Steroid Injections and Other Treatments for Lower Back Pain

The use of steroid injections to treat lower back pain has grown enormously over the past several decades. Though large-scale outbreaks of infection due to contaminated product have made recent news (see shaded box below), risks remain even with properly manufactured medications. Patients and physicians should know when not to use steroids, consider the risks and benefits of the procedure, and understand other treatment options before using steroids to treat lower back pain.

When not to use steroids

Back pain is a condition that affects between 50 and 80 percent of people at some point in their lives. Its many potential causes include damage to the spine, muscle strain, irritated nerves, infection (such as shingles) or arthritis.

Steroid injections are only effective for lower back pain involving compressed or irritated nerves in the lower spine (often called “radiculopathy”). This pain is sometimes linked to a bulging or ruptured (herniated) spinal disk, which is the rubbery cushion separating the bones in your spine. Such nerve-related pain is often described by patients as a shooting or stabbing pain and is likely to radiate into the legs (as in a condition known as sciatica). By contrast, pain that involves the surrounding muscles and supporting structures of the spine, as opposed to the nerves, is often described as a throbbing or aching sensation.

In an attempt to diagnose the cause of back pain, doctors may administer a physical exam or order routine radiographs (x-rays), computed tomography (CT) scans or magnetic resonance imaging (MRI). So far, however, no exam finding or imaging test has proven very accurate in diagnosing the source of the pain. Radiography, CT scans and MRI are also expensive and may turn up abnormalities, such as protruding or bulging disks, that may be harmless and incorrectly identified as the cause of the symptoms. For these reasons, the American College of Physicians and the American Pain Society do not recommend routine imaging for low back pain unless a tumor, infection or other underlying condition is suspected or unless the patient is being evaluated for surgery or epidural steroid injections.

Identifying the cause of lower back pain can be extremely tricky, and in most cases (up to 85 percent by some estimates), the cause will remain unknown. In these cases, steroid injections are not recommended because there is no evidence that they are effective.

Some causes of back pain should be addressed immediately and should not be treated by steroid injections. Tell your doctor if you have experienced unexplained weight loss, pain that does not go away when you lie down, problems walking, urinary or fecal incontinence, or numbness or tingling in your legs or arms, as these may be signs of pressure on the spinal cord caused by a tumor, infection or severe arthritis. Also, tell your doctor if you experience nausea, vomiting, fever, chills, or tenderness or swelling in the abdomen — signs of infection or damage inside the abdomen that require urgent attention.

Risks and benefits

Steroid injections involve inserting a hypodermic needle into the space around the spinal cord and injecting steroids intended to reduce inflammation around irritated nerves. The procedure carries a small risk of infection and in rare cases may result in severe complications, including paralysis. Steroid injections should therefore not be considered unless there is a high likelihood of benefit to the patient.

Steroid injections have proven effective at relieving nerve-related pain in the short-term. However, the pain relief often begins to fade after a few months, at which point many patients are no better off than if they had received inert salt water (as placebo).

Steroids should not be used frequently, as excess steroid exposure can upset the body’s natural steroid hormone balance, weaken spinal bones and nearby muscles, and cause other serious problems.

Studies have shown that steroid injections are more effective if they are injected directly over the nerve roots (as opposed to farther away from the nerves in the epidural space surrounding the spinal cord). Yet injecting steroids directly over the nerve may also increase the risk of serious complications, including loss of sensation or impaired movement in the lower part of the body.

Other treatments

Most cases of lower back pain usually resolve themselves within two weeks. For short-term (acute) back pain, taking nonsteroidal, anti-inflammatory drugs, such as aspirin, ibuprofen and naproxen, can often help. These over-the-counter drugs treat inflammation and help relieve pain symptoms as the body heals itself. The drugs should not be used for long-term (chronic) pain, however, because they have not proven effective for chronic pain, and the risk of side effects — including stomach ulcers and bleeding — increases with long-term use. There is also little evidence that these drugs help with pain related to nerve issues.

Non-benzodiazepine muscle relaxants can also provide short-term relief of muscle spasms associated with acute back pain. Benzodiazepines should be avoided, as they are not effective for back pain, have serious side effects and can be addictive. Opioids are sometimes recommended for episodes of acute back pain but should not be used for chronic, long-term pain because they have not been tested for this use and also present a high risk of addiction.

One of the simplest treatments for chronic lower back pain without any known cause is staying as active as possible. Studies have shown that patients with chronic, unspecified lower back pain who try to stay active have greater reductions in pain than patients who attempt to get more bed rest. However, maintaining activity is not as helpful for patients with nerve issues such as sciatica, and there is not enough information to say whether it helps with acute pain.

For those with chronic pain, physical therapy designed to strengthen or stabilize the spine can help reduce pain and may prevent further injury, as does spinal manipulation, a form of therapy often used by chiropractors to move the spine and loosen surrounding muscles. Physical therapy may be the safer choice, as many patients who receive spinal manipulation find the experience painful, and the practice may cause serious injury if the body is pushed beyond its limits.

Psychological therapy, including techniques in progressive relaxation, may also help patients to reduce pain and avoid missed work. Less is known about the effectiveness of massage therapy and acupuncture, but there is some evidence that these treatments are helpful in treating chronic pain. There is not enough evidence to say whether any of these techniques work with acute pain.

Considering surgery

Spinal surgery has a high complication rate and often requires additional follow-up surgery. For this reason, surgery should generally only be undertaken if there is a clear cause, such as a tumor, fracture or severe arthritis. For less-clear situations, such as nerve-related pain possibly due to pressure from a herniated disk or arthritis, surgery may provide faster short-term relief, but similar results are achievable through a more conservative “wait-and-see” approach while trying other, nonsurgical treatments. Some guidelines recommend waiting up to two years before considering surgery when questions remain about whether the surgery would actually address the cause of the pain. Before you consider undergoing surgery, talk to your doctor to see if your pain has a clear cause that is likely to be solved by surgery or whether the pain might resolve on its own if given enough time.