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What are the risks and side effects of epidural steroid injections for lumbar radiculopathy?
Executive Summary
Epidural steroid injections (ESIs) for lumbar radiculopathy show small, short-term pain relief at best and no consistent long-term functional benefit, while carrying a spectrum of complications from common mild effects to rare catastrophic neurologic injury [1] [2]. Recent systematic reviews and safety analyses emphasize careful patient selection, procedural technique, and informed consent because benefits are modest and risks — although infrequent — can be severe [3] [4].
1. What advocates and skeptics each claim — boiled down to essentials
Clinical reviews and meta-analyses converge on two central claims: that ESIs can produce modest short-term pain reduction but lack robust long-term benefit, and that they carry a range of adverse events from transient to severe. A Neurology assessment summarized that any pain improvement is typically seen between two and six weeks after injection and that the average effect size is small and not reliably generalizable, leading to recommendations against routine use for long-term management [1]. A 2024 perspective review reached a similar conclusion, adding that serious adverse events have been reported and the injections lack FDA approval for epidural use, urging caution [2]. These positions frame the debate: modest, time-limited benefit versus a non-trivial risk profile.
2. Short-term relief exists — but how meaningful is it for patients?
Systematic reviews and randomized trials show measurable short-term pain improvement after lumbar ESIs, usually peaking within weeks, but the magnitude typically falls below thresholds many patients and clinicians consider clinically important. The Neurology review emphasized improvement at the two- to six-week window but highlighted limited generalizability and little to no durable effect on function or long-term pain [1]. The 2024 perspective likewise reported little to no short- or long-term superiority to placebo for both lumbar and cervical injections, noting that even when benefit occurs it may be transient and variable across techniques [2]. This evidence supports using ESIs primarily as a temporizing measure rather than a durable cure.
3. The complication spectrum — from headaches to paralysis and infections
Reports and reviews catalog a wide range of complications that include common, typically transient events such as post-procedure headache and temporary paresthesia, and rare but severe outcomes including epidural abscess, epidural hematoma, arachnoiditis, conus medullaris or cauda equina syndromes, stroke, and death [1] [5]. Several reviews emphasize clusters of catastrophic outcomes associated with contaminated steroid lots and intravascular or intrathecal placement, noting documented outbreaks of meningitis and multiple fatalities tied to contaminated injections [5]. The Clinical Journal of Pain review underscores that catastrophic neurologic complications are uncommon but have been repeatedly linked to particulate steroids and specific transforaminal techniques [4].
4. How often do serious harms happen? The numbers and context
Absolute rates of severe complications are low but not zero. Older epidemiologic work estimated infectious complications like epidural abscess at roughly 1–2 per 10,000 cases and epidural hematoma at roughly 1 in 70,000–190,000, underscoring rarity but potential for devastation [6] [7]. More recent syntheses nuance that risk varies by technique, steroid formulation, and timing relative to surgery: a 2024 meta-analysis found a small increased odds of postoperative lumbar surgical-site infection after preoperative ESIs, particularly when given within 30–90 days of surgery, with a number-needed-to-harm around 111 — statistically significant but clinically small [3]. Other reports tie outbreaks and deaths to contaminated lots rather than routine sterile practice, highlighting system-level vulnerabilities [5].
5. Technique, steroid type, and timing change the risk–benefit calculus
Evidence indicates that transforaminal injections and particulate steroid formulations carry higher odds of severe neurological complications compared with interlaminar approaches and nonparticulate steroids, and that intravascular or intrathecal needle placement drives many catastrophic events [2] [4]. The Clinical Journal of Pain review notes that nonparticulate steroids may reduce embolic risk but may also offer shorter duration of effect; preservative content and sterility of commercial preparations influence neurotoxicity and infection risk [4]. Timing matters too: injections administered shortly before lumbar surgery correlate with a small but measurable increase in postoperative infection risk, shifting clinical decisions for patients with likely surgical indications [3].
6. Practical implications: how clinicians and patients should weigh options
Given the evidence, the prudent approach is shared decision-making that emphasizes modest short-term benefit, uncertain long-term gain, and a clearly articulated set of possible harms. For patients with severe, function-limiting radicular pain who hope to avoid or delay surgery, a limited trial of ESI may be reasonable when performed with meticulous technique, using safer steroid formulations and imaging guidance; clinicians should avoid routine or repeated injections without reevaluation [1] [4]. For patients facing imminent lumbar surgery, delaying elective preoperative injections or selecting alternatives may reduce a small added infection risk [3]. Informed consent should explicitly address the full spectrum of complications, including the rare potential for permanent neurologic injury, infection outbreaks from contaminated lots, and endocrine effects from repeated steroid exposure [5] [6].