What are the treatment options for back pain following an epidural?

Management of Back Pain After Epidural

For back pain following an epidural procedure, initiate multimodal analgesia with NSAIDs plus acetaminophen as first-line therapy, while immediately investigating for serious complications if pain is persistent, severe, worsening, or accompanied by fever or neurologic changes. 1

Immediate Assessment for Red Flags

The critical first step is distinguishing benign post-procedural discomfort from serious complications:

• Investigate alternative diagnoses immediately if back pain persists beyond expected timeframe, increases in severity, or changes in character—these patterns require evaluation for epidural hematoma, infection, or nerve injury 1
• Obtain urgent neuroimaging and specialist consultation if the patient exhibits fever, signs of infection, progressive neurologic deficit, or severe unrelenting pain 1
• Do not dismiss persistent back pain as "normal" post-epidural discomfort—this is a common and dangerous pitfall 1

Specific Red Flags Requiring Emergency Evaluation:

• Progressive weakness or sensory loss 1
• Bowel or bladder dysfunction 1
• Fever or systemic signs of infection 1
• Pain that worsens despite treatment 1
• New neurologic signs developing after initial improvement 1

Pharmacologic Management Algorithm

First-Line: Multimodal Non-Opioid Therapy

• Combine NSAIDs with acetaminophen as the foundation of treatment 1
• NSAID options include ibuprofen, ketorolac, or naproxen 1
• Acetaminophen dosing: 10-15 mg/kg orally every 6 hours 1

Second-Line: Opioid Therapy

• Reserve opioids exclusively for breakthrough pain unresponsive to multimodal non-opioid therapy 1
• Options include tramadol or fentanyl 1

Management of Specific Complications

Epidural Hematoma or Abscess

• These are surgical emergencies requiring immediate neurosurgical consultation 1
• Present with progressive neurologic deficit, severe unrelenting pain, or fever 1
• Do not delay imaging if these features are present—urgent MRI is mandatory 1

Monitoring and Follow-Up Protocol

• Implement structured follow-up until complete symptom resolution 1
• Continue assessment until back pain resolves completely 1
• Arrange pain or neurology specialist referral if symptoms persist beyond the expected timeframe 1

Critical Pitfalls to Avoid

• Never dismiss persistent or worsening back pain as routine post-procedural discomfort—backache that persists, worsens, or changes character mandates investigation 1
• Never delay imaging when red flags are present—urgent MRI is indicated for worsening symptoms, new neurologic signs, or changing pain patterns 1
• Do not perform spinal manipulation or sciatic stretch simultaneously with epidural procedures, as these may adversely affect outcomes 2

Context: Epidural Steroid Injections and Back Pain

While the question addresses post-procedural back pain management, it's worth noting that epidural steroid injections themselves have limited evidence for treating chronic axial spine pain. The 2025 BMJ guidelines provide moderate certainty evidence that epidural injections of local anesthetic (with or without steroids) probably have little to no effect on pain relief for chronic axial spine pain compared to sham procedures 3. Between 1997 and 2014,90 serious adverse events occurred within minutes to 48 hours after epidural steroid injections, including death, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, stroke, seizures, and brain edema 3.