Epidural steroid injections (ESIs) are among the most commonly performed procedures in spine medicine. Millions are performed each year in the United States for neck and back pain, radiculopathy, and sciatica. They are often the recommended next step after a course of physical therapy and oral medications hasn’t provided adequate relief. And yet they are also among the most misunderstood interventions in spine care — both overused in situations where they are unlikely to help and underused in situations where they can provide genuine relief.

What an epidural steroid injection is

An epidural steroid injection delivers a corticosteroid (an anti-inflammatory medication) and often a local anesthetic directly into the epidural space — the space surrounding the spinal cord and nerve roots within the spinal canal. The injection is performed under fluoroscopic (X-ray) or CT guidance to ensure accurate needle placement. There are several types: interlaminar epidural (covering a broader region), transforaminal epidural or selective nerve root block (the most targeted approach, injecting at the specific foramen where a nerve exits), and caudal epidural (through the sacral hiatus).

What they can do

Epidural steroid injections are most effective for radicular pain — pain that travels from the spine into the arm or leg along the path of a compressed or inflamed nerve root. The corticosteroid reduces inflammation around the compressed nerve, which can significantly reduce the intensity of the radiating pain.

In the right patient and the right situation, an epidural steroid injection can provide meaningful relief of acute radicular arm or leg pain; reduce inflammation around a compressed nerve sufficiently to allow participation in physical therapy; provide a temporary reprieve from pain while waiting for a disc herniation to naturally resorb (which many do); help confirm the diagnosis by demonstrating that relief follows a pattern consistent with the suspected level; and delay or defer the need for surgery in some patients.

What they cannot do

Cannot fix a structural problem. A herniated disc, a bone spur, or foraminal stenosis physically compressing a nerve is not changed by a steroid injection. The injection reduces the inflammatory response around the compressed nerve — it does not move, dissolve, or remove the source of compression. If the structural problem is severe or progressing, the relief from an injection will be temporary.

Cannot reliably help axial back or neck pain without a radicular component. The evidence for epidural steroid injections in patients with predominantly back or neck pain — without significant leg or arm pain from nerve root compression — is considerably weaker than for radicular pain.

Cannot treat progressive neurological deficit. If a patient has worsening weakness, expanding numbness, or bladder/bowel dysfunction, an injection is not the appropriate next step. Progressive neurological deficit requires evaluation for surgical decompression without delay.

Cannot provide permanent relief in most patients. The duration of relief is variable — days to weeks in some patients, months in others. For most patients with ongoing structural compression, relief is temporary. There are generally accepted limits to the number of injections appropriate in a given time period.

Cannot substitute for surgery when surgery is indicated. Epidural steroid injections are not a treatment for cervical myelopathy, cauda equina syndrome, or progressive neurological deficit. In patients for whom surgery is clearly indicated, repeated injections that temporarily mask symptoms without addressing the underlying problem can lead to delayed treatment and potentially worse outcomes.

When they are most useful

Epidural steroid injections are most appropriately used as part of a multimodal non-surgical treatment strategy, not as a standalone or indefinitely repeated treatment. The most appropriate uses include: acute cervical or lumbar radiculopathy with severe pain — as a bridge to physical therapy and time while waiting for natural resolution; subacute radiculopathy that has not fully resolved with physical therapy and medications; diagnostic confirmation of a suspected symptomatic level before surgical decision-making; and selected patients with chronic radicular pain who are not surgical candidates, for periodic symptom management.

A word on expectations

The most important question is not “injection or surgery” — it is “what is the underlying problem, and what does the evidence show is the best treatment for it in a patient with your specific anatomy and symptom profile?” That question determines everything else. Dr. Sardar evaluates every patient with spine pain individually and discusses the full range of treatment options — including the role of injections, physical therapy, and surgery — based on what is genuinely most appropriate for each patient’s situation.

This post is for educational purposes only and does not constitute individualized medical advice. Please consult a qualified spine specialist to discuss your specific condition.

Spinal stenosis is one of the most common reasons adults over 60 seek care from a spine specialist. It is also one of the most undertreated conditions in spine medicine — patients often live with significant functional limitation for years, assuming their symptoms are simply part of aging, before being evaluated by a surgeon. Understanding what stenosis is, why it causes the symptoms it does, and what treatment options exist can help patients make better-informed decisions about their care.

What Is Spinal Stenosis?

