What are the next steps for an adult patient with mild Intervertebral Disc Protrusion (IVDP) at L4-L5, who continues to experience pain despite steroid administration?

Management of Persistent Pain After Steroid Administration in Mild L4-L5 IVDP

For mild L4-L5 disc protrusion with persistent pain despite steroid administration, you should pursue a comprehensive multimodal pain management program including physical therapy, NSAIDs, and patient education rather than repeat epidural injections, and only consider additional interventional procedures if there is documented radicular pain below the knee with objective evidence of at least 50% pain relief lasting 2+ weeks from the initial injection. 1

Critical Assessment of Current Situation

Verify True Radicular vs. Axial Pain

• Document whether pain radiates below the knee - this is the specific requirement that distinguishes radicular pain warranting epidural intervention from axial back pain that does not 1
• Epidural steroid injections are explicitly NOT recommended for non-radicular low back pain from disc pathology alone 1, 2
• The 2025 BMJ guideline provides a strong recommendation against epidural injections for chronic axial spine pain, stating "all or nearly all well-informed people would likely not want such interventions" 1

Evaluate Response to Initial Steroid Treatment

• Repeat epidural injection is only appropriate if the initial injection provided at least 50% pain relief for at least 2 weeks 1
• The Spine Intervention Society explicitly states that repeat injection with steroid is appropriate only if there was at least 50% relief for at least 2 months after the first injection 1
• Exposing patients to procedural risks without demonstrated benefit from prior injections is not justified 1

Next Steps Algorithm

If Pain is Truly Radicular (Below Knee) AND Initial Injection Helped

Step 1: Optimize Conservative Multimodal Therapy 1, 2

• Structured physical therapy program (should have completed 4-6 weeks minimum before any injection) 1
• NSAIDs after evaluating gastrointestinal, renal, and cardiovascular risk factors 2
• Patient education about natural history of disc herniation 1
• Activity modification without prolonged bed rest 1

Step 2: Consider Repeat Injection Only If:

• Initial injection provided ≥50% relief for ≥2 weeks (preferably 2 months) 1
• MRI confirms nerve root compression correlating with symptoms 1
• Fluoroscopic guidance is mandatory for safety 1
• Patient counseled about risks: dural puncture, infection, cauda equina syndrome, sensorimotor deficits, discitis, epidural granuloma, retinal complications, and rare catastrophic events including paralysis and death 1

If Pain is Axial (Not Below Knee) OR Initial Injection Did Not Help

Do NOT repeat epidural injection 1

Instead, pursue:

1. Rule out alternative pain generators:

   • Facet joint pathology - consider diagnostic facet blocks if paraspinal tenderness present 1
   • Sacroiliac joint dysfunction - if ≥3 of 6 provocative tests positive, consider diagnostic SI joint injection 1
   • Hip pathology in younger patients 1

2. Consider radiofrequency ablation if facet-mediated pain confirmed - the 2025 BMJ guideline provides a strong recommendation in favor of conventional or cooled lumbar radiofrequency ablation for low back pain 1

3. Optimize oral medications:

   • Gabapentin, pregabalin, or duloxetine for neuropathic pain component 3
   • Time-limited NSAIDs if no contraindications 2
   • Avoid long-term opioids - only 7.7% of patients required opioids at 5-year follow-up after disc herniation treatment 4

4. Intensive physical therapy focusing on:

   • Core strengthening 1
   • Flexibility exercises 1
   • Functional restoration 1

Critical Pitfalls to Avoid

Do Not Use Steroids as Maintenance Therapy

• Never use oral corticosteroids to maintain remission - strong recommendation against this practice 3
• Corticosteroid therapy beyond 6 weeks shows no benefit and significant harm 3
• Prednisone therapy independently associated with serious infections (HR 1.57) 3
• No safe lower limit of dosing identified for avoiding adverse effects 3

Do Not Repeat Injections Without Objective Benefit

• Do not repeat injections based solely on patient request without documented prior benefit 1
• Multiple epidural steroid injections prior to other interventions do not improve outcomes and may delay appropriate care 5
• At 5-year follow-up, 76.9% of patients experienced recurrent pain regardless of whether they received injections or surgery, but only 23.1% had current pain 4

Do Not Ignore Red Flags for Surgery

• Progressive neurological deficit (motor weakness, cauda equina symptoms) requires urgent surgical evaluation 1
• Severe disabling radicular pain unresponsive to 6-12 weeks of comprehensive conservative care warrants surgical consultation 1

Evidence Quality Considerations

The guidelines consistently emphasize that epidural steroid injections are specifically for radicular pain with nerve root compression, not for axial back pain from mild disc bulging 1. The success rate for epidural injections in appropriate candidates (true radiculopathy) ranges from 77-81% in the short term 6, 7, but long-term recurrence rates are high (76.9% at 5 years) regardless of treatment modality 4.

The key clinical decision point is whether the patient has true radicular pain below the knee with documented benefit from the initial injection - without both of these criteria, repeat injection is not indicated and alternative diagnoses and treatments should be pursued 1.