Why Can Pain Get Worse After an Epidural Steroid Injection?

Epidural steroid injections are commonly used to treat pain caused by irritation or inflammation of spinal nerves.

They may be recommended for conditions such as:

• Lumbar radiculopathy
• Cervical radiculopathy
• Sciatica
• Herniated disc
• Spinal stenosis
• Degenerative disc disease with nerve irritation
• Foraminal narrowing
• Other conditions producing radiating nerve pain

The corticosteroid medication is placed into the epidural space near the irritated nerve or nerve root. The goal is to reduce inflammation and, in turn, decrease pain.

The problem is that the corticosteroid does not necessarily work immediately.

There can therefore be a short period after the procedure when the nerve remains irritated, while the tissues around the injection site are also reacting to the procedure itself.

Several factors can explain why pain may temporarily worsen.

An epidural steroid injection requires a needle to pass through tissues near the spine before medication is delivered into the epidural space.

Even when the injection is performed correctly and imaging guidance is used, the procedure can temporarily irritate muscles, ligaments, and other tissues.

This can lead to localized tenderness or soreness at the injection site.

If the nearby nerve root was already highly inflamed before the procedure, even minor temporary irritation may make the patient’s usual nerve pain feel more intense for a short period.

Mild injection-site discomfort and temporary worsening of the original pain are recognized short-term reactions and often settle within several days. [1,3]

The medication injected into the epidural space occupies physical space.

When a nerve root is already inflamed, compressed, or hypersensitive, the temporary change in pressure around that nerve may provoke additional discomfort.

A person with sciatica, for example, may notice that the familiar burning, aching, or electrical pain traveling down the leg becomes temporarily more noticeable.

This does not necessarily mean the nerve has been damaged.

If the pain represents a routine post-injection flare, it should generally stabilize and then begin settling as the medication disperses and inflammation decreases.

This is one of the most common reasons patients become concerned after an epidural steroid injection.

Some injections include a local anesthetic along with the corticosteroid.

The local anesthetic may provide temporary relief shortly after the procedure. A patient may even leave the clinic feeling significantly better.

Several hours later, the anesthetic wears off.

At that point, the corticosteroid may not yet have produced its full anti-inflammatory effect.

The result can be a frustrating sequence:

Pain improves immediately after the injection → pain returns later that day → pain may briefly feel worse → gradual improvement begins over the next several days.

The corticosteroid may take several days to begin reducing inflammation, and the full benefit can take longer to develop. [1,4]

This is why pain during the first several hours after an epidural steroid injection is not always a reliable indication of whether the procedure will ultimately help.

For many patients, increased pain lasts approximately one to three days.

The injection area may be tender during that period, and the pain that originally led to the procedure may temporarily feel stronger.

Pain relief from the corticosteroid often begins after several days rather than immediately. [1,2,3]

There is no exact timeline that applies to every person.

Some patients feel better the next day.

Others notice little improvement for several days.

Some people experience an initial flare followed by gradual improvement.

What matters most is the overall trend.

A pain flare that is somewhat worse during the first day or two but then begins moving back toward baseline is generally more reassuring.

Pain that continues to become progressively worse each day deserves more attention, particularly if new symptoms appear.

Yes, a temporary increase in sciatica can occur.

Sciatica typically results from irritation of one or more nerve roots in the lower spine.

If that nerve becomes temporarily irritated by the injection procedure or the volume of medication delivered around it, the familiar pain may briefly intensify.

A patient might notice:

• More burning down the leg
• Increased aching in the buttock
• More noticeable tingling
• Temporary shooting pain
• Increased sensitivity along the usual sciatic pain pathway

If these symptoms are essentially the same symptoms you had before the injection, just temporarily stronger, they may represent a typical pain flare.

However, completely new neurological symptoms are different.

New foot weakness, difficulty lifting the front of the foot, rapidly increasing numbness, significant loss of sensation, saddle-area numbness, or bladder and bowel dysfunction should not be treated as an ordinary pain flare.

There is no specific pain score that can reliably distinguish a normal flare from a complication.

A person who already has severe radiculopathy may experience significant discomfort during a normal post-procedure flare.

It is therefore more useful to consider three things:

• Is the pain familiar?
• Is it improving or getting progressively worse?
• Are there new symptoms along with the pain?

A routine pain flare often resembles the pain that was already being treated.

For example, someone with right-sided sciatica may notice temporarily increased pain in the same buttock, thigh, and leg.