Spinal stenosis is a narrowing of the spinal canal or the openings through which nerve roots exit the spine (neural foramina). When the canal narrows sufficiently, it compresses the spinal cord or nerve roots, causing the characteristic symptoms of the condition. Stenosis is almost always caused by degenerative changes — the cumulative effect of disc degeneration, facet joint arthritis, and thickening of the ligamentum flavum (a ligament that lines the back of the spinal canal) over decades.

Stenosis can occur anywhere in the spine but is most common and clinically significant in two locations:

• Lumbar stenosis — narrowing in the lower back; compresses the nerve roots of the cauda equina (the bundle of nerve roots below the spinal cord); produces the classic syndrome of neurogenic claudication
• Cervical stenosis — narrowing in the neck; can compress the spinal cord itself (producing myelopathy) or the cervical nerve roots (producing radiculopathy), or both

Symptoms: Lumbar vs. Cervical Stenosis

The symptoms of stenosis differ depending on where it occurs.

Lumbar Stenosis

The hallmark symptom of lumbar stenosis is neurogenic claudication — leg pain, heaviness, cramping, or weakness that comes on with walking or standing and is relieved by sitting, lying down, or leaning forward (such as on a shopping cart). This positional pattern is the key distinguishing feature of neurogenic claudication from vascular claudication (caused by arterial disease), which does not improve with bending forward.

Patients with lumbar stenosis often describe a progressive decline in walking tolerance — being able to walk only half a block before needing to stop and sit, when a year ago they could walk a mile. Back pain is common but is often less prominent than the leg symptoms. Bladder symptoms — urgency or frequency — can occur in severe cases.

Cervical Stenosis

Cervical stenosis causing nerve root compression (radiculopathy) produces arm pain, numbness, or weakness in a specific distribution. Cervical stenosis causing spinal cord compression (myelopathy) produces a broader pattern of dysfunction: hand clumsiness, gait unsteadiness, leg spasticity, and in severe cases bladder dysfunction. Cervical myelopathy is frequently misdiagnosed as carpal tunnel syndrome, peripheral neuropathy, or the normal effects of aging. It requires prompt surgical evaluation once identified.

Diagnosis

The diagnosis of spinal stenosis is made by combining the clinical history and examination findings with imaging. MRI is the primary diagnostic study — it shows the degree of canal and foraminal narrowing and identifies which nerve roots are compressed. CT myelography is used in patients who cannot undergo MRI or when greater bony detail is needed. Standing X-rays assess alignment and stability. Electrodiagnostic studies (EMG/nerve conduction) are occasionally used to differentiate stenosis from peripheral nerve conditions.

Importantly, stenosis on MRI is extremely common in older adults — many people have significant stenosis on imaging but no symptoms. Imaging findings alone do not indicate a need for treatment. The decision to treat — and how — is based on the patient’s symptoms and functional limitations, not the MRI report.

Non-Surgical Treatment

For most patients with lumbar stenosis and mild to moderate symptoms, non-surgical treatment is the appropriate first step:

• Physical therapy — flexion-based exercises and core strengthening can reduce symptoms and improve walking tolerance in many patients; lumbar extension tends to worsen stenosis symptoms and is avoided
• Epidural steroid injections — can provide meaningful but typically temporary relief of leg symptoms; most useful as a bridge or when surgery carries elevated risk
• Activity modification — using a walking aid (cane or walker) allows forward lean and reduces leg symptoms during activity; cycling is often better tolerated than walking
• Weight management — reducing load on the lumbar spine can improve symptoms

Non-surgical treatment does not decompress the nerve roots. It can help manage symptoms, but it does not change the underlying anatomy. For patients with cervical stenosis causing myelopathy, conservative treatment is generally not recommended as the primary approach — the spinal cord compression requires surgical decompression.

When Is Surgery Indicated?

Surgery for spinal stenosis is recommended when:

• Conservative treatment has failed to provide adequate relief after a reasonable trial (typically 3 to 6 months for lumbar stenosis without neurological deficit)
• Functional limitation is significant — inability to walk more than a short distance, difficulty with basic activities of daily living, or progressive decline in walking tolerance
• Progressive neurological deficit — worsening leg weakness, foot drop, or bladder or bowel dysfunction are indications for expedited surgery
• Cervical myelopathy — once moderate myelopathy is diagnosed, surgery is generally recommended without prolonged delay; the natural history of myelopathy is progressive deterioration, and irreversible cord injury can occur with continued compression or minor trauma

Surgical Options

The surgical approach for stenosis depends on the location, the number of levels involved, the presence of instability or deformity, and the patient’s overall anatomy.

