Epidural Steroid Injections

A 38-year-old bond trader has a line of pain running from his right buttock down the back of his calf to the outside of his foot. It started three weeks ago, the morning after he wrestled a suitcase into an overhead bin. Sitting through the 8 a.m. meeting is the worst part of his day, the outer edge of his foot feels numb, and his back barely hurts. His MRI shows an L5-S1 disc extrusion pressing on the right S1 nerve root. Leg pain that follows one nerve, an exam that points to the same nerve, and an image that shows why: that is the pattern an epidural steroid injection was designed for, and the pattern where the evidence is strongest.

Dr. Alex Movshis performs lumbar, cervical, and thoracic epidural steroid injections under live fluoroscopic guidance at Modal Pain Management, 369 Lexington Avenue, Floor 25, in Midtown Manhattan.

What an epidural steroid injection does, and what it does not

A herniated disc is only partly a mechanical problem. Disc material that escapes sets off inflammation around the nerve root it touches, and an inflamed root hurts along its whole length, which is how a disc at L5-S1 puts the worst pain in the foot. An epidural steroid injection (ESI) places a corticosteroid, usually with a local anesthetic, in the epidural space next to that root. The steroid damps the inflammation.

The injection does not push a disc back in, dissolve a bone spur, or widen a narrowed canal. It treats the chemistry around the nerve, not the anatomy, which is why the benefit in trials is mostly short-term. The anatomy often heals on its own: in a systematic review of repeat imaging in patients treated without surgery, 70% of disc extrusions and 96% of sequestered fragments regressed, against 41% of protrusions and 13% of bulges (Chiu 2015). The injection’s job is to make those months tolerable enough to sleep, work, and do the rehab. Our herniated disc animation shows the leak, the inflamed root, and why many herniations shrink.

Who the injection is for, and the back pain it will not fix

The right candidate has radicular pain: pain that travels down a leg or an arm in the territory of one nerve root, often with numbness in the same strip, an exam that agrees (a weak ankle push, a lost reflex, a positive straight-leg raise), and an MRI showing that root compressed at the matching level. The typical patient has sciatica from a herniated disc, or a pinched nerve in the neck sending pain down the arm, both forms of radiculopathy. Most have tried about four weeks of conservative care, the threshold in the Medicare coverage policy for New York (L39036), though pain that stops sleep or rehab can justify moving sooner. Recurrent radicular pain after lumbar surgery, post-laminectomy syndrome, also qualifies.

Plenty of back pain is not an ESI problem. Low back pain that is worse bending backward or twisting, and does not travel below the knee, usually points to the facet joints. One-sided pain below the belt line that is worse sitting may be the sacroiliac joint. Hip arthritis and piriformis entrapment can imitate sciatica well enough to fool a quick exam.

New numbness in the groin or inner thighs, new trouble controlling your bladder or bowel, leg weakness that worsens by the day, or back pain with fever is not a reason to book an injection. Go to the closest emergency room or call 911.

An ESI is postponed or avoided with an active infection, pregnancy (the procedure uses X-ray), a bleeding disorder, or a blood thinner that cannot safely be paused. Poorly controlled diabetes, osteoporosis, and a past reaction to contrast dye or a steroid are not automatic bars, but each changes the plan.

What the evidence shows, condition by condition

Radicular pain from a disc herniation: the strongest case

In a blinded randomized trial of transforaminal injections for lumbar radicular pain, 54% of patients who received steroid at the foramen had at least half their pain relieved at one month, compared with 7% after local anesthetic alone at the same spot, 19% after saline there, 21% after intramuscular steroid, and 13% after intramuscular saline. Acute and chronic pain responded equally. Fewer patients held that relief over the following year, and only some were still better beyond twelve months (Ghahreman 2010).

Pooled across placebo-controlled trials, the average effect is smaller. Pinto’s meta-analysis of 23 trials found a 6.2-point reduction in leg pain on a 100-point scale in the short term (beyond two weeks and up to three months), with no significant long-term effect (Pinto 2012). The 2020 Cochrane update of 25 trials found a 4.93-point reduction (Oliveira 2020). Chou’s review found a lower short-term risk of surgery (relative risk 0.62) but no change in long-term surgery rates (Chou 2015).

