APP Guidance

The downside of repeat epidural steroid injection treatments for lumbar spinal stenosis

Publish date: March 2, 2026

Many providers are moving beyond epidural steroid injections (ESIs) for patients with chronic low back pain associated with lumbar spinal stenosis (LSS).¹

Instead of simply masking the pain caused by an enlarged ligament with epidural injections, which may only provide temporary pain relief,² providers may opt for more effective and durable lumbar spinal stenosis treatment options such as the mild^® procedure.³

Managing LSS with ESIs
An epidural steroid injection, which is a medication that is injected into the epidural space in the lower spine to reduce swelling and offer pain relief, may be offered to patients with chronic low back pain from conditions such as lumbar spinal stenosis.⁴ Recent data indicates that repeat epidural injections for patients who experience only short-term improvement may not be in the patient’s best interest in the long term.⁵ Alternative treatments, such as minimally invasive lumbar decompression, or the mild^® procedure, may be a better option for some patients.⁵

What is LSS?
Lumbar spinal stenosis, also called LSS, contributes to chronic low back pain and is prevalent in approximately 20 percent of patients over the age of 60.⁷ LSS is often caused by an enlarged ligament in the back, which compresses the space around the spinal canal and puts pressure on the nerves in the lower back. This pressure around the spinal cord can cause pain, numbness, heaviness, or tingling in the low back, legs, and buttocks. A common visual cue is often referred to as the “shopping cart syndrome,” where the act of leaning over, often over a shopping cart, cane, or walker, helps to temporarily alleviate pressure felt in the lower back pain.⁸

In addition to epidural steroid injections, some common conservative treatment options for LSS can include the mild^® procedure, medication, and/or physical therapy, with more invasive options including procedures such as spacer implants, spinal stenosis surgery, or other open surgery.⁹

How exactly does an ESI work?
Epidural steroid injections are typically offered to LSS patients when more conservative treatment options, such as exercise and physical therapy, have failed to provide relief.

Steroid medication is injected directly into the epidural space, which may relieve pain by reducing inflammation around the spinal cord and nerves. The effects typically last for less than 6 months, after which additional injections may need to be administered.¹⁰

How effective are ESIs for LSS?
Data shows that epidural steroid injections can effectively relieve pain for LSS patients—but the effects are not lasting, and pain may return, typically in months.¹¹ ESIs may treat the symptoms but do not address a major root cause of pain associated with LSS – ligamentum flavum hypertrophy (LFH).¹²

ESIs—The downsides, side effects and risks
While ESIs can be an effective form of early treatment for some patients, they may not provide reliable, lasting relief for all low back pain.¹⁰ As mentioned in the Best Practices for Minimally Invasive Lumbar Spinal Stenosis Treatment 2.0 (MIST),¹³ certain payer guidelines, including Centers for Medicare and Medicaid Services (CMS), now stipulate that patients should have obtained a minimum of 3 months of pain relief with eventual recurrence of pain before it is reasonable to proceed with additional injection therapy.¹³

This means that for patients exhibiting shorter-term relief of less than 3 months after receiving an ESI, clinicians should consider alternative treatment options.

ESI treatment may require repeat injections over time
Steroid medication reduces inflammation, which can temporarily relieve pain. However, epidural steroid injections only treat the symptoms of LSS—not the root cause canal narrowing in many patients – LFH.¹² The effects of epidural steroid injections typically last less than 6 months, and patients often require an average of 2–3 injections per year to sustain long-term relief from low back pain associated with LSS.¹⁰

Repeat ESIs can have negative impacts on patient health
There are certain patients for whom repeat epidural steroid injections may offer more risks than benefits. For instance, steroid medications have been linked to bone loss, or osteoporosis.¹⁴ ESIs may also introduce risks for patients with certain comorbidities such as diabetes.¹³

As an alternative, epidural injections without the use of steroids may be considered, as well as more advanced decompressive therapies such as the mild^® procedure.

ESI exhaustion – Spotting the 3 common signs*
*The below section on ESI Exhaustion is an opinion piece by author, Anjum Bux, MD. At the time of publishing, Dr. Anjum Bux was a paid Consultant for Vertos Medical, now a part of Stryker.

“In addition to the health concerns associated with repeat steroid injections, the mental and emotional effects experienced by many LSS patients can also reveal the dark side of repeat epidural steroid injection treatments.”

“Due to the temporary nature of epidural steroid injection relief and the requirement for repeat injections, many practices encounter patients with what is increasingly becoming a phenomenon I call “ESI Exhaustion.” ESI Exhaustion can be spotted in patients at any stage of LSS treatment or stenosis severity.”

ESI exhaustion sign #1: Feelings of hopelessness
“When patients experience short-term relief from a condition as challenging as LSS, they can easily become frustrated and lose hope. LSS patients often experience debilitating pain and loss of mobility that can have a devastating impact on their outlook and optimism for the future. Losing additional time and energy to repeated appointments, procedures, and recovery times can also be detrimental to their quality of life, and some patients may start to feel hopeless if injections remain ineffective or lose their efficacy soon after receiving them.”