For lumbar stenosis:

• Laminectomy — removal of the lamina and thickened ligamentum flavum to decompress the nerve roots; the most common surgery for lumbar stenosis; may be performed minimally invasively in selected patients
• Laminectomy with fusion — when instability or spondylolisthesis is present alongside stenosis, decompression alone may worsen instability; fusion is added to stabilize the segment
• Minimally invasive decompression — for carefully selected patients with focal stenosis without instability, minimally invasive techniques offer equivalent decompression with faster recovery

For cervical stenosis:

• ACDF or cervical disc replacement — for anterior compression at one to three levels
• Laminoplasty — a posterior procedure that expands the canal by hinging the laminae open; well-suited for multilevel cervical stenosis with preserved lordosis
• Laminectomy with posterior cervical fusion — for multilevel stenosis with kyphosis or instability

What to Expect from Surgery

Surgery for spinal stenosis, in appropriately selected patients, is highly effective. The SPORT trial showed that patients treated surgically for lumbar spinal stenosis had substantially greater improvement in pain, function, and walking ability than those treated non-operatively, with the clearest advantage through the first four years of follow-up. Longer-term results at eight years were more mixed: the benefit remained durable in the observational group, while the gap between the surgical and non-surgical groups narrowed over time in the randomized comparison — in part because many patients initially assigned to non-operative care ultimately chose surgery. Leg symptoms typically improve more reliably than back pain, and neurological recovery depends on the severity and duration of compression before surgery.

The best outcomes occur when surgery is performed before irreversible nerve injury has occurred — which is why timely evaluation matters, particularly for patients with progressive neurological symptoms.

About Dr. Zeeshan Sardar
Dr. Sardar is Co-Chief of Spinal Deformity Surgery at NewYork-Presbyterian / Columbia University and treats the full spectrum of spinal stenosis — cervical and lumbar — from minimally invasive decompression to complex multilevel reconstruction. To schedule a consultation, call 212-932-5187 or visit the contact page.

This article is for educational purposes only and does not constitute individualized medical advice. Please consult a qualified spine specialist to discuss your specific condition.

Spondylolisthesis is one of the most common conditions evaluated by spine surgeons — and one of the most commonly misunderstood. Patients are often told they have a “slipped disc” when what they actually have is a slipped vertebra. The two conditions are different, their symptoms overlap in important ways, and the treatment decisions are not always straightforward. Here is what spondylolisthesis is, why it causes symptoms, and when surgery is and is not the right answer.

What Is Spondylolisthesis?

Spondylolisthesis is the forward displacement of one vertebra over the vertebra below it. The word comes from the Greek spondylos (vertebra) and olisthesis (slipping). It is graded by severity using the Meyerding classification, from Grade I (less than 25% slip) to Grade IV (greater than 75% slip), with Grade V (spondyloptosis) reserved for complete dislocation.

The most common location is the lower lumbar spine, particularly L4–L5 and L5–S1. There are several types, each with a different underlying cause:

• Degenerative spondylolisthesis — the most common type in adults; occurs when the disc and facet joints degenerate and lose their ability to restrain normal motion, allowing one vertebra to slip forward on the one below; most common at L4–L5 and more prevalent in women and older adults
• Isthmic spondylolisthesis — caused by a stress fracture (spondylolysis) of the pars interarticularis, a small bridge of bone in the posterior arch; common in young athletes, particularly gymnasts, football linemen, and weightlifters; the fracture allows the vertebra to slip forward; most common at L5-S1
• Congenital spondylolisthesis — due to abnormal development of the posterior spinal elements at birth; less common
• Iatrogenic or postoperative spondylolisthesis — can develop after laminectomy or other posterior surgery that destabilizes the spinal segment

What Symptoms Does It Cause?

Many people have spondylolisthesis and never know it — the slip is discovered incidentally on imaging obtained for another reason. Whether spondylolisthesis causes symptoms depends on the degree of slip, the presence of stenosis, the stability of the segment, and individual factors including age and activity level.

When it does cause symptoms, the most common presentations include:

• Lower back pain — often worse with activity, prolonged standing, or extension (bending backward); typically relieved by sitting or flexion
• Leg pain, numbness, or weakness — caused by nerve root compression from the slipped vertebra narrowing the neural foramen or from associated stenosis of the spinal canal; may mimic sciatica
• Neurogenic claudication — leg symptoms that worsen with walking or standing and improve with sitting or leaning forward; a hallmark of lumbar stenosis that accompanies many degenerative spondylolisthesis cases
• Hamstring tightness — particularly in younger patients with isthmic spondylolisthesis; a classic but often overlooked finding
• Visible postural change — in high-grade slips, patients may develop a characteristic crouched posture or altered gait

When Is Non-Surgical Treatment Appropriate?

