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BackTable / MSK / Article
Lumbar Epidural Steroid Injections: From Referral to Relief
Sam Strauss • Updated May 26, 2025 • 35 hits
Lumbar epidural steroid injections (ESIs) are widely utilized in the treatment of radicular pain, but clinical approaches to referral, diagnosis, and patient counseling remain highly variable. Referral sources range from primary care and spine surgeons to neurologists and pain physicians, and many providers rely on clinical experience rather than formal training to determine when an injection is appropriate. As a result expectations for what an ESI can achieve—and who benefits from it—can differ widely depending on the clinical environment.
Establishing clear criteria for patient selection begins with recognizing pain patterns that suggest a true radiculopathy versus axial back pain or neurogenic claudication. The distribution of symptoms, patient history, and functional limitations all play a role in determining whether a patient is likely to respond. Once the diagnosis is , physicians must guide patients toward a realistic understanding of what the injection is intended to do – namely, provide temporary relief to support mobility, therapy participation, or natural healing. When timed and targeted appropriately, lumbar epidural spinal injections can offer meaningful benefits even without long-term resolution. This article features excerpts from the BackTable MSK Podcast. You can listen to the full podcast below.
The BackTable MSK Brief
• Referral sources for lumbar ESIs vary widely, often depending on institutional workflow, training exposure, and provider confidence.
• Radiculopathy should be distinguished from axial back pain or claudication based on history, symptom distribution, and exam findings.
• Patients with leg-dominant or dermatomal symptoms tend to respond better to ESIs than those with isolated back pain.
• Setting clear expectations for treatment effect can help guide patient satisfaction and minimize adverse outcomes.
• ESIs are best used to support mobility, rehab participation, or recovery during the subacute phase—typically 4–6 weeks after onset.
Table of Contents
(1) Pain Referral Patterns & Provider Variability
(2) Identifying Radicular Pain & Related Diagnoses
(3) Managing Expectations with Lumbar Epidural Spinal Injections
Pain Referral Patterns & Provider Variability
The decision to pursue a lumbar epidural steroid injection (ESI) usually begins with a referral, but the pathway leading to that decision can vary significantly between different providers and practices. Some physicians receive referrals directly from spine surgeons and neurologists after an MRI has been done, while others will take patients earlier in the diagnostic process based solely on reported symptoms. The referral source often shapes not only the timing of the injection, but the expectations placed on the intervention as well.
There is also wide variability in how clinicians are trained to approach ESIs. While some pain physicians gain hands-on procedural experience during fellowship, others are expected to build their practice and interventional guidelines on their clinical experience. This variability can affect how diagnostic criteria are applied and how comfortable the provider is with turning a patient down for an injection when the clinical picture doesn’t support it. In some cases, procedural volume or workflow pressure may influence decisions that ideally should be guided by symptom type, duration, and physical exam findings. Improving workflow and building relationships with referral networks can help minimize this workflow pressure and improve patient outcomes.
[Dr. Jacob Fleming]
…One thing that I found with these is there are many different ways to skin a cat. I think we can talk about the different techniques and maybe some pearls. While we just jump in, we'll start with some talk about lumbar. Just tell me, what's been your experience with ESIs?
[Dr. Chris Beck]
…When I went through fellowship, I was classically interventional trained in the old model in which I did diagnostic radiology for four years and then one year of fellowship. I did a total of zero epidural steroid injections. I did have a little bit of exposure in residency. We had a diagnostic neuro-rad who would, just when you were on a neuro-rotation, you might do some. Maybe I had done 20 or 30, some of them but a relatively low number, definitely under 50.
I really conceptually understood a lot of the times what I was doing, because it was so spotty. I just wasn't doing them with like a lot of reps. Then when I got out, I took a private practice job and the role that I stepped into, there was a lot of bread and butter interventional radiology, but then there was all these things that were just little add-ons.
…I fell into this practice where I had to learn it, had to learn it quickly. We also had a practice where they put you out on an island and it was like, "Swim." Hold on, is that the expression? They just put you out on-- I don't know what that said, but they put you out on an island and you were expected to be able to do these procedures and do them quickly. There wasn't a lot of shadowing involved.
Then, now it's 10 years later and it's a procedure I feel very comfortable with, but I didn't have an academic approach to coming at these procedures. It's just something I had to learn on the go. Then I've developed my own way of working or navigating these patients with our referral patterns, which we'll get into talk about too.
[Dr. Jacob Fleming]
For sure. My experience in residency, I think, was somewhat similar to yours. We had a pretty robust neuroradiology spine service which performed-- The bulk of the work was definitely like LPs, intrathecal chemo and myelograms, but did a pretty decent amount of both targeted and non-targeted blood patches. ESIs would come along once in a blue moon, but so many of those procedures were done under CT. That's an approach I became very familiar with.
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Identifying Radicular Pain & Related Diagnoses
While many patients present with chronic back pain, only a subset have true radiculopathy – typically defined by dermatomal pain distribution, leg-dominant symptoms, and evidence of nerve root irritation or compression. These patients are most likely to benefit from a lumbar ESI, particularly if the pain is subacute but limits mobility or rehabilitation progress.
In contrast, patients with axial back pain without radicular features are less likely to experience relief from steroid injections. Neurogenic claudication due to spinal stenosis may similarly present with leg discomfort, but the pain is often positional and lacks a discrete nerve root distribution. These cases require careful history-taking to distinguish from radiculopathy, as they may not respond to the same interventions.
