Specializing in Spine, Sports & Physical Medicine

“A Series of Three Epidurals” Is it Necessary?

As a Physical Medicine and Rehabilitation specialist,  I see on a daily basis and often several times per day, people that have radiculopathies or “pinched nerves” in either their necks or lower backs. The nerves that exit the spine can be irritated by disc bulges and protrusions, bone spurs or combinations of these. Non-surgical treatments include physical therapy, medication, traction, and epidurals frequently done in series of three shots. First of all what is an epidural. An epidural as it relates to pain management, is an injection into the spine using real time x-ray, also known as fluoroscopy, to guide a needle near a irritated nerve so that the doctor can deposit cortisone. The cortisone can significantly reduce inflammation and with that lessen pain.

So why a series of three shots? Honestly, I do not know. About 25-30 years ago epidurals were performed without x-ray guidance and even in the best hands the epidural space was missed in upwards of 1/3rd of patients. So, I could see how it would make sense to try a second or third injection if the first did not work. However, once we could see exactly where the medication was going the need for three injections pretty much went out the window.

A quote from a very well respected peer-reviewed evidence based guideline for the treatment of back related problems states:

Epidural steroid injections, “series of three”

“Not recommended. Original recommendations that suggested a “series of three injections” generally did so prior to the advent of fluoroscopic guidance. These previous recommendations were based primarily on case studies and anecdotal evidence. There does not appear to be any evidence to support the current common practice of a series of injections.”

For the most part, what the medical research tells us is that on average, two or less epidurals are required in patients who have successful outcomes for the treatment of their “pinched nerves”.

So, I ask again, why are pain management doctors still doing a series of three epidurals? It is anybody’s guess……

Lumbar Epidural 2         Lumbar TFE

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