The majority of patients with spondylolisthesis — including those with significant symptoms — can be managed successfully without surgery. Non-surgical treatment is the appropriate first step for most patients and may include:

• Physical therapy — core strengthening, postural training, and flexion-based exercises can significantly reduce symptoms and improve function in many patients; this is the most important non-surgical intervention
• Activity modification — avoiding activities that aggravate symptoms while maintaining general fitness
• Anti-inflammatory medications — NSAIDs can help manage pain flares
• Epidural steroid injections — can provide meaningful, though typically temporary, relief of leg pain from nerve compression; most useful as a bridge to physical therapy or while awaiting surgical planning
• Bracing — particularly in adolescents with isthmic spondylolysis or low-grade spondylolisthesis; bracing during the acute phase can allow the stress fracture to heal

An important point: the degree of slip on imaging does not directly predict the severity of symptoms or the need for surgery. A Grade II slip in one patient may cause debilitating symptoms; the same grade in another patient may cause none. Treatment decisions are driven by symptoms and function, not imaging findings alone.

When Is Surgery Indicated?

Surgery for spondylolisthesis is recommended when:

• Conservative treatment has failed — typically after 3 to 6 months of appropriate non-surgical management without adequate improvement in symptoms and function
• Progressive neurological deficit — worsening leg weakness, foot drop, or loss of bladder or bowel control warrant urgent or expedited surgical evaluation regardless of how long conservative treatment has been tried
• Severe or intractable pain — pain that significantly impairs quality of life and does not respond to non-surgical measures
• High-grade slip — Grade III or IV slips are generally unstable and carry a higher risk of neurological compromise; surgery is more frequently recommended even in the absence of severe symptoms
• Progressive slip — documented worsening of the degree of displacement on serial imaging, particularly in adolescents with isthmic spondylolisthesis

What Does Surgery Involve?

Surgery for spondylolisthesis typically involves two goals: decompression of the compressed nerve roots and stabilization (fusion) of the unstable segment. The specific procedure depends on the type and grade of spondylolisthesis, the degree of stenosis, the patient’s anatomy, and other factors.

Common surgical approaches include:

• Posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion (TLIF) — the most common approaches; decompression is performed from the back, an interbody cage is placed in the disc space for stability and fusion, and pedicle screws and rods complete the construct
• Minimally invasive TLIF (MIS-TLIF) — for selected patients, the same procedure can be performed through smaller incisions with less muscle disruption
• Anterior lumbar interbody fusion (ALIF) — an anterior approach may be used alone or in combination with posterior fixation for selected cases, particularly when greater disc height restoration or lordosis correction is needed
• Reduction of the slip — in high-grade spondylolisthesis, partial reduction of the vertebral displacement before fusion may be performed to improve alignment and neural decompression; this is technically demanding surgery that requires specific expertise

Dr. Sardar uses robotic-assisted navigation and intraoperative neuromonitoring as standard for all spondylolisthesis fusions, providing enhanced screw accuracy and real-time feedback on nerve function throughout the procedure.

What to Expect from Surgery

Surgery for spondylolisthesis, when performed in appropriately selected patients, reliably improves leg pain and neurological symptoms. Back pain improvement is meaningful in most patients, though complete elimination of all back pain is not guaranteed. The landmark SPORT trial — one of the largest surgical trials in spine surgery — demonstrated significant and durable advantages of surgery over non-operative care for symptomatic degenerative spondylolisthesis at 4-year follow-up.

Recovery from a single-level lumbar fusion for spondylolisthesis typically involves a hospital stay of 1 to 3 days, return to light activity within 4 to 6 weeks, and return to most normal activities within 3 to 4 months. Full fusion maturation takes 12 months.

About Dr. Zeeshan Sardar
Dr. Sardar is Co-Chief of Spinal Deformity Surgery at NewYork-Presbyterian / Columbia University and treats the full spectrum of lumbar spine conditions including spondylolisthesis, stenosis, disc herniation, and complex deformity. To schedule a consultation, call 212-932-5187 or visit the contact page.

This article is for educational purposes only and does not constitute individualized medical advice. Please consult a qualified spine specialist to discuss your specific condition.