What are the treatment options for spinal stenosis using injections?

Spinal Stenosis Injections: Treatment Recommendations

Epidural steroid injections for spinal stenosis should NOT be routinely offered, as the most recent high-quality evidence from the 2025 BMJ guideline provides a strong recommendation AGAINST their use for chronic axial spine pain, and long-term benefits have not been demonstrated. 1, 2

Critical Distinction: Radicular vs. Axial Pain

The effectiveness of injections for spinal stenosis depends critically on the symptom pattern:

For Spinal Stenosis WITHOUT Significant Radicular Symptoms (Axial Pain Only)

• The 2025 BMJ guideline strongly recommends AGAINST epidural injections for chronic axial spine pain 1
• The 2021 American College of Occupational and Environmental Medicine guideline explicitly recommends against lumbar epidural injections for spinal stenosis in the absence of significant radicular symptoms 1
• The 2020 NICE guideline states: do not offer spinal injections for managing low back pain 1
• These recommendations reflect that "all or nearly all well-informed people would likely not want such interventions" 1

For Spinal Stenosis WITH Radicular Symptoms

The evidence is contradictory, requiring careful clinical judgment:

Supporting injection use:

• The 2022 American Society of Pain and Neuroscience provides a strong recommendation in favor of epidural injections (interlaminar, transforaminal, or caudal) with local anesthetic, steroids, or their combination for chronic low back pain due to spinal stenosis 1
• The 2021 ASIPP guidelines recommend fluoroscopically guided epidural injections with or without steroids for spinal stenosis (moderate to strong recommendation) 1

Against injection use:

• The 2025 BMJ guideline provides a strong recommendation AGAINST epidural injections for chronic radicular spine pain 1
• Long-term benefits of epidural steroid injections for lumbar spinal stenosis have not been demonstrated in systematic follow-up 2

Evidence Quality and Clinical Outcomes

Given the conflicting guidelines, the most recent and highest quality evidence (2025 BMJ guideline) should take precedence, recommending against routine use of epidural injections for spinal stenosis. 1

Short-Term vs. Long-Term Efficacy

• A 2017 observational study showed that 44% of patients with spinal stenosis treated with transforaminal epidural steroid injection were satisfied with non-surgical management at 2 years and required no further treatment 3
• However, only 32% avoided surgery at 2-year follow-up in this cohort 3
• A 2004 study of transforaminal epidural steroid injections for degenerative lumbar scoliotic stenosis showed success rates declining from 59.6% at one week to only 27.3% at two years 4
• Multiple epidural steroid injections prior to other interventions do not improve outcomes and may delay definitive care 5

Practical Algorithm for Clinical Decision-Making

Step 1: Determine if radicular symptoms are present and significant

• If NO radicular symptoms → Do NOT offer epidural injections 1
• If YES, significant radicular symptoms → Proceed to Step 2

Step 2: Assess severity and duration of symptoms

• If symptoms are severe, progressive, or associated with neurologic deficits → Consider surgical evaluation rather than injections 1
• If symptoms are moderate and patient prefers conservative management → Consider ONE trial of fluoroscopically guided epidural injection 3, 4

Step 3: If injection is performed

• Use fluoroscopic guidance (transforaminal, interlaminar, or caudal approach) 1
• Limit to ONE injection initially 5
• Reassess at 6 weeks 3

Step 4: Post-injection management

• If significant improvement (>50% pain reduction) → Continue conservative management with activity modification and physical therapy 2
• If minimal or no improvement after ONE injection → Do NOT repeat injections; proceed to surgical evaluation if symptoms warrant 5
• Multiple injections do not improve outcomes and delay appropriate care 5

Important Caveats and Safety Considerations

Risks of Epidural Injections

• Small risk of moderate to serious harms including deep infection and temporary altered level of consciousness 1
• Very small risk of catastrophic harms including paralysis and death 1
• These risks must be weighed against the limited and temporary benefits

Access and Cost Barriers

• Patients must travel to specialized clinics for procedures 1
• Repeat injections required approximately every 2 weeks to 3 months if perceived effective 1
• Expense may be prohibitive without insurance coverage 1

Alternative Approaches

• Activity modification (reducing standing/walking periods) is first-line treatment 2
• NSAIDs for pain management 2
• Physical therapy focused on lumbar flexion exercises 2
• In carefully selected patients with persistent symptoms despite conservative management, surgical decompression is more effective than continued non-operative treatment 1, 2

The bottom line: For spinal stenosis, epidural injections should be considered only in highly selected patients with significant radicular symptoms who have failed conservative management, limited to a single trial, and should not delay surgical evaluation in appropriate candidates. 1, 5, 2