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Epidural Steroid Injection Complications
Epidural steroid injections are among the most common procedures in pain medicine. They are used for radiating arm or leg pain from a herniated disc, spinal stenosis, and related conditions. Most are uneventful. Rarely, a complication changes a patient's life: spinal cord injury, stroke, a spinal hematoma, a serious infection, or a persistent headache after a dural puncture.
Because the procedure is so common and the serious complications are so rare, these cases tend to focus on whether recognized safety steps were followed and whether a problem was recognized and acted on in time. This article explains how a physician expert in pain medicine reviews those questions.
The main complications
- Spinal cord injury and stroke. These catastrophic injuries are rare. They have been linked to injection into an artery that supplies the spinal cord or brain, particularly with transforaminal injections.
- Epidural hematoma. Bleeding into the spinal canal can press on the cord or nerve roots. Blood-thinning medications are a key consideration.
- Infection. Epidural abscess and meningitis are rare but serious.
- Dural puncture. The needle can enter the spinal fluid space, causing headache or, if medication is injected there, unexpected effects.
- Steroid-related effects. Elevated blood sugar and other systemic effects can follow, especially in patients with diabetes.
The consensus safeguards
In 2015, a multidisciplinary working group convened with the U.S. Food and Drug Administration's Safe Use Initiative and 13 specialty societies published Safeguards to prevent neurologic complications after epidural steroid injections (Rathmell and colleagues, Anesthesiology, 2015). The group produced 17 clinical considerations aimed at improving safety. They address transforaminal and interlaminar injections specifically, including the use of nonparticulate steroid, anatomic considerations, and the use of radiographic guidance. The authors concluded that adherence to the recommended practices should reduce neurologic injuries.
Approach also matters for transforaminal injections. Dr. Urits co-authored The Infraneural Approach to Lumbar Transforaminal Epidural Steroid Injections (Hasoon and colleagues, Orthopedic Reviews, 2026). The review explains that the region traditionally targeted, called the "safe triangle," may contain arteries supplying the spinal cord, and that inadvertent injection into an artery has been implicated in spinal cord infarction and paralysis. It describes the infraneural approach as an alternative that may reduce needle placement in that region. It also stresses that careful review of imaging beforehand, fluoroscopic guidance, contrast injection, and preferential use of nonparticulate steroid remain essential whatever approach is used.
Blood thinners and bleeding risk
Guidelines specific to interventional pain procedures address when blood thinners should be held. The second edition of the multisociety guidelines led by the American Society of Regional Anesthesia and Pain Medicine (Narouze and colleagues, 2018) stratifies spine and pain procedures by bleeding risk into low, intermediate, and high categories. The American Society of Interventional Pain Physicians published updated guidelines in 2024 (Manchikanti and colleagues, Pain Physician) that weigh bleeding risk against the risk of clotting when these medications are stopped. That balance matters. Stopping a blood thinner can expose a patient with heart or vascular disease to serious harm. A review should identify which guidance was in effect on the date of care, and whether the prescribing physician was consulted when appropriate.
Standard-of-care questions an expert asks
- Indication. Was the injection reasonable for the diagnosis, imaging findings, and prior response to treatment?
- Consent. Were serious risks and alternatives discussed?
- Medications. Was a medication history taken, including blood thinners, with timing documented?
- Approach and level. Was the approach (transforaminal, interlaminar, or caudal) and the level reasonable given the anatomy and prior imaging?
- Image guidance and contrast. Was fluoroscopy used, was contrast injected to confirm spread, and were images saved? This is covered in Week 10 of this series.
- Steroid choice. Was the steroid particulate or nonparticulate, and was that choice reasonable for the approach?
- Sterile technique. Is skin preparation and sterile technique documented?
- Recovery and discharge. Was the patient observed and given instructions on warning signs?
