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

Frequency of Cervical Epidural Steroid Injections

Cervical epidural steroid injections should be repeated every 2 weeks to 3 months when they provide benefit, but only if the initial injection resulted in at least 50% pain relief lasting at least 2 weeks. 1

Standard Frequency Guidelines

• Repeat injections are typically administered every 2 weeks to 3 months if they demonstrate effectiveness 2, 1
• Most practitioners allow approximately four cervical epidural steroid injections per year at a given spinal segmental level 3
• A small percentage of physicians (6%) report allowing more than six injections annually, though this exceeds typical practice patterns 3

Critical Prerequisites Before Repeat Injection

Do not repeat injections without objective evidence of prior benefit. The following criteria must be met:

• The initial injection must have produced at least 50% pain relief 1
• Pain relief must have lasted at least 2 weeks (preferably 2 months) 1
• Patient request alone, without documented objective benefit, does not justify repeat injection 1
• Injections must be part of a multimodal treatment regimen including physical therapy, patient education, psychosocial support, and oral medications 1

Important Efficacy Caveat

The 2025 BMJ guideline found moderate certainty evidence that epidural injections with steroids probably have little to no effect on pain compared to sham procedures for chronic axial spine pain. 2, 1

• The guideline provides a strong recommendation AGAINST epidural injections for chronic axial (non-radicular) spine pain, stating "all or nearly all well-informed people would likely not want such interventions" 2, 1
• Cervical epidural steroid injections should only be considered for radicular pain with imaging-confirmed nerve root compression, not for axial neck pain 1
• The American Academy of Neurology explicitly recommends against epidural steroid injections for non-radicular pain 1

Safety Considerations

All cervical epidural injections must be performed under fluoroscopic guidance to ensure proper needle placement and minimize complications. 1, 4

Risk Profile

• Small risk of moderate harms including prolonged pain/stiffness, temporary altered consciousness, dural puncture, and deep infection 2, 1
• Very rare but catastrophic complications include spinal cord injury, paralysis, meningitis, and death 2, 1
• Neurologic complications occur in approximately 0.5% of cases within 7 days 5
• Overall complication rates increase from 1.7% at 7 days to 8.0% at 90 days 5

Approach-Specific Risks

• Transforaminal approach carries higher risk than interlaminar approach, with 1.55 times greater odds of procedural complications and 1.69 times greater odds of neurologic complications 5
• Interlaminar cervical epidural injections at levels above C7-T1 have been shown safe in large case series, with no correlation between spinal level and complication rates 6

Risk Factors for Complications

• Anticoagulant prescription increases odds of any complication 5.40-fold 5
• History of venous thromboembolism increases odds 3.01-fold 5
• Existing neurologic deficit increases procedural complication odds 3.04-fold 5
• Antiplatelet medication prescription increases procedural complication odds 2.21-fold 5

Shared Decision-Making Requirements

Patients must be counseled about potential complications before each injection, including: 1, 4

• Dural puncture
• Insertion-site infections
• Sensorimotor deficits
• Cauda equina syndrome
• Discitis
• Epidural granuloma
• Retinal complications
• Spinal cord injury and paralysis

Cost Considerations

• Average cost for a single cervical epidural steroid injection in the US exceeds $1,000 and can reach $5,000 1
• Exposing patients to these risks and costs without demonstrated benefit from prior injections is not justified 1

Common Pitfalls to Avoid

• Do not perform repeat injections based solely on patient request without objective documentation of at least 50% pain relief lasting at least 2 weeks from the prior injection 1
• Do not use cervical epidural steroid injections for axial neck pain without radicular symptoms and imaging-confirmed nerve root compression 1
• Do not proceed without fluoroscopic guidance, as this is essential for safety 1, 4
• Do not ignore alternative pain generators when physical examination suggests other pathology 1