What This Means
Spinal stenosis is narrowing of the spinal canal that compresses nerves, causing leg pain with walking (neurogenic claudication). Treatment options range from conservative care (physical therapy, medications) to injections to surgery.
Epidural steroid injections deliver anti-inflammatory medication directly to the compressed nerves, reducing swelling and pain. They don't fix the structural narrowing—they just reduce inflammation. Surgery removes the bone and ligament causing compression, creating more space for nerves permanently.
Neither approach is universally better. The right choice depends on symptom severity, how much stenosis exists, whether you have instability, and your functional goals.
When Injections Are Appropriate
Good Candidates for Epidural Injections:
- Mild-to-moderate stenosis: Narrowing present but not severe; symptoms manageable with activity modification
- Recent symptom onset: Symptoms present for weeks to months, not years
- Inflammatory component: Swelling around nerves contributing to symptoms
- Not a surgical candidate: Medical comorbidities make surgery high-risk
- Wants to avoid surgery: Willing to accept temporary relief and possible repeat injections
- Diagnostic purposes: Confirming stenosis is the pain source before considering surgery
Expected Outcome: 50-70% of patients experience temporary improvement lasting weeks to months. Repeat injections may be needed. Injections don't fix the structural problem—they manage symptoms.
When Surgery Is Appropriate
Good Candidates for Surgical Decompression:
- Moderate-to-severe stenosis: Significant narrowing on MRI with clear nerve compression
- Failed conservative treatment: Physical therapy, medications, and injections haven't provided adequate relief
- Significant functional impairment: Can't walk more than 1-2 blocks; quality of life severely affected
- Progressive neurological symptoms: Worsening weakness, numbness, or balance problems
- Wants definitive treatment: Prefers permanent solution over repeated injections
- Good surgical candidate: Healthy enough for surgery with acceptable risk profile
Expected Outcome: 70-85% of patients experience significant improvement in leg pain and walking ability. Results are typically permanent unless stenosis develops at other levels over time.
When Injections Are NOT Appropriate
- Severe stenosis with myelopathy (spinal cord compression)—surgery is needed
- Progressive motor weakness—injections won't reverse nerve damage
- Multiple failed injection series—unlikely to help with additional attempts
- Instability (spondylolisthesis)—fusion may be needed, not just decompression
- Severe functional impairment—quality of life too compromised to wait for injection trial
What Typically Comes Next
Step 1: Conservative Treatment (4-6 weeks)
Physical therapy focusing on flexion-based exercises, NSAIDs, activity modification (use shopping cart, lean forward when walking). Many patients improve with conservative care alone.
Step 2: Epidural Steroid Injections (If Needed)
If conservative treatment fails, epidural injections are tried. Typically 1-3 injections over 3-6 months. If significant improvement, continue conservative care. If minimal improvement after 2-3 injections, surgery is discussed.
Step 3: Surgical Evaluation (If Injections Fail)
Imaging review to assess stenosis severity and stability. Discussion of surgical options: decompression alone (laminectomy) if stable, or decompression with fusion if instability exists.
Step 4: Shared Decision-Making
Understanding risks, benefits, and realistic expectations for surgery. The decision is yours based on symptom severity, functional goals, and risk tolerance.
Questions Patients Should Ask
How severe is my stenosis on imaging?
What are realistic expectations for injection relief?
How many injections should I try before considering surgery?
Do I have instability that would require fusion?
What are the risks of delaying surgery if my symptoms worsen?
What is the success rate for surgery in my specific case?
Can surgery be done minimally invasively?
References
- 1. Friedly JL, et al. A Randomized Trial of Epidural Glucocorticoid Injections for Spinal Stenosis. N Engl J Med. 2014;371(1):11-21.
- 2. Weinstein JN, et al. Surgical versus Nonoperative Treatment for Lumbar Spinal Stenosis Four-Year Results of the Spine Patient Outcomes Research Trial. Spine. 2010;35(14):1329-1338.
- 3. Atlas SJ, et al. Long-term Outcomes of Surgical and Nonsurgical Management of Lumbar Spinal Stenosis: 8 to 10 Year Results from the Maine Lumbar Spine Study. Spine. 2005;30(8):936-943.
- 4. North American Spine Society (NASS). Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis and Treatment of Lumbar Disc Herniation with Radiculopathy. 2012.
- 5. Ammendolia C, et al. Nonoperative Treatment for Lumbar Spinal Stenosis with Neurogenic Claudication. Cochrane Database Syst Rev. 2013;(8):CD010712.
Authored by Dr. Marc Greenberg, MD — Greenberg Spine
Fellowship-trained orthopedic spine surgeon
Last updated: December 2024