Epidural Steroid Injections
What Is an Epidural Steroid Injection?
If you have been dealing with neck or back pain that shoots into your arm or leg, there is a good chance it is coming from a nerve that is being irritated or compressed in your spine. An epidural steroid injection — also called an ESI — is a procedure that delivers anti-inflammatory medication directly to the area around that nerve.
The goal is not to fix the underlying problem, but to calm down the inflammation around the nerve enough to significantly reduce your pain. For many patients, this window of relief is enough to engage more fully in physical therapy and make meaningful progress toward long-term recovery.
What Causes the Pain an Epidural Treats?
Your spinal nerves exit the spine through small openings and travel down your arms and legs. When one of those nerves becomes compressed or irritated — from a herniated disc, bone spur, or narrowing of the spinal canal — it can cause pain, numbness, tingling, or weakness that travels along the path of that nerve.
Common conditions treated with epidural steroid injections include:
Herniated disc — when the soft inner material of a disc pushes out and presses on a nerve
Spinal stenosis — narrowing of the spinal canal that compresses nerves
Radiculitis/radiculopathy — the medical term for nerve pain that travels into an arm or leg (commonly called sciatica when it involves the leg)
Degenerative disc disease — age-related disc changes that can cause nerve irritation
The Two Main Approaches
There are two common ways to perform an epidural steroid injection. Your doctor will recommend one based on your diagnosis, imaging findings, and which approach is most likely to get the medication where it needs to go.
Transforaminal Epidural (TFESI)
A transforaminal epidural targets the injection through the foramen — the small opening on the side of the spine where the nerve root exits. Because the medication is placed right at the opening where the nerve leaves the spine, this approach is very precise. It delivers the steroid directly to the area most likely causing your symptoms, and it typically uses a smaller volume of medication than the interlaminar approach.
This approach is commonly used when the pain is one-sided, when imaging shows a specific disc herniation or nerve compression at a known level, or when prior injections have not provided adequate relief.
Interlaminar Epidural (ILESI)
An interlaminar epidural is performed from the back of the spine, between two vertebrae. The medication is injected into the epidural space — the area just outside the protective covering of the spinal cord — and spreads to bathe a broader region of the spine.
This approach is often used when symptoms are present on both sides, when multiple spinal levels may be contributing to pain, or when spinal stenosis is the primary diagnosis. It is also the approach used for the epidural anesthesia given during childbirth, so many patients are already familiar with the concept.
The Procedure: What to Expect
Regardless of which approach is used, the overall experience is similar.
You will lie on a procedure table, and the skin and deeper tissue over the injection site will be numbed with local anesthetic. Your doctor will use fluoroscopy (live X-ray) to guide the needle to the correct position. Contrast dye is injected first to confirm placement before any medication is given.
Once the needle is confirmed to be in the right location, a combination of steroid and local anesthetic is injected. The procedure itself typically takes 15 to 30 minutes, and most patients describe feeling pressure at the injection site rather than significant pain.
After the procedure, you will rest briefly and then be discharged home. You may notice your usual pain is temporarily increased for a day or two as the local anesthetic wears off before the steroid takes effect. This is normal.
Cervical (Neck) Epidurals: Important Safety Information
Epidural injections in the cervical spine — the neck — require extra care and carry a higher level of risk compared to injections in the lower back. This is because the spinal cord is present throughout the neck, and the blood vessels and nerves in this region are more closely packed together.
Bleeding risk in the cervical spine is a serious concern. A collection of blood near the spinal cord — called an epidural hematoma — can compress the cord and cause serious neurological injury, including weakness or paralysis. While this complication is rare, its potential severity means blood thinner management must be taken seriously for all cervical procedures.
If you are scheduled for a cervical epidural injection and you take any of the following, your doctor will need to review your specific medication and timing before the procedure:
Aspirin or NSAIDs (ibuprofen, naproxen, etc.)