Both findings are true. An average blends big responders with non-responders, and Ghahreman concluded that the steroid’s advantage is obscured in group averages and emerges when outcomes are counted patient by patient. A well-selected patient has a real chance of a large improvement for weeks to months, not a guarantee of where they will be in a year.

Cervical radicular pain has fewer trials. In a multicenter trial of 169 patients, arm pain at one month did not differ significantly among cervical epidural steroid, medication plus physical therapy, and the two combined. Three months after treatment, 56.9% of the combination group had a positive outcome, against 36.7% with injections alone and 26.8% with medication and therapy alone (Cohen 2014). That is the argument for pairing the injection with rehab rather than choosing between them.

Spinal stenosis with neurogenic claudication: weak

In central canal stenosis, the legs ache, weaken, or go numb with standing and walking and recover when you sit or lean on a shopping cart. Epidurals are widely used for it, and the evidence is weak. In the largest trial, 400 patients received epidural glucocorticoid plus lidocaine or lidocaine alone. At six weeks there was no significant difference in disability (1.0 point on the 24-point Roland-Morris scale) or leg pain (0.2 points on a 10-point scale), for interlaminar and transforaminal injections alike (Friedly 2014). Chou’s meta-analysis also found no clear effect in stenosis (Chou 2015).

A patient whose stenosis is really one pinched root in a narrowed foramen, one leg and one dermatome, behaves like a radicular patient and is judged that way. For classic claudication, an ESI is one step in a spinal stenosis plan, reassessed after each injection and stopped if it is not working. The spinal stenosis animation shows why walking hurts and leaning forward helps.

Back pain without leg pain, and facet joint pain

For back pain that stays in the back, the federal AHRQ evidence review found limited, low-strength evidence and no difference between epidural steroid and placebo in pain, function, or surgery (Chou 2015, AHRQ report), and the Medicare policy for New York classifies ESIs for axial spine pain as investigational (L39036). The back pain workup looks at the facet joints, sacroiliac joints, and disc first.

Facet pain is a joint problem, and an epidural does not target the joint or the medial branch nerves that carry its pain. The test is a medial branch block, and confirmed facet pain is treated with radiofrequency ablation.

Why other sources quote bigger numbers

The American Society of Interventional Pain Physicians’ 2021 guideline grades epidural injections for disc herniation at Level I for long-term effectiveness. Its grades cover fluoroscopically guided epidural injections “with or without steroids,” so they do not isolate what the steroid adds, the question the placebo-controlled meta-analyses were built to answer (Manchikanti 2021).

Interlaminar, transforaminal, or caudal: how the route is chosen

All three routes reach the same epidural space through different doors.

Interlaminar. The needle passes between two laminae at the back of the spine, and medication spreads up, down, and to both sides. It suits pain in both legs, pain across several levels, and central canal narrowing.

Transforaminal. The needle is guided to the foramen, where a single nerve root leaves the spine, and the medication runs along that root into the front of the epidural space, where a herniation sits. It suits one root on one side, and when the MRI shows two possible culprits, the response at a single root can help settle which is responsible.

Caudal. The needle enters through the sacral hiatus, the small opening just above the tailbone, and reaches the lowest lumbar and sacral roots from below. That makes a caudal steroid injection a practical choice after lumbar surgery, because it avoids the scarred surgical field.

Chou’s review found no clear difference in outcome by technique, and a study of 16,638 injections found transforaminal and interlaminar routes comparably safe (Chou 2015, El-Yahchouchi 2016). So the anatomy decides: one root on one side, transforaminal. Both sides or central narrowing, interlaminar. Prior surgery at the target level, caudal. A lumbar transforaminal epidural steroid injection can treat more than one level in a session when more than one root is involved.

