Did You Know?

Despite their widespread use, epidural steroid injections (ESIs) are not appropriate as a first-line treatment for spinal pain. Instead, they should be reserved for carefully selected cases where conservative care has failed and specific clinical signs are present.

When Conservative Care Isn’t Enough

Before considering an injection, patients should undergo at least four physical therapy visits with a practitioner trained in the McKenzie Method (Mechanical Diagnosis and Therapy or MDT). One of the key assessments in this method is whether the patient has a Directional Preference (DP)—a specific movement or position that centralizes or reduces symptoms.

An ESI may be indicated if:

• The patient does not have a DP, meaning their symptoms do not improve with specific movements.
• A lumbar shift (lateral deviation of the spine) is present and:
  
  • Has not resolved after 4 treatments.
  • Is toward the painful side rather than away from it.

Neurological and Imaging Findings Matter

In addition to physical therapy findings, neurological testing and imaging should support the decision to proceed with an ESI:

• A Straight Leg Raise (SLR) test is positive below 45 degrees, indicating significant nerve root involvement.
• A Crossed SLR test (pain on the affected side when the opposite leg is raised) is also present.
• Imaging (such as CT or MRI) confirms one or more of the following:
  
  • Disc herniation
  • Spinal stenosis
  • A combination of both

Steroid injections should be used only when clearly indicated by failed conservative care, specific physical signs, and confirmatory imaging. This approach ensures that ESIs are not overused—and helps identify the right moment to consider Platelet-Rich Plasma (PRP) as a potentially safer and more effective alternative.

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?
• How PRP Compares to Steroids in Spine Treatment (Coming Soon)
• The Protocol for Using PRP in Spine Care (Coming Soon)