Prescription blood thinners such as warfarin (Coumadin), rivaroxaban (Xarelto), apixaban (Eliquis), clopidogrel (Plavix), or similar medications
Fish oil, vitamin E, or other supplements that affect bleeding
Do not stop any prescription blood thinner on your own. Your doctor will give you specific instructions based on your medication and your overall health. Missing doses of certain blood thinners without medical guidance can carry its own risks.
If you experience any of the following after a cervical epidural, seek emergency care immediately:
Sudden or rapidly worsening weakness in the arms or legs
Loss of bladder or bowel control
Numbness that spreads quickly
Severe neck pain that is different from your usual symptoms
These symptoms can be signs of spinal cord compression and require urgent evaluation.
A Note on Blood Thinners for Lumbar Injections
For lumbar transforaminal epidural injections — injections in the lower back targeting a specific nerve root — patients do not need to hold blood thinners before the procedure. The risk profile for this approach in the lumbar spine is different from cervical injections, and it is safe to proceed on your normal medication regimen.
If you are scheduled for a lumbar interlaminar injection or any cervical injection, your doctor will review your medications individually, as different guidelines apply.
When in doubt, always ask before stopping or adjusting any medication on your own.
What to Expect After the Injection
The first 24 to 48 hours
It is common to feel increased soreness at the injection site for a day or two. Some patients also notice a temporary flare of their usual nerve pain as the local anesthetic wears off. Ice applied to the area for 15 to 20 minutes at a time can help. Avoid heat to the area for the first 48 hours.
You can resume light daily activity the same day or the next day. Avoid strenuous activity, heavy lifting, and soaking in pools or baths for 24 to 48 hours.
When will I feel relief?
The local anesthetic may provide brief relief in the hours immediately after the injection. The steroid, which is the main treatment component, typically takes 3 to 7 days to take effect. Some patients notice gradual improvement over 2 to 3 weeks.
Day 1–3: Possible brief relief from local anesthetic; some soreness at injection site
Days 3–7: Steroid begins to take effect; many patients notice early improvement
Weeks 2–3: Most patients experience meaningful relief if the injection is going to work
Weeks to months: Duration of relief varies widely by individual and diagnosis
How long does relief last?
This varies significantly from person to person. Some patients experience relief for several weeks, others for several months. The injections are not intended to be a permanent cure — they are most effective when combined with physical therapy and rehabilitation that addresses the underlying cause of your symptoms.
How Many Injections Will I Need?
Most guidelines allow up to three epidural steroid injections in a given region within a 12-month period, though the exact number depends on your response and your doctor's judgment. If the first injection provides meaningful relief, a second may be offered if symptoms return. If the first injection provides no relief at all, your doctor may want to reassess the diagnosis before proceeding further.
Steroid injections are not meant to be repeated indefinitely. They work best as a bridge — reducing pain enough to allow you to participate in therapy and make lasting progress.
Risks and Complications
Epidural steroid injections are generally safe, and serious complications are uncommon. Risks include:
Temporary pain flare at the injection site — very common, resolves in a few days
Headache — more common with interlaminar approaches; caused by a small leak of spinal fluid if the needle passes slightly too far
Flushing or warmth — a brief side effect of the steroid medication, typically lasting a day or two
Elevated blood sugar — steroid injections can temporarily raise blood sugar levels, which is important to monitor if you have diabetes
Infection — rare, as sterile technique is used throughout
Bleeding or hematoma — rare in the lumbar spine; higher concern in the cervical spine as noted above
Nerve injury — very rare when the procedure is performed under image guidance
Your doctor will review your individual risk profile with you before the procedure.
Questions to Ask Your Doctor
Which approach will be used — transforaminal or interlaminar — and why?
Which level of my spine will be targeted?
Do I need to hold any medications before this procedure?
Will I need someone to drive me home?
How will I know if it worked, and what counts as a good response?
What should I do if my symptoms get significantly worse after the injection?
How does this injection fit into my overall treatment plan?
This article is for educational purposes only and does not replace a conversation with your physician. Treatment decisions should always be made together with your care team based on your individual history, exam findings, and imaging. If you have questions about whether this procedure is right for you, please schedule a consultation.