Cervical and thoracic epidural steroid injections

A cervical epidural steroid injection works in a narrow space next to the spinal cord and the arteries that feed it. In 2015 a multidisciplinary working group convened through the FDA’s Safe Use Initiative, with 13 specialty societies, published 17 safety considerations for these injections (Rathmell 2015). For the neck, particulate steroids should not be used for cervical transforaminal injections, contrast must be injected under live fluoroscopy before any medication in a transforaminal injection, and a cervical interlaminar injection belongs at C7-T1 ideally and no higher than C6-C7, where the space behind the dura is widest. The International Pain and Spine Intervention Society’s 2024 safety review restates those rules and adds that imaging should be reviewed before any cervical interlaminar injection (Holder 2024).

The strokes and spinal cord infarcts reported after cervical transforaminal injections have been attributed mainly to particulate steroid entering an artery (Holder 2024). Avoiding it costs little: a systematic review found no significant difference in pain relief between particulate and non-particulate steroid in cervical injections, and recommended non-particulate steroid as first-line for epidural injections generally (Mehta 2017). In the neck the interlaminar route is the more commonly used of the two (Holder 2024), and it is the one Dr. Movshis uses, at a lower cervical level, with dexamethasone, a non-particulate steroid. The neck pain page covers the rest of the cervical workup.

The thoracic indication is narrow: a band of radicular pain wrapping from the spine around the chest, from a thoracic disc or foraminal narrowing, once heart, lung, and abdominal causes are ruled out. Even the ASIPP guideline rests its thoracic grade on a single randomized trial (Manchikanti 2021).

Before the injection: blood thinners, a driver, and contrast allergy

An epidural hematoma is rare but can compress the spinal cord or nerve roots. The joint guideline from ASRA, ESRA, AAPM, INS, NANS, and the World Institute of Pain classifies interlaminar and transforaminal ESIs at every spinal level as intermediate-risk procedures for serious bleeding, and moves patients with a higher bleeding risk (older age, a bleeding history, more than one anticoagulant or antiplatelet drug, serious liver disease, or late-stage kidney disease) into a higher category. It flags cervical interlaminar injections as a setting where stopping NSAIDs, and aspirin taken for primary prevention, deserves consideration, and calls for decisions about stopping a drug to be shared with the physician who prescribed it (Narouze 2018), because stopping a blood thinner after a stent, a heart valve, or a clot carries its own risk.

Do not stop a blood thinner on your own. Bring your full medication list, including aspirin and over-the-counter anti-inflammatories, and our office coordinates the plan with your prescribing physician before a date is set.

Arrange a ride home and do not drive that day. The local anesthetic can leave a leg or arm numb or weak for a few hours.

Tell us about any reaction to iodinated contrast (CT dye) or to a steroid, and whether you could be pregnant. A contrast allergy does not automatically rule out the injection, but it changes the plan and must be known before the day. A fever or active infection means rescheduling.

The procedure day at our Midtown office

The injection is done in our office procedure suite under fluoroscopy, a live X-ray that shows the needle against the spine. You lie face down, with a pillow under the hips for a lumbar or caudal injection or the forehead supported for a cervical one. The skin is cleaned and numbed with lidocaine. Dr. Movshis advances the needle to the target, then injects a small amount of contrast dye under live imaging. The contrast should outline the epidural space or trace along the nerve root. If it flows into a vessel, the needle is repositioned before any steroid goes in.

You are awake. The 2015 consensus advises against moderate or heavy sedation for epidural injections, because a patient who can talk is the earliest warning that something is wrong (Rathmell 2015, Holder 2024). Most patients find the lidocaine sting the sharpest part and feel pressure rather than pain after that. During a transforaminal injection the medication can briefly reproduce your familiar leg or arm pain as it reaches the root, which is expected and fades quickly.

The injection takes about 15 to 20 minutes, and you are observed for another 15 to 20 minutes. Dr. Movshis completed his anesthesiology residency at The Mount Sinai Hospital and his interventional pain medicine fellowship at the Icahn School of Medicine at Mount Sinai, and holds dual ABA board certification in Anesthesiology and Pain Medicine.