A complication is more likely to involve something new, rapidly progressive, unusually severe, or neurologically different.

Serious complications following epidural steroid injections are uncommon, but possible problems include infection, bleeding in the epidural space, nerve injury, accidental dural puncture, and rare neurological events. [5,6]

Certain symptoms should not simply be watched for several days in the hope that they disappear.

Contact the treating physician promptly or seek urgent medical evaluation if you develop:

• New or worsening weakness in an arm or leg
• Significant new numbness
• Loss of bladder control
• Loss of bowel control
• Numbness around the groin or saddle area
• Fever or chills
• Increasing redness or swelling around the injection site
• Drainage from the injection site
• Severe pain that continues to escalate
• Severe headache that is much worse while sitting or standing
• New vision changes
• Severe dizziness
• Seizures
• Other sudden neurological symptoms

Fever, new neurological symptoms, severe positional headache, wound drainage, and sudden bowel or bladder changes are among the symptoms that warrant medical review after a spinal injection. [5]

Rare but serious neurological complications have also been reported following epidural corticosteroid injections, which is why sudden weakness, unusual numbness, severe headache, vision disturbance, dizziness, or seizures require urgent attention. [6]

The intensity of pain matters, but the pattern matters even more.

Some people with severely irritated nerves can experience a fairly strong flare after an injection.

However, pain that suddenly becomes dramatically worse should not automatically be dismissed.

Suppose your typical pain before the procedure was a 5 out of 10 and it suddenly becomes a 9 out of 10.

That may still represent temporary irritation, but if the pain remains severe, continues increasing, or is associated with neurological changes, you should contact the treating physician.

Pay particular attention when the character of the pain changes.

Localized tenderness where the needle entered is one thing.

New electrical pain into an area that never hurt before is another.

Similarly, an increase in familiar leg pain is different from suddenly being unable to move the foot normally.

Severe, sharp, or unusual pain during or after an epidural steroid injection should be reported to the treating provider. [1]

Not necessarily.

The first one or two days are usually too early to decide whether the injection worked.

Corticosteroids reduce inflammation gradually.

A person may experience increased pain initially and still obtain meaningful relief several days later.

This is different from a truly unsuccessful epidural steroid injection.

With a temporary flare, pain usually becomes worse briefly and then begins settling.

With an ineffective injection, the patient may simply return to the same baseline level of pain without obtaining meaningful or sustained improvement.

There are many reasons why an epidural steroid injection may work better for one person than another.

These include:

• The cause of the nerve pain
• The degree of nerve compression
• The location of the disc problem
• The severity of spinal stenosis
• How long symptoms have been present
• The approach used for the injection
• Individual anatomy
• The degree of inflammation surrounding the nerve

For these reasons, the success of the procedure should generally be assessed over the timeframe recommended by the treating physician rather than judged entirely on how you feel during the first 24 hours.

This is a common experience.

Immediate relief following an epidural steroid injection may be caused partly by the local anesthetic used during the procedure.

That anesthetic can temporarily block or reduce pain signals.

When it wears off, the original pain returns.

At the same time, tissues around the injection site may be mildly irritated, making the pain seem worse than it did before the procedure.

The corticosteroid then begins working later.

In other words, immediate pain relief is not necessarily the final effect of the injection, and the return of pain several hours later does not automatically mean that the procedure failed.

It can be.

The second day is still within the commonly reported timeframe for a temporary post-injection pain flare.

Symptoms can remain worse for approximately two to three days before improvement becomes noticeable. [1,2]

Again, the direction matters.

If day two feels slightly better than day one, that is generally reassuring.

If the pain is still uncomfortable but otherwise feels like the same pain you had before the injection, and there are no new warning signs, it may still be part of the expected course.

If the pain becomes substantially worse each day rather than stabilizing, the treating physician should be contacted.

Pain that remains noticeably worse after several days deserves a call to the treating provider.

This does not automatically mean a serious complication has occurred.

Possible explanations include:

• The nerve remains inflamed
• The steroid is taking longer to work
• The underlying spinal condition remains active
• The injection has not provided meaningful benefit
• The procedure caused a longer-than-average pain flare

However, when the expected trend toward improvement does not occur, the physician may want to reassess the situation.

They may need to determine whether the symptoms represent persistent radiculopathy, progression of the original condition, a prolonged post-procedure flare, or an uncommon complication.

Infection after an epidural steroid injection is uncommon, but it is important to recognize the warning signs.