Effective use of lumbar epidural steroid injections hinges on identifying the underlying cause of the patient’s pain. While imaging can support the diagnosis, clinical pattern recognition – based on symptom location, aggravating factors, and neurologic findings – remains the foundation of good decision-making. Treating the wrong pain source leads to poor outcomes and unmet expectations, regardless of the technique of treatment.
[Dr. Jacob Fleming]
My fellowship…was probably about 85%, 90% spine related. As you alluded to, a lot of these patients come in and they have leg pain. They've got sciatica and a lot of them attribute it to their hip or their knee because referral patterns can be complicated. I think this is something that's always worthwhile to keep in mind. It really comes down to, in my opinion, the MRI, the lumbar spine, figuring out where are you going to go and what is actually causing it. One of the nice things about the ESI is it is a diagnostic tool as well. You can get pretty quick feedback on whether you targeted the right level of pathology. Although I will say that most ESIs, they're not very selective per level.
…The indications for lumbar epidural steroid injections would be lower extremity radiculopathy with or without back pain. Notice that back pain alone is not a very good indication for ESI. Those of us who have done it know that for just solely axial back pain, you might get a little bit of relief, but it typically doesn't last. It's definitely not a good durable treatment. Then spinal stenosis is another one. I look at that more of a diagnostic tool to figure out if their neurogenic claudication is coming from that particular area.
Usually there's not a whole lot of doubt about it, but prepare the patient that with any of these injections, it's hard to say the durability of the relief that you'll get, you'll certainly get some, and we'll know today if that's the right switch, but it could last for two hours, could last for two years. It's very difficult to approach this.
[Dr. Chris Beck]
…The two categories I'm always trying to put patients in a box to choose what procedure I'm going to do, I try and select the patients who are primarily neurogenic claudication, and those are the ones I'm primarily thinking, let's start with interlaminar injections, and then the patients who are primarily radicular symptoms.
Everyone who treats back pain knows that this is a messy category, but I really drill down with my patients, do some targeted H&P and some physical exam maneuvers to try and tease those two apart. If they have both, I'll just ask them, I'll say, "What's bothering you the most? If I were to take away your leg pain today, do you think you could start gardening or riding motorcycles tomorrow?" That's how I'll start the conversation with also leaving the door open to my patients and telling them, "Look, let's dig in for the long haul because back pain is something-- Everything that we do today, it's just to control the symptoms." I just broadly talk about it in broad strokes, but it's like, "All that arthritis, all those pinched nerves, they're still there. What we're doing is just symptom management. There's going to be opportunities to try different therapies or try different things to get you dialed in."
Managing Expectations with Lumbar Epidural Spinal Injections
While ESIs can offer meaningful symptom relief, they are not curative – and positioning them as a definitive solution often leads to disappointment. Patients should understand that the goal of the injection is to reduce inflammation and pain long enough to support physical therapy, promote mobility, or allow natural healing to continue. It may also provide a diagnostic window to evaluate how much of the pain is driven by a compressive or inflammatory process, but it is not always a cure-all for the entirety of their pain.
Part of this process is preparing the patient for a response to treatment that can be unpredictable. Some may experience relief within hours, while others may notice gradual improvement over days. A portion of patients – particularly those without well-defined radicular symptoms – may not benefit at all. By acknowledging this during pre-procedure counseling, clinicians can maintain trust even when the outcomes are limited and may be able to redirect further interventions.
Timing of lumbar ESI also plays an important role in clinical decision making. For patients with subacute radiculopathy a lumbar ESI can manage pain without the risk for opioid use or surgical interventions. In other cases, like chronic idiopathic back pain, an ESI may just offer transient relief. Helping patients understand what the procedurecan – and can’t – do allows them to participate more actively in their care plan and reduces the risk of misaligned expectations.
[Dr. Chris Beck]
I always take pain assessment score and I think people can get a little bogged down in the numbers. What's your pain score at, what's your pain score at it's worse, when it's at its best, whatever. I always tell them that those numbers are important to me, but what I'm really trying to do is restore them to a certain symptom relief to where I don't care if they're at a three or a 10 or a 6/10. If 3/10 means that they can go do the things that they love to do, like ballroom dancing or jumping out of airplanes, then that's a success.
If that number needs to be two for them or if that number needs to be four for them, that's the goal of therapy for me, is to chip away at this back pain to where they're going to be able to do the things that they love to do and not be afraid of back pain or ridiculous symptoms getting in the way of that, lifestyle limiting symptoms. I just wanted to say that.
…I usually tell patients, similar to you, this is just talking in broad strokes. I'm just thinking about all my patients as a whole, as I'll say, anywhere between two days and two years worth of symptom relief with the average, our average internally within our group is somewhere between three and four months if we're hitting the right area. That's like the presumption that I've targeted the correct area and we land a successful injection. All the caveats there, but I think that it's good expectation management that you might only get a week worth of symptom relief and depending on the situation, it can still give you some diagnostic information that can help with therapy after that, things that maybe are not in the IR bag.
[Dr. Jacob Fleming]
Absolutely. Some things that are, and it's just a sidebar is that there's this dichotomy that I've heard over and over again, is that it's either injections or surgery. I think that there's a lot in between there that can be maximized. That's a different subject, but I will say, it depends on your relationship with your referents, especially if they're surgeons. A lot of times if they're a little more prescriptive about what they're asking for, then the conversation with the patient can go a little bit differently in terms of what could be the next thing.
Podcast Contributors
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Dr. Jacob Fleming
Dr. Jacob Fleming is a diagnostic radiology resident and future MSK interventional radiologist in Dallas, Texas.
Cite This Podcast
BackTable, LLC (Producer). (2024, August 6). Ep. 55 – BackTable Basics: Lumbar Epidural Injections [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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