Spinal injections.
Which ones work, which do not.
Injections & surgery
NICE NG59 · Dutch LRS guideline
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
Score per procedure
Epidural injection for acute, severe radiating pain
Small, short-lived effect. Worth considering when pain medication falls short.
Epidural injection for back pain without radiation
NICE advises against this.
Facet injection and facet denervation
No longer covered by Dutch basic insurance since 2016.
SI joint injection and denervation
Very limited evidence, preferably within a study.
Trigger point, prolotherapy, PRP and stem cell injections
Explicitly not recommended.
An injection into the back is not one treatment but a whole family of them, and the differences between them are large. One question decides almost everything: do you have pain radiating into your leg, or pain that stays in your back?
The distinction that decides everything
NICE puts two recommendations side by side that look contradictory but are not. Recommendation 1.3.1 reads: “do not offer spinal injections for managing low back pain”. Recommendation 1.3.5 reads: “consider epidural injections of local anaesthetic and steroid in people with acute and severe sciatica”.
So: injections for back pain that stays in your back are not recommended. An epidural injection for severe pain radiating into your leg from a pinched nerve root can be considered. Most of the confusion around back injections comes from mixing up these two situations.
Epidural corticosteroid injection for radiating pain
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
A corticosteroid is injected around the pinched nerve root to reduce inflammation and pain. The Dutch guideline for lumbosacral radicular syndrome (2020) recommends: consider a fluoroscopically guided glucocorticoid injection in people with acute LRS and severe pain despite adequate pain medication. The transforaminal route is generally preferred.
Be realistic about the size of the effect. A Cochrane review (2020) of 25 placebo-controlled trials with 2,740 participants found the injections do work better than placebo, but the effect is small and short-lived: about 5 points less leg pain on a scale of 0 to 100 in the short term. After three months the difference has largely disappeared. Chou et al. (Ann Intern Med 2015) reached the same conclusion.
The injection is not without risk. A puncture of the dura happens in 2 to 5% of injections and causes headache; temporary increases in back or leg pain occur regularly. Serious complications such as bleeding or infection are rare (Dutch LRS guideline). NICE explicitly advises against epidural injections for neurogenic claudication caused by central spinal canal stenosis.
A nuance for herniated discs
A Dutch cohort study (van Helvoirt et al., Pain Medicine 2014) suggests more may be possible with the right approach: of 69 surgical candidates who received transforaminal epidural injections followed by MDT (McKenzie) exercise therapy, only about 22% still needed surgery after one year. This requires careful patient selection, the right timing and the combination with exercise therapy. Because this was a cohort study without a control group, it cannot prove that the injections themselves made the difference.
Facet and SI joint injections and denervation
Not covered in NLHow do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
These treatments target the small facet joints between the vertebrae or the sacroiliac joint, either with a corticosteroid injection or by burning the nerve that supplies the joint (radiofrequency denervation). The decisive study is Dutch: the MINT trials (Juch et al., JAMA 2017) randomised 681 patients across three trials and found that adding radiofrequency denervation to a standardised exercise programme produced no clinically relevant improvement in pain.
NICE still leaves a narrow door open: radiofrequency denervation may be considered when non-surgical treatment has failed, the pain is moderate to severe and localised, and only after a positive response to a diagnostic medial branch block (recommendations 1.3.2 and 1.3.3). The Dutch guideline on spine-related low back pain says SI joint injections may be considered after conservative treatment has failed, preferably within a study, and calls the underlying evidence very limited.
Reimbursement in the Netherlands: an important practical difference
Since 1 January 2016 facet injections, facet denervations, SI joint injections, SI denervations and treatments for discogenic pain are no longer part of the Dutch basic health insurance. The National Health Care Institute concluded that these treatments do not meet the criterion “state of science and practice”, largely on the basis of the MINT trials.
An epidural injection for radiating pain from a herniated disc or narrowing is a different matter: that one is still covered. If a clinic offers you a facet or SI treatment, ask beforehand what it costs and who pays. What you pay yourself does not count towards your deductible either.
More about what insurance coversInjections that are not recommended
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
NICE names a group of injections that should not be offered for low back pain: intra-articular facet joint injections, intradiscal therapy, platelet rich plasma (PRP), stem cell injections, prolotherapy and trigger point injections with any agent. For most of these the evidence is not merely thin; the better-designed trials simply show no benefit over a placebo injection.
Where an injection fits in
Week 0–6
Conservative first
Keep moving, pain medication, exercise therapy. Most radiating pain settles by itself.
Week 6–8
Evaluation
Still severe radiating pain? Time to discuss the next step with your doctor.
If pain persists
Injection as an option
An epidural injection can bridge a severe period, not cure the herniation.
After 10–12 weeks
Talking about surgery
Insufficient improvement? Then surgery comes into the conversation.
Key message
An injection never fixes the underlying problem; at best it buys you time. For severe radiating pain from a pinched nerve root an epidural injection is a reasonable option, with a small and temporary effect. For back pain without radiation, injections into facet or SI joints are not recommended and are not covered by Dutch basic insurance. Exercise therapy remains the foundation in both cases.
Sources
- NICE Guideline NG59, Low back pain and sciatica in over 16s (2020)
- Richtlijn Lumbosacraal Radiculair Syndroom, module epidurale steroïdinjecties (2020)
- Oliveira CB, et al. Epidural corticosteroid injections for lumbosacral radicular pain. Cochrane Database Syst Rev (2020)
- Chou R, et al. Epidural corticosteroid injections for radiculopathy and spinal stenosis. Ann Intern Med (2015)
- Juch JNS, et al. Effect of radiofrequency denervation on pain intensity among patients with chronic low back pain: the MINT randomized clinical trials. JAMA (2017)
- van Helvoirt H, et al. Transforaminal epidural steroid injections followed by mechanical diagnosis and therapy to prevent surgery for lumbar disc herniation. Pain Medicine (2014)
- Richtlijn Wervelkolomgerelateerde pijnklachten van de lage rug, invasieve interventies SI-gewricht (2014)
- Zorginstituut Nederland. Radiofrequente denervatie bij aspecifieke chronische lage rugpijn uit basispakket (2015)
Next step