skin and deeper tissue first, and most patients describe what follows as pressure or a brief sting rather than sharp pain. Spine injections are done under fluoroscopic X-ray guidance, most in about 15 to 30 minutes, usually without any sedation. If you want sedation, the procedure is done at a surgical center instead of the office. The familiar pain can come back the first evening as the numbing medicine wears off, before the steroid has had time to work. Soreness at the injection site for a day or two is common, and a real increase in pain is uncommon.
It depends on the procedure. Diagnostic blocks (medial branch blocks, selective nerve root blocks, sacroiliac blocks) use a small volume of local anesthetic — typically 0.5 to 1 mL of bupivacaine or lidocaine — to test a suspected pain generator. Therapeutic injections (epidural steroid injections, sacroiliac joint injections, joint and bursa injections, and at some practices intra-articular facet injections) combine a corticosteroid such as dexamethasone, methylprednisolone, or triamcinolone with a local anesthetic to reduce inflammation. Trigger point injections use a local anesthetic such as bupivacaine or ropivacaine, with or without a small dose of steroid. Radiofrequency ablation injects no medication. It uses heat from a probe to stop the nerves to painful facet joints from carrying pain signals.
Only for the rest of the day, and not in bed. Walk around the house that evening, do not drive until the next day, and avoid heavy lifting and strenuous exercise for 48 hours. Most people go back to desk work the next day. The numbing medicine can make you feel better than you are for a few hours, while the steroid works over days, so the result is judged two to four weeks later. Bed rest does not speed recovery from sciatica (Vroomen 1999). The full instructions are on the epidural aftercare page.
An epidural steroid injection delivers anti-inflammatory medication into the epidural space around the spinal nerve roots, and it is used for radicular pain like sciatica from a herniated disc or spinal stenosis. A nerve block targets a specific nerve. The most common nerve block for axial low-back pain is the medial branch block, which silences the small medial branch nerves that carry pain signals from the facet joints. The decision is anatomic: epidural for nerve-root inflammation, nerve block for facet-joint or peripheral-nerve pain. Both are performed under fluoroscopy, but they answer different clinical questions. An epidural is mainly a treatment. A medial branch block is mainly a test.
An epidural steroid injection is one specific kind of cortisone shot. 'Cortisone' is shorthand for the corticosteroid medication class that includes dexamethasone, methylprednisolone, triamcinolone, and others — these medications are used in nearly every steroid injection. The difference is anatomic: an epidural injection places the corticosteroid into the epidural space around the spinal cord and nerve roots, while a 'cortisone shot' for a knee, shoulder, hip, or trigger point places the same medication class into a different target for a different condition. So all epidural injections are cortisone shots, but most cortisone shots are not epidurals.
Duration varies by injection type and underlying pathology. The benefit of a lumbar epidural steroid injection is usually short-term, and in pooled trials it was small and did not last beyond the short term (Chou 2015). Diagnostic medial branch blocks last only hours by design — they are intended to test a pain source, not to provide lasting relief. Radiofrequency ablation, performed after positive medial branch blocks, gives relief that lasts about 9 months on average in people who respond, and it can be repeated if the pain returns (Smuck 2012). Trigger point injections and sacroiliac joint injections vary widely, from days to a few months.
