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Fact check: Are there studies showing the difference in pain relief when getting epidural spine injections with sedation or without sedation?
Executive Summary
There is no strong, consistent evidence that sedation during epidural spinal injections improves long-term pain relief; randomized trials and surveys show similar short-term pain outcomes whether sedation is used or not, while some studies report higher procedural complications or greater immediate discomfort with sedation or without, depending on technique and patient selection [1] [2]. Recent procedure-specific comparisons—transforaminal injections, thoracic blocks for ablative procedures, and studies combining radiofrequency—demonstrate heterogeneous findings tied to injection approach, patient anxiety, and procedural goals, so the decision to sedate largely reflects trade-offs between patient comfort, safety profiles, and operator preference rather than clear efficacy differences for analgesia [3] [4] [5].
1. Why the debate persists: comfort versus clinical outcomes
Clinical literature frames sedation during epidural spine injections primarily as a comfort and safety question rather than one of efficacy for long-term pain reduction. Surveys and observational studies indicate many patients do not initially request sedation, and a minority change preference for subsequent injections, suggesting that routine sedation is not universally necessary [2]. Randomized and prospective trials focusing on transforaminal epidural steroid injections report no significant improvement in procedural pain, anxiety, or satisfaction when sedation is added, while some note increased complication rates in sedated groups, which reframes sedation as a risk–benefit calculation rather than a therapeutic enhancer [1]. The literature therefore separates immediate procedural experience from therapeutic analgesic endpoints, with short-term pain during the procedure and longer-term pain relief being distinct outcomes that studies address unevenly [5].
2. What randomized trials actually show: mixed signals with a tilt toward no added analgesic benefit
Randomized controlled data on sedation specifically added to epidural steroid injections are limited but informative. A 2019 randomized trial comparing transforaminal injections with and without sedation found similar patient and physician satisfaction, anxiety levels, and procedural pain overall, and highlighted a higher complication incidence in the sedated cohort, implying no clear analgesic advantage to sedation for these procedures [1]. Earlier and related observational work confirms low baseline demand for sedation and suggests that most patients tolerate the procedure without general sedation [2]. These trials focus largely on immediate and short-term endpoints; they do not provide strong evidence that sedation changes the trajectory of chronic pain improvement, an important distinction clinicians must weigh when counseling patients [1].
3. Procedure type changes the calculus: cervical, thoracic, and transforaminal nuance
Evidence varies by spinal level and adjunct interventions. A 2009 study on sedation during cervical versus lumbar translaminar injections emphasized differing complication profiles and procedural technicalities that can influence sedation decisions, but it did not demonstrate superior analgesia from sedation [5]. More recent comparative work outside routine lumbar TFESI shows different findings: for instance, a 2025 trial in the setting of thermal lung tumor ablation found thoracic epidural anesthesia provided superior analgesia compared with conscious sedation plus local nerve block, a scenario that involves major procedural pain and a different risk/benefit landscape than outpatient epidural steroid shots [4]. Similarly, studies combining dorsal root ganglion radiofrequency with injections found variable outcomes depending on medications used, implying that the specific intervention, not sedation per se, often drives analgesic durability [3].
4. Safety signals and patient selection: who benefits from sedation and who faces risk
Safety data and patient preferences shape practice more than evidence of improved pain relief. The randomized trials that found no analgesic superiority of sedation also identified increased procedural complications among sedated patients, an important counterweight for clinicians considering sedation for routine injections [1]. Surveys demonstrate that only a fraction of patients initially request sedation, but a nontrivial subset would opt for it later—signaling that individual anxiety, prior experience, and comorbidities determine appropriateness [2]. High-pain or complex procedures, such as thoracic epidurals for ablative procedures, show clearer analgesic benefit from deeper regional techniques, but these are not equivalent to routine outpatient epidural steroid injections and carry different surveillance needs [4].
5. Bottom line for clinicians and patients: tailor the approach, document the goals
Synthesizing randomized trials, observational surveys, and procedure-specific studies yields a practical conclusion: sedation does not consistently improve long-term pain outcomes for routine epidural steroid injections, and it may increase certain procedure-related risks while addressing immediate discomfort or anxiety [1] [2]. For high-intensity procedures or when local anesthesia techniques differ substantially, regional blocks or deeper anesthesia may offer superior analgesia, but these scenarios are distinct from outpatient steroid injections and require individualized informed consent [4] [3]. Clinicians should therefore discuss the trade-offs with patients—immediate comfort versus potential complications—and document the clinical rationale for or against sedation on a case-by-case basis [5] [2].