Lower back pain is one of the most common ailments and exacts a huge cost on us all. These costs are borne by society and the individual alike. With lower back pain, and the sciatica symptoms sometimes associated with it, it is only reasonable for people to turn to procedures such as spinal injections or epidural injections for lower back pain relief. The prospect of having a simple injection in your lower back, and for the debilitating pain to be eliminated instantly is an enticing one, especially if you’ve been battling such lower back pain for a long time.
Nothing sounds better than you being rid of the inconvenience of lower back pain in an instant, a night and day difference! But is it really all it is cracked up to be, no procedure, especially the invasive sort, is without risk, and what about the upside. Is it really a complete fix for the lower back pain you’ve been experiencing or is this a misrepresentation of the reality? Today, we’ll be taking a deep dive into the subject. If you, or someone you know is considering spinal injections for your lower back pain, or sciatica, then this is a must read. We hope that by the end of it, you feel much more informed about the process and your expectations are set clearly.
Removing the confusion around back pain injections
In our experience we see that those having injections are often focused on this type or that type of injection, for clarity here are a list of some of the injections that you might be scheduled for below:
- Epidural injection
- Facet joint injection
- Sacroiliac injection
- Medial branch block
- Lateral branch block
- Nerve root block
You’d be forgiven for thinking we missed the obvious “steroid injection” and here lies one of the big misconceptions around spinal injections. To help you understand this, we’ll break these spinal injections down into two parts:
What is injected into your back to provide pain relief
All injections are a form of pain relief or inflammation reduction. This is to say that often it will be that you’re having an injection of steroids of some sort as a targeted way of alleviating the pain that you’re experiencing. It might be another form of proprietary pain relieving solution that is injected into the low back, but the point remains. It is some form of medication that is being injected.
Where is the medication being injected into the lower back
The list above referenced the common injection sites. These are areas of the lower back that the injection is being targeted at. This could be specific tissues, like the medial branch block, which are a small group of nerves that innervate the facet joints. Another example would be a simple “nerve block” which is a less specific way of describing what could well be a medial or lateral branch block. The epidural spinal injection for example refers to the epidural space, which is a space between the spinal cord and the dura, a fibrous sheet of connective tissue that encases the spinal cord.
To conclude this, your injection will have two components, the location i.e. epidural space, sacroiliac joint, medial branch etc. It will then have a medication component, i.e. steroid or some other pain relieving medication.
There are other injection procedures that we could get into such as a rhizotomy or radiofrequency ablation, however these are much more permanent injections which seek to create permanent damage to the nerves so they cease to function. This raises two questions. Firstly, is pain the problem or is pain making us aware of the problem? Secondly, what if we are not hitting the right nerves? That being said, these sorts of injections will often be done subsequent to the previously mentioned injections.
Why are you having injections for your lower back pain?
Understanding the clinical goals for your injection is important and often this is not quite grasped (or communicated) during your consultation. We know this as oftentimes, speaking to patients after consultations with surgeons, this fact remains ambiguous. Part of this could be due to white coat syndrome… But I digress. The first and most obvious objective is to inject medication, let us say a steroid substance, into the epidural space. The hope here is that we are injecting in the region that is generating the painful nerve signals and that the pain goes away. Secondarily, the objective might be more diagnostic, for example, prior to a surgical intervention, or one of the more severe injection types mentioned earlier (rhizotomy or radiofrequency ablation). Often both objectives are evaluated subsequent to the procedure. In this second case, the specialist will perhaps suspect that an injection is not going to be enough and so is working to be sure that the next procedure has the best chances of success. For example, if you got no relief at all from the injection, perhaps that was not the part responsible for your back pain?
This reality is exposing perhaps a fundamental error in how back injuries and back pain in general are approached but we can discuss this later.
Your expectations and how spinal injections work
Now we have discussed what they are, that injections fundamentally are all the same, and that the difference comes down to which specific medication and which specific location, we can get into what “working means”. Assuming we are injected in the right place, the injection will reduce the local inflammation or suppress the pain coming from the local region. Just like taking an oral medication might affect your body globally, the injection is simply a targeted way to deliver higher dosages of medication to the region. All it is doing however, is temporarily reducing the inflammation at the site, or making you less aware of the signals coming from the site.
All medical procedures carry risk, injections are no different.
Nowadays procedures are incredibly safe, and professionals take every necessary step to ensure the best possible conditions, but it is important to understand the risk beforehand. You should also compare the risk to the perceived reward and what the actual reward will be. Many have the false expectation that injections are “fixing the back pain” when they are simply nothing more than targeted pain relief. Therefore, before we get into the risks, the knowledge of this simple fact will inevitably change your “tolerable risk”.
For example, if you knew that the procedure was fixing the underlying problem then you would tolerate more risk, than if it was just blinding you to the problem.
