What injection is recommended for lower back pain?

Injection Options for Lower Back Pain

For lower back pain, epidural steroid injections, trigger point injections, and facet joint injections are recommended as treatment options for temporary symptomatic relief in selected patients, but none are recommended for long-term pain management. 1

Types of Injections for Lower Back Pain

Epidural Steroid Injections (ESIs)

• Indications: Most effective for radicular pain (pain radiating down the leg) rather than axial back pain 2, 3
• Approaches:
  • Parasagittal interlaminar (PIL) approach shows significantly better outcomes than midline interlaminar (MIL) approach (68.4% vs 16.7% effective pain relief at 6 months) 4
  • Transforaminal approach shows strong evidence for short-term and moderate evidence for long-term relief 2
  • Caudal approach shows strong evidence for short-term and moderate evidence for long-term relief 2
• Medication: Typically includes corticosteroid (e.g., triamcinolone acetonide 40-80mg) with local anesthetic 5
• Limitations: Not recommended for long-term relief of chronic low back pain 1

Trigger Point Injections (TPIs)

• Evidence: Decreases low back pain, with dry needling being as effective as medication injections (63% vs 42% response) 1
• Medication: Local anesthetic (e.g., lidocaine 0.5%) is more effective than saline injections (52% vs 39% improvement) 1
• Note: Glucocorticosteroids are not recommended for use in trigger point injections according to some guidelines 1

Facet Joint Injections

• Role: Recommended as a diagnostic tool rather than a therapeutic intervention 1
• Limitations: Not recommended as long-term treatment for chronic low back pain 1

Algorithm for Selecting Appropriate Injection

1. Determine pain pattern:

   • Radicular pain (radiating down leg): Consider epidural steroid injection (ESI)
   • Localized back pain with tender points: Consider trigger point injection (TPI)
   • Pain worsened by extension but not flexion: Consider facet joint injection as diagnostic tool

2. For radicular pain:

   • First attempt: Parasagittal interlaminar (PIL) epidural approach with triamcinolone 40-80mg 5, 4
   • Alternative: Transforaminal approach if PIL is not feasible
   • Duration: Expect short-term relief (2-6 weeks); not for long-term management 1, 2

3. For non-radicular back pain:

   • If discrete tender points: Trigger point injection with local anesthetic (dry needling is also effective) 1
   • If suspected facet-mediated pain: Consider diagnostic facet injection 1

Important Caveats and Pitfalls

• Temporary relief only: None of these injections provide long-term relief for chronic low back pain 1
• Inconsistent guidelines: There is significant inconsistency in recommendations across guidelines for interventional procedures 1
• Potential bias: Positive results for epidural injections are three times more likely when reviews are authored by interventionalists versus non-interventionalists 1
• Patient selection: Patients should have failed at least 4 weeks of conservative treatment before considering injections 6
• Safety concerns: While generally safe, epidural injections can have rare but catastrophic complications including permanent disability 7
• Diagnostic vs therapeutic: Facet injections are more valuable as diagnostic tools than as therapeutic interventions 1

Dosing Considerations

• Epidural steroids: Triamcinolone acetonide 40-80mg, with dosage adjusted based on patient response 5
• Trigger point injections: Local anesthetic (e.g., 0.5% lidocaine) without steroids 1
• Facet injections: When used diagnostically, local anesthetic with or without steroid 1

Remember that these injections should be part of a comprehensive approach that includes physical therapy and appropriate medication management, with the understanding that they provide temporary rather than permanent relief.