What are the guidelines for administering intramuscular (IM) steroid injections, specifically methylprednisolone (methylprednisolone) or triamcinolone (triamcinolone), to an adult patient over 18 years old with a clear diagnosis of chronic back pain who has failed conservative treatments?

Intramuscular Steroid Injections for Chronic Back Pain

Do not administer intramuscular steroid injections for chronic back pain—the most recent high-quality guideline from BMJ (2025) issues a strong recommendation against this practice for both chronic axial and radicular spine pain.

Guideline-Based Recommendation

The 2025 BMJ clinical practice guideline provides the most definitive and recent evidence on this topic 1:

• Strong recommendation against intramuscular injection of local anesthetic with or without steroids for people with chronic axial spine pain (≥3 months duration) 1
• This recommendation applies to all patients with chronic spine pain not associated with cancer or inflammatory arthropathy 1
• The guideline panel concluded that "all or nearly all well-informed people would likely not want such interventions" 1

Why This Recommendation Matters

Lack of Evidence for Efficacy

The rapid increase in use of interventional procedures for chronic spine pain has occurred despite uncertain supporting evidence 1:

• Between 1994 and 2001 in the US, there was a 271% increase in lumbar epidural steroid injections and 231% increase in facet injections, yet the evidence base remains weak 1
• An analysis of 17 review articles on epidural steroid injections found inconsistent conclusions, with positive results three times more likely when authored by an interventionalist versus non-interventionalist 1

Scope of Application

These recommendations specifically apply to 1:

• Chronic spine pain persisting ≥3 months
• Pain present on at least half of the days in the past six months
• Both axial (midline) and radicular (referred distally) pain patterns
• Do NOT apply to acute spine pain management

Important Clinical Distinctions

IM Injections vs. Other Routes

The guideline distinguishes between different injection approaches 1:

• Intramuscular injections: Strong recommendation AGAINST for chronic back pain
• Epidural injections: Also strong recommendation AGAINST for both chronic axial and radicular spine pain 1
• Facet joint injections: Strong recommendation AGAINST 1

Conflicting Guidelines Create Confusion

The 2025 BMJ guideline addresses the inconsistency in prior recommendations 1:

• A 2023 synthesis of 21 clinical practice guidelines found "no consistency in recommendations for or against any interventional procedure" 1
• The 2022 American Society of Pain and Neuroscience provided strong recommendations IN FAVOR of trigger point injections for chronic back pain 1
• The 2021 American College of Occupational and Environmental Medicine recommended AGAINST most injection therapies 1

The 2025 BMJ guideline represents the most rigorous, evidence-based approach and should supersede older, conflicting recommendations 1.

FDA-Approved Formulations (For Reference Only)

While FDA labels exist for IM steroid formulations, their approval does not indicate efficacy for chronic back pain 2, 3:

Triamcinolone (Kenalog)

• Systemic IM dosing: 60 mg injected deeply into gluteal muscle, adjustable to 40-80 mg range 2
• Warning: Atrophy of subcutaneous fat may occur if injection not properly given 2

Methylprednisolone (Depo-Medrol)

• IM dosing for systemic effect: 40-120 mg weekly for maintenance therapy 3
• Dosage varies from 20-60 mg for local dermatologic conditions 3

Alternative Evidence-Based Approaches

Rather than IM steroid injections, focus on 1:

• Physical therapy and exercise programs
• Patient education about chronic pain mechanisms
• Psychosocial support interventions
• Appropriate oral analgesics (NSAIDs, acetaminophen)
• Consideration of multidisciplinary pain management programs

Critical Caveats

When Older Guidelines May Still Apply

The 2010 ASA guideline suggested epidural steroids "may be used" for radicular pain as part of multimodal treatment 1, but this predates the 2025 BMJ systematic review and should be considered outdated 1.

Research Context vs. Clinical Practice

Some older research suggested short-term benefit (≤3 weeks) for epidural steroids in disk-related radiculopathy 4, 5, 6, but:

• These studies primarily evaluated epidural routes, not intramuscular 4, 7, 5
• Short-term pain relief did not translate to functional improvement or reduced surgical need 6
• The 2025 guideline synthesized this evidence and concluded against routine use 1

Trigger Point Injections Are Different

Studies of trigger point injections (TPI) for myofascial pain showed some benefit 1, but:

• These target specific muscle trigger points, not general IM administration 1
• Evidence is limited to acute exacerbations, not chronic pain (≥3 months) 1
• The 2025 BMJ guideline's recommendation against IM injections supersedes this older evidence for chronic presentations 1

Common Pitfalls to Avoid

1. Do not confuse IM injections with epidural or facet joint injections—these are different procedures with different (though still negative) evidence profiles 1

2. Do not rely on older consensus-based guidelines that favor interventional procedures—these often violate principles of evidence-based medicine 1

3. Do not use IM steroids as a "bridge" to other treatments—there is no evidence this improves outcomes and it exposes patients to unnecessary risks 1

4. Do not assume patient demand justifies the procedure—the 2025 guideline explicitly states well-informed patients would not want these interventions 1