ESI exhaustion sign #2: Decreased durability of relief
“One of the more common questions patients have about a steroid injection is, “How long will the results last?” Unfortunately, with epidural steroid injections, efficacy can vary by patient, and it can be difficult to predict the degree of relief or durability of effect for the individual. While studies have shown symptom relief for up to 6 months10 in some lumbar spinal stenosis patients, other studies have demonstrated the limited effectiveness of epidural steroid injections.”

ESI exhaustion sign #3: Solution shopping
“If patients are dissatisfied with their results and feel they have run out of options in your practice, they may search for another solution. By offering alternative treatments such as the mild^® procedure as an early intervention, you can help retain the patients in your practice and increase productivity, while continuing to develop closer relationships and increase your reach within your community.”

– Dr. Anjum Bux, MD, Bux Pain Management (At the time of publishing, Dr. Anjum Bux was a paid Consultant for Vertos Medical, now a part of Stryker)

Avoiding repeat ESIs
Given the significant advances in minimally invasive spine technology, current research confirms that repeat epidural steroid injections should be reserved only for patients who experience significant and lasting relief after the injections, and/or those who are not candidates for higher-level interventions or surgical decompression.¹³

For patients experiencing relief that lasts fewer than 3 months, clinicians may wish to consider more durable treatment options.

Move past injections and make the move to mild^®
Epidural steroid injections may provide short-term symptom relief in patients with lumbar spinal stenosis; however, they have not been shown to alter the underlying disease process or provide a long-term solution.⁵ Without addressing the enlarged ligament, which contributes up to 85% of spinal canal narrowing,¹² relief may only be experienced on a short-term or temporary basis.

Minimally invasive lumbar decompression may be the next step for long-lasting* relief from LSS and to reduce pressure in the canal.⁶ By decreasing the amount of space taken up by the enlarged ligament, patients can experience decreased pressure on the spinal nerves, which may lead to decreased pain.

Performing multiple epidural steroid injections only delays patients from receiving treatment with more lasting results, such as minimally invasive lumbar decompression—the mild^® procedure.⁵

Turning to mild^® as the first line of therapy addresses a major root cause of LSS by removing excess ligament tissue around the spine, proven to provide a 5-year durability of results.⁶

Move to mild^® after the first ESI fails
The mild^® procedure is an outpatient procedure that can be performed using only local anasthetic and sedation. The procedure is performed through a single incision in the low back, approximately the diameter of a pencil top eraser (5.1mm).¹⁷

By removing excess ligament tissue that has built up around the spine, mild^® restores space in the spinal canal. This reduces pressure on the nerves in the low back, addressing a major root cause of LSS, which can help reduce pain.¹⁸

• The mild^® procedure does not leave an implant behind, and patients typically discharged within 24 hours¹⁹
• mild^® does not require stitches, staples, or complex bandaging 
  • Typically, patients leave the outpatient procedure facility with just a covering over their incision and visit their doctor a few days post-procedure for a quick wound check to ensure healing is progressing normally 
• The safety profile of mild^® is similar to epidural steroid injections,² but with lasting results^6* 
• mild^® has been shown to provide lasting relief, with 88% of patients avoiding open back surgery for at least 5 years⁶ 

*Up to 5 years

The mild^® difference
When epidural steroid injections (ESIs) don’t provide lasting relief, mild^® can improve patient outcomes across a variety of measures.

Walking/standing
In a study performed at the Cleveland Clinic 1 year after the mild^® procedure, patients were able to:

• Increase their standing time from 8 minutes to 56 minutes with less pain.¹⁶ 
• Increase their average walking distance from 246 feet (comparable to walking to the mailbox) to 3,956 feet (comparable to walking around the mall).¹⁶

Possible risks of the mild^® procedure
As with most surgical procedures, serious adverse events can occur. This procedure is not for everyone. Physicians should discuss potential risks with patients. Potential adverse events include, but are not limited to, damage to surrounding structures (e.g. nerve roots, dural sac, blood vessels), bleeding, cerebrospinal fluid leaks and infection.

Please refer to the IFU for a full list of indications, contraindication, warnings and precautions.

Pain relief & mobility
mild^® demonstrated excellent long-term durability with significant improvements in both pain and mobility over 2 years. Clinical data from the MiDAS ENCORE 2-Year Study finds mild^® provided patients with lasting pain relief and increased mobility.³

Long-term durability
A 5-year study performed at the Cleveland Clinic demonstrated that mild^® helped 88% of patients avoid back surgery for at least 5 years while providing lasting relief.⁶
*Up to 5 years

About Dr. Anjum Bux
Anjum Bux, MD, is a board-certified Anesthesiologist who specializes in Pain Management. Dr. Bux completed his medical training at the University of Kentucky and has been practicing Interventional Pain Management for over 15 years. He is an active member of numerous national pain societies, including the North American Neuromodulation Society (NANS), American Society of Pain and Neuroscience (ASPN), and American Society of Interventional Pain Physicians (ASIPP). Dr. Bux acts as the director at large for the Kentucky Society of Interventional Pain Physicians (KYSIPP). At the time of publishing, Dr. Anjum Bux was a paid Consultant for Vertos Medical, now a part of Stryker.

The opinions of Dr. Anjum Bux stated throughout are those of the Dr. Anjum Bux and may not necessarily be those of Stryker.

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