How many epidural (epi) injections can be administered for a herniated disk?

From the Guidelines

The number of epidural injections for a herniated disk should be limited to 1-3 injections within a 12-month period, as recommended by recent guidelines, including the 2021 American Society of Interventional Pain Physicians (ASIPP) comprehensive evidence-based guidelines 1. When considering epidural injections for a herniated disk, it's essential to weigh the potential benefits against the risks of repeated steroid exposure. The injections typically contain a corticosteroid, such as methylprednisolone, triamcinolone, or dexametholone, combined with a local anesthetic, like lidocaine or bupivacaine. Some key points to consider when deciding on the number of epidural injections include:

• The 2021 ASIPP guidelines recommend in favor of fluoroscopically guided epidural injections, with or without steroids, for chronic spine pain associated with disc herniation, spinal stenosis, axial discogenic pain, and post-surgery syndrome 1.
• The 2022 American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain also supports the use of epidural injections for chronic low back pain due to disc disease, spinal stenosis, or post-surgical syndrome 1.
• However, the 2020 NICE Guideline on Low back pain and sciatica in over 16s: assessment and management recommends against spinal injections for managing low back pain, highlighting the need for careful patient selection and consideration of alternative treatments 1.
• The potential risks of repeated steroid exposure, such as bone weakening, elevated blood sugar, adrenal suppression, and tissue damage, must be taken into account when determining the number of injections.
• Alternative treatments, such as physical therapy, medication, or surgery, should be considered if a patient does not experience meaningful improvement after a limited series of epidural injections.

From the FDA Drug Label

The duration of anesthesia with bupivacaine hydrochloride injection is such that for most indications, a single-dose is sufficient These doses may be repeated up to once every three hours. In clinical studies to date, total daily doses have been up to 400 mg Until further experience is gained, this dose should not be exceeded in 24 hours.

The number of epi injections for a herniated disk is not explicitly stated in the provided drug labels. However, it can be inferred that:

• Single-dose is sufficient for most indications
• Repeat doses can be administered up to once every three hours
• Total daily dose should not exceed 400 mg in 24 hours 2, 2, 2 It is essential to individualize the dosage based on the patient's size, physical status, and the usual rate of systemic absorption from the injection site.
• Key considerations:
  • Dose limitation: Total daily dose should not exceed 400 mg
  • Repeat dose interval: Up to once every three hours
  • Individualization: Dosage should be tailored to each patient's needs

From the Research

Epidural Injections for Herniated Disk

• The number of epidural injections that can be done for a herniated disk is not explicitly stated in the provided studies 3, 4, 5, 6, 7.
• However, the studies suggest that epidural steroid injections can be an effective treatment for symptomatic herniated lumbar discs, with success rates ranging from 77% to 81% 3, 6.
• The dosage of corticosteroid in transforaminal epidural steroid injections can vary, with a recommended minimal effective dose of 10 mg of triamcinolone 5.
• The frequency of injections is not specified, but one study mentions that patients received two epidural injections of triamcinolone in one-week intervals 5.
• Another study found that epidural steroid injections can provide relief for up to 12-27 months, allowing patients to avoid surgical treatment during this period 6.

Key Findings

• Epidural steroid injections can reduce pain and improve functional status in patients with symptomatic herniated lumbar discs 3, 4.
• The effectiveness of epidural steroid injections can vary depending on the dosage and type of corticosteroid used 5.
• Epidural steroid injections can be a useful treatment option for patients with herniated disks who are surgical candidates, allowing them to avoid surgery for a period of time 6.
• Epidural methylprednisolone can enhance recovery after discectomy for herniated disc disease, reducing neurological impairment and hospital stay 7.