When Back Pain Persists, Targeted Injections Can Help
Back and neck pain affect millions of people each year, often limiting daily activities and reducing quality of life. When conservative measures such as rest, medication, or physical therapy fail to provide adequate relief, injection therapies offer a minimally invasive way to manage pain and restore function without surgery.
Two common types are epidural steroid injections (ESIs) and facet joint injections. Both deliver medication directly to the source of pain under image guidance — typically fluoroscopy (live X-ray) — ensuring accuracy and safety. These outpatient procedures can provide significant temporary relief by reducing inflammation in targeted areas.
The primary goal is to calm inflamed nerves or arthritic joints, giving patients a window to participate more comfortably in physical therapy and other rehabilitative exercises. The Orthopedic Spine Institute of St. Louis specializes in these conservative treatments, starting with thorough evaluation and patient-first care to design a personalized plan that addresses the root cause of pain.
Epidural Steroid Injections for Nerve Pain
Epidural steroid injections (ESIs) target inflammation around irritated spinal nerve roots. The epidural space is a narrow area (3–6 mm wide) between the spinal column and the protective dura mater that contains spinal nerves, connective tissue, and blood vessels. When a herniated disc or other condition irritates a nerve root in this space, it can cause radiating pain, numbness, or weakness into the arms or legs.
An ESI delivers a corticosteroid and a local anesthetic directly into the epidural space. The steroid suppresses inflammation by blocking the release of inflammatory substances such as prostaglandins and cytokines, which calms the irritated nerve and reduces swelling. The anesthetic provides immediate numbing, while the steroid’s anti-inflammatory effect builds over days. Many patients also benefit from a transforaminal ESI, which places medication through the foramen (the small bony opening where a specific nerve root exits) for precision targeting.
ESIs are commonly used for conditions such as herniated discs, sciatica, spinal stenosis, and degenerative disc disease. Three main delivery approaches exist: interlaminar (between vertebrae), transforaminal (through the foramen to a specific nerve root), and caudal (through the sacral hiatus). About 50% of patients experience temporary pain relief from an ESI, with effects often lasting from several weeks to a few months.
Facet Joint Injections for ArthritisPain
Facet joints are small stabilizing structures located on each side of every vertebra, running from the neck down through the lower back. They guide motion and provide stability, but they are also vulnerable to arthritis, injury, and the wear-and-tear of aging. When the cartilage inside a facet joint wears down or the joint becomes inflamed, the result is localized back or neck pain that can worsen with twisting, bending, or standing.
A facet joint injection delivers a combination of local anesthetic and corticosteroid directly into or near the affected joint. The anesthetic provides immediate but short-lived numbing, while the steroid reduces inflammation for longer-lasting relief. The injection serves two purposes: it can confirm that the facet joint is the source of pain (diagnostic) and, if successful, provide weeks to months of symptom relief (therapeutic).
Ideal candidates for facet injections have axial back or neck pain — meaning the pain stays in the spine and does not radiate into the arms or legs. Imaging studies such as MRI or CT often show arthritic changes or fluid buildup in the facet joints. For patients with clear facet joint issues and localized pain, success rates can reach up to 80% when the injection is performed by a specialist with fellowship training in image-guided spinal procedures.
Recovery from a facet joint injection is quick. Soreness at the injection site typically lasts a day or two. Light daily activities are fine within 24 hours, but heavy exercise or weight training should be avoided for at least 48 hours. The anesthetic wears off within hours, so some patients notice a temporary return of discomfort before the steroid begins working. Pain relief from the steroid typically starts 3 to 7 days after the injection and can last from several weeks to months.
Facet injections differ from epidural steroid injections in their target and purpose. Epidurals deliver medication into the epidural space around the spinal cord and nerve roots, making them the preferred choice for radiating nerve pain such as sciatica or spinal stenosis. Facet injections, by contrast, focus on the small joints that connect the vertebrae and are best suited for localized mechanical or arthritic pain. The team at the Orthopedic Spine Institute of St. Louis evaluates each patient's specific pain pattern and imaging findings to determine which injection approach — or combination of approaches — is most appropriate.