Recognition and response
When a patient develops new weakness, numbness, severe back pain, fever, or bowel or bladder changes after an injection, timing becomes central. Was the patient told what to watch for? When the patient called or returned, was the concern triaged, imaged, and referred promptly? As with spinal hematoma after neuraxial anesthesia (see spinal epidural hematoma), the time from first symptom to imaging and treatment is often the most important part of the timeline.
Dr. Urits has written on two related complications. He is the author of a case report on the diagnosis and spontaneous resolution of an epidural hematoma after a cervical epidural steroid injection (Pain Management Case Reports, 2018). He was also first author of a report on managing dural puncture headache caused by a caudal epidural steroid injection (Journal of Clinical Anesthesia, 2019).
What malpractice claims show
Dr. Urits co-authored a pilot analysis of 82 federal and state interventional pain malpractice cases (Kamath and colleagues, Pain Physician, 2020). The study reported that procedural error was the leading reason claims were brought, followed by lack of informed consent and an unnecessary procedure. The authors noted limits of the data, including incomplete procedural detail.
Records that usually matter
- The procedure note, including approach, level, needle, injectate, and steroid used
- Saved fluoroscopic images, including contrast spread
- Pre-procedure imaging and clinic notes documenting the indication
- Medication lists, anticoagulant instructions, and any communication with the prescribing physician
- Consent forms and discharge instructions
- Phone logs, emergency department records, MRI, and surgical records after the procedure
Key takeaways
- Serious complications of epidural steroid injections are rare, but some are catastrophic.
- The 2015 consensus safeguards and later reviews emphasize image guidance, contrast, nonparticulate steroid for certain approaches, and anatomic care.
- Anticoagulant decisions balance bleeding risk against clotting risk under procedure-specific guidelines.
- Recognition and response after the injection are often as important as the injection itself.
References
- Rathmell JP, Benzon HT, Dreyfuss P, et al. Safeguards to prevent neurologic complications after epidural steroid injections: consensus opinions from a multidisciplinary working group and national organizations. Anesthesiology. 2015;122(5):974-984. Abstract: https://pubmed.ncbi.nlm.nih.gov/25668411/
- Hasoon J, Robinson CL, Yazdi C, Urits I, Kaye AD. The Infraneural Approach to Lumbar Transforaminal Epidural Steroid Injections: A Practical Review for Trainees and Interventionalists. Orthop Rev (Pavia). 2026;18:166794. Abstract: https://pubmed.ncbi.nlm.nih.gov/42631325/
- Narouze S, Benzon HT, Provenzano D, et al. Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition): Guidelines From the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med. 2018;43(3):225-262. Abstract: https://pubmed.ncbi.nlm.nih.gov/29278603/
- Manchikanti L, Sanapati MR, Nampiaparampil D, et al. Perioperative Management of Antiplatelet and Anticoagulant Therapy in Patients Undergoing Interventional Techniques: 2024 Updated Guidelines from the American Society of Interventional Pain Physicians (ASIPP). Pain Physician. 2024;27(S6):S1-S94. Abstract: https://pubmed.ncbi.nlm.nih.gov/39133736/
- Urits I. Diagnosis and spontaneous resolution of an epidural hematoma in a patient presenting after cervical epidural steroid injection. Pain Management Case Reports. 2018. doi:10.36076/pmcr.2018/2/213. DOI: https://doi.org/10.36076/pmcr.2018/2/213 (not indexed in PubMed)
- Urits I, Viswanath O, Petro J, Aner M. Management of dural puncture headache caused by caudal epidural steroid injection. J Clin Anesth. 2019;52:67-68. Abstract: https://pubmed.ncbi.nlm.nih.gov/30216928/
- Kamath D, McIntyre S, Byerly S, et al. Descriptive Analysis of Federal and State Interventional Pain Malpractice Litigation in the United States: A Pilot Investigation. Pain Physician. 2020;23(4):413-422. Abstract: https://pubmed.ncbi.nlm.nih.gov/32709176/
Related: Interventional Procedure Complication Cases
Educational information only. Not legal or medical advice.
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