Recovery, side effects, and rare serious complications

Most people go home with a driver, walk around that evening, and are back at a desk the next day. The familiar pain often returns that night as the anesthetic wears off, before the steroid has acted, and that gap is normal. In a series of 16,638 injections, 2.6% of patients had a central steroid response (sleeplessness, facial flushing, or a non-positional headache), about 2% had a temporary increase in pain, and 1.2% had a fainting-type vasovagal reaction during the procedure (El-Yahchouchi 2016). People with diabetes should expect higher blood sugar for a couple of days (Even 2012). The full aftercare instructions, including sleep, driving, bathing, exercise, blood thinners and the warning signs that need a call or an emergency room, are on the epidural steroid injection aftercare page, which also prints as a one-page sheet.

Rare serious complications. That series recorded no major neurologic injury or bleeding, but infection, hematoma, and nerve injury remain recognized risks. In 2014 the FDA required a label warning about rare but serious neurologic events after epidural corticosteroid injection, including loss of vision, stroke, paralysis, and death, and stated that it has not approved corticosteroids for epidural use (FDA 2014, Racoosin 2015). Every ESI in the United States is an off-label use of an approved drug, and you should hear that before you consent.

Go to the closest emergency room or call 911 for loss of or change in vision, sudden weakness or numbness of the face, arm, or leg, a severe headache, a seizure, new numbness in the groin, new loss of bladder or bowel control, or fever with worsening back pain in the days afterward.

The follow-up. At two to four weeks, the questions are concrete: how much of your familiar pain is gone, for how long, and what you can do now that you could not before.

When the injection does not help

A well-placed injection that changes nothing is information. The pain may not come from an inflamed root at all, since a facet joint, the sacroiliac joint, the hip, or a muscle can imitate radicular pain, and a targeted diagnostic injection tests the alternative. The level or route may have been wrong when the MRI shows more than one candidate, and a second attempt at a different level or by a different route can settle it. The compression may be mechanical, from severe narrowing or a large fragment with a weakening foot, and then a surgical opinion comes next. Or central sensitization may be amplifying the pain beyond what a spinal injection can reach.

What does not happen is the same injection, at the same level, repeated in hope.

How often an ESI can be repeated

There is no fixed series. Booking three injections in advance has no basis in the trials, and the Medicare policy for New York calls a predetermined series not medically reasonable. It limits ESIs to four sessions per spinal region in a rolling twelve months and covers a repeat only when the previous injection gave at least 50% improvement lasting at least three months (L39036). Modal Pain Management does not bill Medicare, but Dr. Movshis applies those limits to every patient, and our office checks your commercial plan’s own criteria before scheduling.

The limits exist because steroid acts on the whole body. In a retrospective cohort of 3,000 injected patients and 3,000 matched controls, each additional lumbar ESI raised the risk of a vertebral fracture by a factor of 1.21 (Mandel 2013). That is why the dose is kept to the lowest amount that works, and why a patient with osteoporosis weighs that trade-off before the first injection.

What an epidural steroid injection costs in NYC

Self-pay prices are flat and all-inclusive, covering Dr. Movshis’s physician fee, the fluoroscopic guidance, and the medication, with no separate facility fee.

• Lower-back epidural, interlaminar or caudal: $1,000
• Lumbar transforaminal epidural: $1,000 for the first level, plus $500 for each additional level treated in the same session
• Neck or upper-back epidural, cervical or thoracic: $1,500

The new-patient consultation is $250. HSA and FSA cards are accepted, and payment plans through Cherry include 0%-APR options on shorter terms. Every price is on our self-pay pricing page.

Modal Pain Management accepts most commercial PPO plans, including Aetna, Anthem Blue Cross Blue Shield, Cigna, Empire Blue Cross Blue Shield, the Empire Plan, Oscar, Oxford, UMR and UnitedHealthcare. The practice does not accept Medicare, Medicaid, HMO plans, or workers’ compensation. When your plan requires prior authorization, our office submits it after the consultation. Verify your insurance before the visit.

If your pain runs down one leg or one arm along a line you can trace with a finger, and you have an MRI that may show why, book a consultation and bring the images, or call (646) 290-6660.