What to Expect During the Procedure
Both epidural steroid injections and facet joint injections are performed as outpatient procedures, typically taking 10 to 30 minutes. You will lie on your stomach or side on an X-ray table. The physician uses live X-ray guidance (fluoroscopy) to precisely guide a thin needle to the targeted area, minimizing tissue trauma and ensuring accurate medication delivery.
After cleaning and numbing the skin with a local anesthetic, most patients feel only mild pressure or a brief pinch during needle insertion. Sedation is generally not needed for these injections, but it can be offered to manage anxiety. The team at Orthopedic Spine Institute of St. Louis discusses sedation options if appropriate. Following the injection, you are monitored briefly and can typically return to light daily activities within 24 hours.
The discomfort of the procedure is often far less than the chronic pain it treats. After the numbing wears off, temporary soreness at the injection site may last a day or two and can be managed with ice or over-the-counter pain relievers.
After Your Injection: Recovery and Precautions
Proper aftercare following an epidural steroid injection or a facet joint injection helps maximize relief and minimize complications. While both procedures are minimally invasive and allow most patients to return home the same day, following a few simple guidelines during the first 24 to 48 hours can speed recovery.
Immediate aftercare: rest, avoid driving day of injection. You should not drive or operate machinery for at least 12 to 24 hours after the procedure. If sedation was used, arrange for someone to drive you home. Plan to rest for the remainder of the day — light activity around the house is fine, but avoid bending, twisting, or heavy lifting.
First 24 hours: avoid bending, twisting, heavy lifting. It is common to feel mild soreness or a temporary increase in pain (often called a "steroid flare") as the local anesthetic wears off. Apply ice packs to the injection site for 15 to 20 minutes at a time to ease discomfort. Do not use heating pads or hot packs on the injection area for at least three days.
Bandage and showering. The small bandage over the injection site can be removed the next day. You may shower 24 hours after the procedure, but avoid soaking in a bathtub, swimming pool, or hot tub for 48 hours to reduce infection risk.
Resume normal activities gradually. If you feel stable, you can return to normal daily activities (walking, sitting, light desk work) within 24 hours. Avoid strenuous exercise, intense cardio, or weight training for at least 48 hours. Pain relief from the corticosteroids typically begins within two to seven days, with peak benefits occurring at one to two weeks.
When to call the doctor. Contact your provider if you experience any of the following after the injection: a severe headache that improves when lying down (may indicate a dural puncture), fever or chills (sign of infection), new or worsening leg numbness or weakness, or loss of bladder or bowel control. These complications are rare but require prompt medical attention.
Potential Side Effects and Risks
Both epidural steroid injections and facet joint injections are safe procedures, but like any medical intervention, they carry potential side effects and risks. Understanding these helps you make an informed decision with your physician.
Common and Temporary Side Effects
Most side effects are mild and resolve on their own within a few days. At the injection site, you may experience temporary soreness, tenderness, swelling, or bruising. A small number of patients report a temporary increase in pain after the anesthetic wears off, sometimes called a "steroid flare," which typically subsides within a few days. Steroid-related side effects can include facial flushing, insomnia, and an increase in blood sugar levels, particularly in diabetic patients, which usually returns to normal within a few days.
Rare But Serious Risks
Serious complications are rare when injections are performed by an experienced specialist. Potential risks include infection, bleeding, nerve injury, or a spinal headache caused by leakage of spinal fluid. According to the Cleveland Clinic, side effects such as numbness, weakness, dizziness, and headache are rare and usually resolve within a few hours, while complications like bleeding, infection, or nerve injury are very low for transforaminal injections. The Hospital for Special Surgery notes that when performed properly, the risk of bleeding, infection, or nerve damage is exceedingly low for epidural injections in general.