The two main risks are the risk of infection, which is present whenever we pierce the skin. A risk you acknowledge when you even go for a simple pin prick test or blood test. The difference here is the potential site of infection, not your finger or arm, but the spine. Thankfully again we cannot overstate that these are very very rare. But they must be commented on and you should discuss this with your surgeon beforehand, so they can accurately communicate this.
The second main risk, is not so much a risk, but a temporary side effect particularly with steroid injections, something widely researched in shoulder and achilles injections. This is the reality that there is a short window of days to weeks, where the integrity of ligaments and/or tendons is reduced. In such a congested area these tissues are inevitably exposed to the medication. This coupled with perhaps reduced awareness of the area, means that you’re perhaps more likely to move in ways which strain the local tissues more. This should again be communicated prior to, and immediately following spinal injections to increase the likelihood of success and decrease the likelihood of worsening of the condition of the lower back. Even if the quality of the ligamentous tissues is unaffected by the medication, the lack of feedback in the area is, and something which would be wise to address.
Are spinal injections accurate enough to be effective for lower back pain?
If you’re having spinal injections then it goes without saying that this should be done under image guidance which will be very accurate. Accuracy or the likely accuracy of a procedure has a direct effect on the risk to reward ratio and so if you are considering injections for back pain, you better make sure it’s not without imaging.
Fortunately if there is one thing that has humbled us over the years it has been the use of imaging making us appreciate the severe limitations of physical examination in the back care and posture space. When it comes to injections the same is true. Seasoned professionals, surgeons with significant experience, simply are not accurate enough when targeting tissues from the surface. If you’re not using imaging to guide your injections, the question really begs, why not, especially when dealing with the spine, and a procedure that amounts to “temporary pain relief”.
Why spinal injections are not the magic bullet for back pain
Ultimately back pain is a multifactorial issue, and as much as we would like to think otherwise, one tissue is not the cause of back pain. Questions around why that tissue failed, and what is preventing things from healing the way they should? We are all human beings and you’re not the first human to have that “facet joint” or L4,L5 disc herniate. Why is yours not healing properly when so many others are.
A major clue is in the woefully inadequate state of health that so many of us are in. At least when you look at a country as a whole. To risk repeating the analogy for back injuries.
If you have a child constantly skidding the back tyre on their bicycle every time they break, who keeps getting flat tyres, would you expect replacing the tyre to fix the problem? Of course not. It might offer a moment’s relief, but if you do not address factors like constant skidding you’re going to continue to deal with flat tyres.
People very rarely turn to injections right away, it is usually that back pain has been on and off or gradually worsening over months or years. Just like the child, every time the tyre is repaired, the back pain abates, they’re right back at the same old habits and practices that prevent the tyre from staying fixed, or the back from continuing to heal.
This is one of the fundamental reasons for why back pain becomes chronic, something we covered extensively on a recent podcast episode on the matter.
Intelligent use of injections for lower back pain
You’d be forgiven for thinking we are against the use of injections, we are against the uninformed use of injections under false pretences when other avenues have not been worked on and fixed first. And “trying a few exercises” doesn’t count as fixed. Here is a “checklist” of areas you should have addressed completely before you undergo injections:
- Do you eat a proper diet or are you filling your body with junk food?
- Do you get an adequate protein intake of 1.4g per Kilogram of bodyweight?
- Do you sleep well (the pain could be a disrupting factor here).
- Have you modified activities of daily living significantly?
- Is your cardiovascular system in good shape?
- Do you have appropriate muscle strength on movements like squat & hip hinge?
For the last two points above, there are objective measures for these “without pain” which you can find online. For some of you, the sleeping point, and the last two as pertains to physical activity will often be factors that are limited by your pain, for some the pain is so severe that you’re not able to do the tasks that are necessary to build strength to protect the low back, this is where injections make sense.
Over the years you do see a handful of people who are in so much pain they just need some help, an injection or oral pain killers allow the person to reduce the pain levels enough so they are able to do the exercises necessary with enough consistency to get results and improvement. This is an intelligent use of injections for your back pain. Unfortunately, for many who end up having injections, they are given next to no guidance on the rehabilitation and this is really a failure of the medical system to appropriately support the individual with the right tools to maximise the effectiveness of the procedure.
A step by step guide to injections for your lower back pain
We’ll conclude this article with a guide to help you if you are considering injections for your lower back pain, make sure you progress the steps in order without missing any!
Starting point: you’ve been recommended injections
We’ll put a starting point of an injection being scheduled in 6 to 9 weeks time after thorough conversation with your surgeon and discussion of the exact procedure being recommended, as well as risk to reward profile. If you have not had injections suggested, the next steps are still going to be relevant to you as a “strategy” to fix your back pain, so read on!
