Spine injections and pain management options

Many spine conditions are managed without surgery. Physiatrists (doctors trained in physical medicine and rehabilitation, or PM&R) and pain medicine specialists concentrate on restoring function and relieving pain through exercise-based care, medications, and image-guided injections. This page explains common non-surgical options, including epidural steroid injections, and how they fit into an overall plan.

Non-surgical spine care and injections are commonly considered for:

• Leg pain from a pinched nerve in the lower back (sciatica), or arm pain from a pinched nerve in the neck
• Leg pain with walking from spinal stenosis
• Back or neck pain from arthritis of the facet joints
• Pain that has not improved enough with time, activity changes, medications, and physical therapy
• People who prefer to avoid or delay surgery, or who are not candidates for it

A physiatrist or pain specialist reviews your history, examines strength, sensation, and reflexes, and looks at any prior imaging. An MRI or CT scan is usually reviewed before a spinal injection to identify the target. Nerve studies (EMG and nerve conduction studies) may help sort out whether symptoms come from the spine or from a nerve elsewhere in the arm or leg.

Some injections are diagnostic as well as therapeutic: if numbing a specific nerve or joint relieves the pain, that helps confirm where the pain is coming from.

A typical plan combines several approaches:

• Active rehabilitation: physical therapy and a home exercise program to improve strength, flexibility, posture, and endurance
• Medications when appropriate, such as anti-inflammatories, acetaminophen, nerve-pain medicines, or short courses of muscle relaxants
• Pain-coping skills, such as cognitive behavioral therapy and activity pacing
• Approaches such as acupuncture, spinal manipulation, or TENS (mild electrical nerve stimulation), which help some people

Image-guided injections commonly used for spine pain:

• Epidural steroid injection: a steroid, often mixed with a numbing medicine, is placed in the epidural space around irritated nerves, using live X-ray guidance and contrast dye to confirm placement. It is mainly used for arm or leg pain from a herniated disc or stenosis, and may be given between the vertebrae (interlaminar), alongside a single nerve (transforaminal), or through the tailbone (caudal).
• Facet joint injection or medial branch block: numbing medicine, sometimes with a steroid, is placed in or near a facet joint to diagnose and treat joint-related back or neck pain.
• Radiofrequency ablation: when medial branch blocks bring relief, heat can be used to interrupt the small nerves carrying pain from the facet joints; the nerves may regrow over time.

Injections can calm pain enough for you to take part in therapy, but they do not fix the underlying problem, and relief may be partial or temporary. Because repeated steroid doses can affect bone and other tissues, the number of injections in a year is usually limited. For selected people with long-lasting nerve pain, including after spine surgery, spinal cord stimulation may be discussed. When non-surgical care is not enough, or nerve compression is causing weakness, a spine surgeon can review surgical options.

Spinal injections are outpatient procedures, usually done while you are awake with local numbing medicine, and you are watched for a short time afterward. Plan for a ride home if you receive sedation. Soreness at the injection site, a temporary increase in pain, facial flushing, trouble sleeping, or a short-term rise in blood sugar can occur. A steroid typically takes several days to take effect. Most people return to usual activities the next day and continue their exercise program.

Serious complications, such as infection, bleeding, nerve injury, or allergic reaction, are uncommon. Before the procedure, tell your clinician if you take blood thinners, have diabetes, are or may be pregnant, are allergic to contrast dye, or are feeling ill.