Your safety depends on a thorough pre-procedure evaluation. The team at Orthopedic Spine Institute of St. Louis reviews your medical history, current medications, and imaging to ensure you are a good candidate. Patients on blood thinners or with infections may need to postpone or avoid the procedure.
Limiting Injections for Long-Term Safety
Most providers limit injections to two to three per year to reduce long-term risks such as bone weakening from repeated steroid exposure. The Cleveland Clinic notes that it is generally safe to have three to six injections per year, but if there is no improvement after two or three injections, more are unlikely to help. If a facet joint injection helps, the next step for longer relief is often radiofrequency ablation, which can provide pain control for six months to a year.
Do These Injections Actually Work?
Both epidural steroid injections (ESIs) and facet joint injections serve two roles: they provide temporary pain relief and they help identify the source of pain. They do not cure the underlying condition, such as a herniated disc or arthritis. Instead, their value lies in creating a window of reduced pain that allows a patient to participate more comfortably in physical therapy and daily activities.
For ESIs, approximately 50% of patients experience temporary pain relief, according to the Cleveland Clinic. The success rate varies by diagnosis: it ranges from 50% to 84% for conditions like lumbar disc herniation and spinal stenosis. Relief can last from several weeks to several months, with most providers limiting use to two or three injections per year to minimize long-term risks.
Facet joint injections show a success rate of up to 80% when given to properly selected patients whose imaging clearly points to the facet joints as the pain source, as reported by the Hospital for Special Surgery. Relief from a single injection may last three to six months or longer. When relief is short-lived, radiofrequency ablation is often the next step and can extend pain control for six months to a year.
The real measure of success is whether the injection enables a patient to resume rehabilitation and avoid or delay more invasive procedures. At the Orthopedic Spine Institute of St. Louis, specialists work with each patient to determine if an injection is appropriate based on a thorough clinical exam and imaging results. When injections are combined with physical therapy and lifestyle changes, the temporary relief they provide can become a foundation for lasting improvement.
When Injections Are Not Enough
When your back pain does not respond to repeat injections, it does not mean you are out of options. If you see no improvement after two or three injections, further ones are unlikely to help. At that point, the focus shifts to other strategies that can address the underlying cause more directly.
Reassessing the Diagnosis
A lack of response to injections often signals that the pain source may not be where it was originally thought to be. For instance, facet injections that fail to provide relief suggest the facet joints may not be the main source of your discomfort. Your physician may order additional imaging or diagnostic nerve blocks to pinpoint the true origin of the pain before moving on to the next treatment phase.
Alternative Procedures
If injections do not deliver the expected relief, several minimally invasive alternatives are available. Radiofrequency ablation uses heat to disrupt the nerves transmitting pain signals from the facet joints, often providing relief for six months to a year. Spinal cord stimulation uses a small implanted device to interrupt pain signals before they reach the brain. Nerve blocks can also serve both diagnostic and therapeutic roles. Treatment at the Orthopedic Spine Institute of St. Louis starts with a thorough evaluation by Dr. David S. Raskas to match the procedure to the specific cause of your pain.
Building a Broader Treatment Plan
Injections are most effective as part of a comprehensive treatment approach that includes physical therapy, regular exercise, and maintaining a healthy weight. Physical therapy strengthens the muscles supporting your spine and improves mobility, while weight reduction decreases the load on painful joints. A combination of lifestyle changes and follow-up therapies can help you regain function and keep pain at bay. The goal is not just temporary relief but long-term improvement in your quality of life.
Partner with a Specialist for Your Spine Health
Spinal injections are a valuable tool for managing pain, but they are not a cure. Their success depends on proper patient selection, accurate diagnosis, and a comprehensive treatment plan.
At the Orthopedic Spine Institute of St. Louis, Dr. David S. Raskas provides personalized care focused on conservative treatments first, with minimally invasive options like epidural and facet injections when appropriate. The goal is to help patients return to pain-free function and improve their quality of life.
If you are experiencing persistent back or neck pain, schedule a thorough evaluation with Dr. Raskas to determine the right path forward.