Fix what you can immediately to fuel healing
This can be done instantly, get your diet sorted out, eat whole foods, remove junk, hydrate well, for example drinking 2 litres of water daily. Get enough protein on a daily basis from food sources ideally, although if you have particular dietary restrictions a simple unflavoured protein supplement can be necessary. Hitting these targets is entirely up to you, but i would put it that if you’re not willing to do this, do you really want to get better? There is no reason whatsoever for you not to eat properly, and if debilitating back pain won’t motivate you to fuel your body, what will? The food you eat is the fuel you use and the resources your body uses to heal and regenerate, garbage in garbage out, so get it right.
Start modifying the way you use your body daily
Again another instant change, you need to reflect on your daily activities, the Back In Shape Podcast is a great source of information to help you understand your back better with many episodes devoted to various activities to help educate you. The membership to the program is an even more thorough way to get support in identifying ways you can do things better. But if you’re spending your days sitting down, you habitually round your lower back when bending along with other bad habits, these need modification or adjustment immediately.
Understand that this is an evolving and ongoing process, but it should start now!
Start a rehabilitative exercise program (part 1)
You might be thinking that your back pain is too bad to do exercises. It is a major source of frustration when people message us saying they cannot do exercises, for example those in Phase 1 or even Phase 2. We know from over 15,000 members that used various parts of the program, as well as over 10,000 patients in our clinic and others over the years, that the overwhelming majority of people, even with really bad back pain or sciatica ARE NOT BED BOUND! The notion that you then cannot lie on the bed and do some of the movements is not going to fly. You’re probably getting dressed every day, you’re getting out of bed, you’re sitting on the toilet, you’re perhaps even leaving the house occasionally, walking the dog, the list goes on. If you’re doing any of these things you CAN AND SHOULD DO THE EXERCISES!
Yes, there is perhaps pain, but at least you get a reward out of the process of doing the exercises, in that with help and feedback from our team, or whichever expert is helping you, you can be guided to do the exercises correctly.
Most people with bad back pain are moving badly, and so it’s no wonder you have pain from doing the exercises, you’re doing them wrong! That’s ok, the only way to do them right and protect your back is to do them, get help, get corrections and then do them better. It takes time and that’s ok!
Start a rehabilitative exercise program (part 2)
Immediately begin working on exercises that promote back stability, learning to move correctly, with simple, safe exercises – NO cat-cow stretch, pelvic tilts and child’s pose stretch are NOT the right exercises.
Instead you’ll be learning the skills to protect your lower back. In the Back In Shape Program we support those with back pain with the right progression of exercises and support to help them do these exercises correctly. Sometimes you need to regress the exercise to find a way to do a variation that does not exacerbate pain. For example, if you get pain in your back when you squat, it is often because your back is moving when you go past a certain depth. A simple modification here would be to reduce the depth of your squat to a pain free one, then you can work on progressing with good form, safely.
Continue your rehabilitative exercise program leading up to your injection
Continue to lay the foundations of good movement with regular practice over the weeks leading up to the injection appointment. This will lead to two outcomes. Firstly, you are going to be moving more effectively and more aware of how you should move in a back friendly way, as well as the other modifications we made in earlier steps. These all improve your prognosis post injection, great news. Secondly, you may find that this is the first time you have stuck to a plan and had support along the way, as a result you actually are already starting to feel improvements. Discuss this with your surgeon and it might well be that the appointment for the injection can be pushed back or even, as has happened many times before with members and patients, you feel you no longer need the back injection!
After your spinal injection what are the next steps
Speak to your consultant, they will give you a timeline to return to your activities and the exercises you were doing prior, be specific about the exercises that you’re doing and they will be able to be specific with their answer.
The quality of the answer is closely related to the quality of the question.
If you just say, “when can I do exercise again” that’s a bad question. Exercise could mean running a marathon, jumping on a trampoline, deadlifting 200kg, lying on the floor doing a core engagement, deep abdominal breathing, you get the idea. Be specific and you’ll have helpful information.
The most important thing you can do is continue to use this time to continue to solidify the good practices that you have put in place. If your injection has taken away some or all of the pain this is your golden opportunity. Healing will be taking place and it is your job to keep committed.
The biggest mistake you can make here is stopping all the good things you’ve been doing, and going back to your old habits because pain “the great motivator” is no longer there. I’ve seen this before in clinical settings and it’s so frustrating and disappointing.
Although pain can be taken away from a procedure like spinal injections, healing takes time and your rehabilitative exercises do just that. Continued progression with resistance in the appropriate time frames will guide you to success as the exercises and forces that are steadily put on your body continue to direct the strengthening process taking place within your back. If you do this right, whether you’ve had the injection in your spine or not, you will get long term success with your lower back pain. If you feel confident enough to do this on your own, great. If you feel like you’d like some support along the way and expert guidance then check out the Premium Membership, we’d love to help guide you on this journey to getting your Back In Shape.