References

• Ghahreman A, Ferch R, Bogduk N. The efficacy of transforaminal injection of steroids for the treatment of lumbar radicular pain. Pain Med. 2010;11(8):1149–68. doi:10.1111/j.1526-4637.2010.00908.x · PubMed
• Pinto RZ, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Ann Intern Med. 2012;157(12):865–77. doi:10.7326/0003-4819-157-12-201212180-00564 · PubMed
• Oliveira CB, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database Syst Rev. 2020;4(4):CD013577. doi:10.1002/14651858.CD013577 · PubMed
• Chou R, Hashimoto R, Friedly J, et al. Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med. 2015;163(5):373–81. doi:10.7326/M15-0934 · PubMed
• Chou R, Hashimoto R, Friedly J, et al. Pain Management Injection Therapies for Low Back Pain. AHRQ Technology Assessment. Rockville (MD): Agency for Healthcare Research and Quality; 2015. PubMed
• Friedly JL, Comstock BA, Turner JA, et al. A randomized trial of epidural glucocorticoid injections for spinal stenosis. N Engl J Med. 2014;371(1):11–21. doi:10.1056/NEJMoa1313265 · PubMed
• Cohen SP, Hayek S, Semenov Y, et al. Epidural steroid injections, conservative treatment, or combination treatment for cervical radicular pain: a multicenter, randomized, comparative-effectiveness study. Anesthesiology. 2014;121(5):1045–55. doi:10.1097/ALN.0000000000000409 · PubMed
• Chiu CC, Chuang TY, Chang KH, et al. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clin Rehabil. 2015;29(2):184–95. doi:10.1177/0269215514540919 · 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;24(S1):S27–S208. PubMed
• Rathmell JP, Benzon HT, Dreyfuss P, et al. Safeguards to prevent neurologic complications after epidural steroid injections: consensus opinions from a multidisciplinary working group and national organizations. Anesthesiology. 2015;122(5):974–84. doi:10.1097/ALN.0000000000000614 · PubMed
• Holder EK, Lee H, Raghunandan A, et al. FactFinders for patient safety: Minimizing risks with cervical epidural injections. Interv Pain Med. 2024;3(3):100430. doi:10.1016/j.inpm.2024.100430 · PubMed
• Mehta P, Syrop I, Singh JR, Kirschner J. Systematic Review of the Efficacy of Particulate Versus Nonparticulate Corticosteroids in Epidural Injections. PM R. 2017;9(5):502–512. doi:10.1016/j.pmrj.2016.11.008 · PubMed
• Narouze S, Benzon HT, Provenzano D, et al. Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition): Guidelines From the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med. 2018;43(3):225–262. doi:10.1097/AAP.0000000000000700 · PubMed
• El-Yahchouchi CA, Plastaras CT, Maus TP, et al. Adverse Event Rates Associated with Transforaminal and Interlaminar Epidural Steroid Injections: A Multi-Institutional Study. Pain Med. 2016;17(2):239–49. doi:10.1111/pme.12896 · PubMed
• Even JL, Crosby CG, Song Y, McGirt MJ, Devin CJ. Effects of epidural steroid injections on blood glucose levels in patients with diabetes mellitus. Spine (Phila Pa 1976). 2012;37(1):E46–50. doi:10.1097/BRS.0b013e31821fd21f · PubMed
• Mandel S, Schilling J, Peterson E, Rao DS, Sanders W. A retrospective analysis of vertebral body fractures following epidural steroid injections. J Bone Joint Surg Am. 2013;95(11):961–4. doi:10.2106/JBJS.L.00844 · PubMed
• U.S. Food and Drug Administration. FDA Drug Safety Communication: FDA requires label changes to warn of rare but serious neurologic problems after epidural corticosteroid injections for pain. April 23, 2014. fda.gov
• Racoosin JA, Seymour SM, Cascio L, Gill R. Serious Neurologic Events after Epidural Glucocorticoid Injection — The FDA’s Risk Assessment. N Engl J Med. 2015;373(24):2299–301. doi:10.1056/NEJMp1511754 · PubMed
• Centers for Medicare & Medicaid Services. Local Coverage Determination L39036: Epidural Steroid Injections for Pain Management (Wellpoint Federal, jurisdiction including New York). Effective May 7, 2026. cms.gov