What is the recommended frequency for administering cervical epidural steroid injections?

Frequency of Cervical Epidural Steroid Injections

Cervical epidural steroid injections, if they provide any benefit at all, are typically repeated approximately every 2 weeks to 3 months, with a maximum of 4 injections per year at a given spinal level being the most common practice pattern. 1, 2

Standard Frequency Guidelines

Typical Repeat Interval

• Epidural injections are generally repeated every 2 weeks to 3 months when they are perceived to provide benefit 1
• The 2025 BMJ guideline explicitly states that intramuscular, joint-targeted, or epidural injections are "typically repeated approximately every 2 weeks to 3 months" if they have any effect 1

Annual Limits

• The most common practice pattern is to allow 4 injections per year at a given spinal segmental level (cervical/thoracic/lumbosacral) 2
• A 2020 survey of 314 Spine Intervention Society physicians found that 40% allow four ESIs annually at a given spinal level 2
• A small minority of practitioners reported allowing more than 6 injections annually (6%) or more than 10 injections annually (1%) 2

Critical Prerequisites for Repeat Injections

Documented Benefit Requirement

• Repeat injections should only be performed if the initial injection resulted in at least 50% pain relief lasting at least 2 weeks 3
• The Spine Intervention Society's appropriate use criteria explicitly state that repeat injection with steroid is appropriate only if there was at least 50% relief for at least 2 months after the first injection 3
• Do not repeat injections based solely on patient request without objective evidence of prior benefit 3

Multimodal Treatment Context

• Epidural steroid injections should be used as part of a multimodal treatment regimen including physical therapy, patient education, psychosocial support, and oral medications 3
• These injections are not curative and should not be used as maintenance therapy when no further gains are clear or likely to occur 3

Important Safety Considerations

Risk Profile

• Cervical epidural injections carry a small risk of moderate harms including prolonged pain/stiffness (8.6%), temporary altered consciousness (2.1%), dural puncture (1.4%), and deep infection (0.7%) 1
• Very rare but catastrophic complications include spinal cord injury, paralysis, meningitis, and death 1, 4
• In a large retrospective series of 12,168 cervical epidural injections, there were 129 minor complications and 7 serious complications (though no paralysis or death), with no correlation between spinal level and complication rates 5

Mandatory Safety Protocols

• All cervical epidural injections must be performed under fluoroscopic guidance to ensure proper needle placement and minimize complications 3, 4, 5
• Cervical epidurography should be routinely performed prior to injection of therapeutic steroid and local anesthetic mixture 5
• Shared decision-making must include discussion of potential complications including dural puncture, insertion-site infections, sensorimotor deficits, cauda equina syndrome, discitis, epidural granuloma, and retinal complications 3, 4

Critical Efficacy Caveat

Limited Evidence of Benefit

• The 2025 BMJ guideline found moderate certainty evidence that epidural injection with steroids and local anesthetic probably has little to no effect on pain compared to sham procedures 1
• The guideline provides a strong recommendation AGAINST epidural injections for chronic axial spine pain (non-radicular back pain), stating "all or nearly all well-informed people would likely not want such interventions" 6
• Studies report back pain relief for assessment periods ranging from only 2 weeks to 3 months 3

Appropriate Indications Only

• Cervical epidural steroid injections should only be considered for radicular pain with imaging-confirmed nerve root compression, not for axial neck pain 3, 6, 7
• The American Academy of Neurology explicitly recommends against epidural steroid injections for non-radicular pain 3, 6

Practical Considerations

Cost and Burden

• The average cost for a single epidural steroid injection in the US is more than $1,000 and can be as high as $5,000 1
• Patients must travel to a clinic or hospital for each injection, creating significant burden 1
• Exposing patients to these risks and costs without demonstrated benefit from prior injections is not justified 3