Did You Know?

While insurance policies often allow up to four Epidural Steroid Injections (ESIs) in a 12-month period, emerging evidence shows this frequency may be medically unnecessary—and potentially harmful.

The Risk of Overuse

Research has shown that after just two injections, patients may be at risk for systemic osteoporosis, particularly if high steroid doses are used. This risk increases significantly when the steroid dose exceeds 180 mg of Depo-Medrol or Triamcinolone.

To reduce harm:

• Lower doses should be used routinely, as higher doses offer no added benefit.
• Most patients do not need more than 1-2 ESIs per year.

The Transforaminal ESI (TFESI) approach does, however, offer an advantage in that it delivers the steroid directly to a single nerve sheath, allowing for lower doses while still achieving clinical relief.

Steroid Formulations: What’s Safe?

Only four steroid preparations have been commonly used for ESI:

Non-particulate (safer if inadvertently injected into an artery):

• Dexamethasone

Particulate (can clot an artery if mis-injected):

• Methylprednisolone
• Triamcinolone
• Betamethasone

Particulate steroids were once favored for their presumed longer-lasting effect, but two clinical studies have since shown no significant difference in duration of relief compared to non-particulate steroids. As a result, particulate steroids are no longer recommended, especially given the risk of arterial embolism.

The Myth of the “Series of 3”

In the past, many practitioners—especially anesthesiologists performing blinded injections—would administer a “series of 3 injections” at 1-2 week intervals. This was based on custom rather than evidence. There is no scientific basis for this practice, and with miss rates of 36-40% in blind ESIs, the approach is now discouraged.

Additionally, repeated injections too closely spaced can suppress the body’s natural hormone function. Experts recommend waiting at least 2-3 weeks between injections to avoid adrenal gland suppression.

Steroid injections must be used cautiously and thoughtfully. High doses, frequent injections, and outdated techniques all raise safety concerns. As the limitations of steroid use become more apparent, the search for safer, effective treatments—like Platelet-Rich Plasma (PRP)—gains momentum.

Read more from the series “Evidence for Platelet-Rich Plasma in Spine Care”:

• The History of Epidural Steroid Injections
• How Many Steroid Injections Are Too Many?
• When Is a Steroid Injection Actually Warranted? (Coming Soon)
• How PRP Compares to Steroids in Spine Treatment (Coming Soon)
• The Protocol for Using PRP in Spine Care (Coming Soon)