Injections: Cortisone vs Epidural

As a spine specialist focused on non-surgical and non-invasive procedures, I don’t prescribe injections in my office. Thus far in my career, I’ve consulted with over one thousand patients. Each person comes to me with a unique case, which includes pain, dysfunction, and immobility. With every case, I have to understand where a patient has been, what procedures they have had, and where they want to go. Often, these patients are looking to avoid addictive opioids, risky injections, and invasive spine surgeries.

Healthcare, as a whole, is actively trying to avoid spine surgery. The reason is that it is costly (even with the best insurance), and the outcomes (result) can often be 50/50 depending on the type of procedure. Though my specialty is conservative means like non-surgical spinal decompression, I get asked about injections every day. Below is a comparative analysis between cortisone injections and epidural injections.

Note: This article is not written as medical advice. This is an educational article written for the general population. Any procedure you’ve had or are considering having should be discussed with a licensed professional.

Cortisone Injections

Cortisone injections, also known as corticosteroid injections, are a broad category of injections that deliver anti-inflammatory medication directly to a specific area of the body[1]. In spine care, these injections are typically used to target localized areas of inflammation, such as facet joints, sacroiliac joints, or trigger points in muscles.

Mechanism of Action

The primary mechanism of action for cortisone injections is the potent anti-inflammatory effect of corticosteroids. When injected, these steroids reduce inflammation by suppressing the immune response and inhibiting the production of inflammatory mediators[1]. This leads to decreased pain, swelling, and improved function in the targeted area.

Injection Site

In spine-related conditions, cortisone injections can be administered to various structures:

1. Facet joints: Injected directly into the small joints between vertebrae.
2. Sacroiliac joints: Delivered into the joint between the sacrum and ilium.
3. Trigger points: Injected into specific trigger points in muscles where tension and pain are concentrated.

Epidural Injections

Epidural steroid injections (ESIs) are a specific type of injection that targets the epidural space surrounding the spinal cord and nerve roots[1][4]. They are more expensive and are typically regarded as a more serious procedure. Medical providers are currently discussing the safety of this type of injection. As of this writing, epidural injections are not approved by the FDA for spine pain relief. They were initially designed for late-stage cancer patients to ease their pain. While epidural injections are standard practice in spine care, it is still considered off-label and does not have adequate or definitive evidence documenting their safety.

Mechanism of Action

Epidural steroid injections work by delivering a combination of corticosteroids and local anesthetics directly to the epidural space. This approach reduces inflammation around compressed or irritated spinal nerves, alleviating pain and other symptoms associated with conditions like herniated discs, spinal stenosis, or radiculopathy[2][4].

Injection Site

The epidural space is the area between the dura mater (the outermost membrane covering the spinal cord) and the vertebral wall. There are three main approaches for epidural injections:

1. Interlaminar: The needle is inserted between the laminae of two adjacent vertebrae.
2. Transforaminal: The injection is made through the neural foramen, where nerve roots exit the spine.
3. Caudal: The needle is inserted through the sacral hiatus at the base of the spine[4].

Key Differences

1. Target Area: Cortisone injections target specific joints or trigger points, while epidural injections focus on the epidural space around the spinal cord and nerve roots[1][4].
2. Indications: Cortisone injections are often used for localized joint pain or muscle-related issues. Epidural injections are primarily indicated for radicular pain or conditions affecting multiple spinal levels[2][4].
3. Technique: Epidural injections require more precise needle placement and are typically performed under fluoroscopic guidance to ensure accurate delivery to the epidural space[4].
4. Risks: While both procedures carry risks, epidural injections have additional potential complications due to the proximity to the spinal cord and nerve roots[4].
5. Duration of Effect: Epidural injections often provide longer-lasting relief compared to localized cortisone injections, with effects potentially lasting several months[2][4].

In conclusion, while both cortisone and epidural injections utilize corticosteroids for their anti-inflammatory effects, their specific applications, techniques, and target areas differ significantly. Many patients come to my office looking for a more natural treatment process. Often, these patients have had multiple injections and yet still needlessly suffer from bulging, herniated, or degenerative discs. It is crucial to understand that while injections can decrease pain, they are not treating the underlying cause. This is where treatments like non-surgical spinal decompression can be so effective because it is FDA-cleared to reduce the pressure within the disc, which allows the discs to heal naturally without addictive opioids, risky injections, or invasive spine surgeries.

Citations:
[1] https://www.hopkinsmedicine.org/health/conditions-and-diseases/epidural-corticosteroid-injections
[2] https://www.hss.edu/conditions_epidural-injections-faqs.asp
[3] https://oscsurgical.com/trigger-point-injections-vs-epidural-steroid-injections/
[4] https://my.clevelandclinic.org/health/treatments/22301-epidural-steroid-injection-esi
[5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7386972/
[6] https://www.health.harvard.edu/pain/back-pain-what-you-can-expect-from-steroid-injections
[7] https://neuroinjurycare.com/trigger-point-injections-vs-epidural-steroid-injections/
[8] https://cost.sidecarhealth.com/f/what-is-the-difference-between-an-epidural-steroid-injection-and-a-cortisone-shot