Can an injection help with pain related to a herniated (slipped) disc?

Injections for Pain Related to Herniated Discs

Epidural steroid injections can provide short-term relief for pain related to herniated discs, but are not recommended for long-term management of chronic low back pain without radicular symptoms. 1

Types of Injections for Disc-Related Pain

Epidural Steroid Injections (ESIs)

• For radicular pain (pain radiating down the leg):
  • Strong evidence supports ESIs for pain from disc herniation with radicular symptoms 1
  • Can provide significant pain relief for 77% of patients with herniated discs for up to 12-27 months 2
  • Most effective when used for disc herniation with clear radicular symptoms rather than axial back pain alone
  • Three main approaches: interlaminar, transforaminal, and caudal

Facet Joint Injections

• Not recommended for herniated disc pain:
  • Moderate evidence against intraarticular facet injections for chronic low back pain from lumbar degenerative disease 1
  • More appropriate for facet-mediated pain rather than disc herniation

Trigger Point Injections (TPIs)

• Limited value for disc-related pain:
  • May provide short-term relief for associated muscle spasms but not directly for the disc herniation 1
  • Should be considered only after failing conservative treatment 3
  • Limited to 4 sets of injections, not repeated more frequently than every 7 days 3

Effectiveness Based on Evidence

Short-term Benefits

• ESIs show superior results compared to placebo for leg pain at 6,12, and 24 weeks for single-level lumbar disc herniation 4
• Patients with inflammatory end-plate changes on MRI respond better to both epidural and intradiscal steroid injections 5
• Approximately 77% of surgical candidates with herniated discs may avoid surgery after ESIs 2

Long-term Outcomes

• Limited evidence for long-term benefits beyond 3-6 months 1
• At 12 months, the probability of requiring back surgery was similar between patients receiving methylprednisolone (25.8%) and placebo (24.8%) 6
• Less than one-third of patients treated with ESIs avoid additional invasive treatment at 2-year follow-up 5

Patient Selection Criteria

Good Candidates for Injections

• Patients with:
  • Disc herniation confirmed by imaging
  • Radicular symptoms (leg pain) corresponding to the level of herniation
  • Failure of conservative treatment for at least 4 weeks
  • No progressive neurological deficits or other red flags 3

Poor Candidates for Injections

• Patients with:
  • Primarily axial back pain without radicular symptoms
  • Progressive neurological deficits requiring urgent surgical evaluation
  • Infection at the injection site
  • Coagulopathy or anticoagulant therapy that cannot be safely interrupted

Risks and Considerations

Potential Complications

• Small risk of moderate to serious harms such as deep infection
• Very small risk of catastrophic harms such as paralysis and death 1
• Temporary altered level of consciousness
• Steroid-related side effects (elevated blood glucose, facial flushing, etc.)

Cost and Access Issues

• Requires travel to a clinic or hospital for administration
• May need repeat injections every 2 weeks to 3 months
• Coverage varies by insurance plan 1

Alternative and Emerging Treatments

• Platelet-rich plasma (PRP) epidural injections show promising results compared to triamcinolone for single-level lumbar disc herniation 4
• Intradiscal injections of hypertonic dextrose may benefit some patients with advanced degenerative disc disease 7

Clinical Decision Algorithm

1. First line: Conservative treatment (physical therapy, NSAIDs, activity modification) for 4-6 weeks
2. If persistent radicular symptoms: Consider epidural steroid injection
3. If primarily axial back pain: ESIs less likely to be effective; consider other pain management approaches
4. After injection:
   • If significant improvement: Continue conservative care
   • If temporary improvement: May repeat injection after appropriate interval (typically 2-3 weeks)
   • If minimal/no improvement after 2-3 injections: Consider surgical evaluation or alternative treatments

Remember that while injections may provide significant temporary relief, they should be part of a comprehensive treatment plan and not viewed as a definitive solution for herniated disc pain.