Pain alone does not mean infection.

More concerning symptoms include:

• Fever
• Chills
• Increasing warmth around the injection site
• Redness that continues spreading
• Swelling
• Drainage
• Worsening spinal pain
• Feeling generally unwell

Rare infections can involve deeper spinal structures, including the epidural space, vertebrae, discs, or the tissues surrounding the spinal cord. [5]

A routine pain flare usually begins stabilizing within a few days.

Pain from an evolving infection may continue worsening rather than improving and may be accompanied by systemic symptoms such as fever or chills.

Those symptoms should not be ignored.

Rarely, bleeding can occur within the epidural space and form what is called an epidural hematoma.

This is potentially serious because accumulated blood can place pressure on spinal nerves or the spinal cord.

Possible symptoms include:

• Severe worsening back pain
• New weakness
• Progressive numbness
• Difficulty walking
• Loss of bladder control
• Loss of bowel control

People taking medications that affect blood clotting may have an increased risk of bleeding, which is why physicians carefully review anticoagulants and antiplatelet medications before spinal injections. [5]

Severe pain together with new neurological symptoms should always be evaluated urgently.

Another uncommon complication occurs if the needle unintentionally punctures the membrane containing spinal fluid.

This can cause a postdural puncture headache.

The most recognizable feature is that the headache is strongly affected by body position.

It is usually much worse when sitting or standing and improves noticeably when lying flat.

The headache may also occur with:

• Neck pain
• Nausea
• Light sensitivity
• Dizziness

A mild headache after a medical procedure does not automatically mean a dural puncture occurred.

However, a severe headache that repeatedly becomes worse when upright and improves while lying down should be reported to the treating physician. [5]

Follow the specific post-procedure instructions provided by the physician who performed the injection.

Recommendations can vary depending on the location and type of injection, your medical history, and the medications you take.

Patients are commonly advised to avoid strenuous activity immediately after the procedure and gradually return to normal activities. [1]

If the injection site is sore, the clinic may recommend simple measures such as temporary activity modification or cold therapy.

Any pain medication should be taken only as advised, particularly in patients with kidney disease, stomach problems, cardiovascular disease, bleeding risk, or other medical conditions that affect medication safety.

It can also help to judge your recovery based on function and symptom pattern rather than checking your pain score constantly.

Ask yourself:

• Is this essentially the same pain I had before the injection?
• Is it stable or beginning to improve?
• Can I walk and move the way I could before the procedure?
• Have I developed any new weakness or significant numbness?
• Do I have fever, chills, bladder changes, or bowel changes?

Those questions are often more useful than asking only whether the pain is a 6 or a 7.

An epidural steroid injection should not usually be judged by what happens during the first few hours.

Pain relief may begin within a few days, while the maximum benefit can take longer to develop. [1,4]

Some patients experience substantial improvement.

Others notice only partial relief.

Some do not obtain meaningful benefit at all.

The purpose of the injection is generally to reduce inflammation and nerve-related pain enough to improve function, mobility, sleep, or participation in rehabilitation.

The goal is not always complete elimination of pain.

The treating physician may also use the response to an epidural steroid injection as part of the broader treatment plan, especially when deciding whether additional conservative treatment, repeat injections, further imaging, or surgical evaluation should be considered.

Temporary worsening is far more common than permanent worsening.

A short period of increased pain does not mean that permanent nerve damage has occurred.

Serious neurological injury is considered rare. [5,6]

However, persistent severe pain combined with new weakness, sensory loss, bladder or bowel dysfunction, or other neurological abnormalities should be evaluated promptly.

The mistake to avoid is assuming that every post-injection symptom is either completely harmless or automatically dangerous.

Most temporary pain flares resolve.

What matters is identifying the small number of cases where the symptom pattern falls outside the expected recovery course.

The procedure itself can temporarily irritate tissues and an already inflamed nerve. The local anesthetic may also have worn off before the corticosteroid has had enough time to reduce inflammation. Temporary worsening during the first few days is a recognized post-injection reaction. [1,2]

A pain flare commonly lasts approximately one to three days, although the exact duration varies. Improvement from the corticosteroid may take several days to become noticeable. [1,3]

A temporary increase in the same sciatic pain you had before the injection can occur. New or progressive weakness, major sensory loss, saddle-area numbness, or bladder and bowel dysfunction are not typical pain-flare symptoms.

An already sensitive nerve can become temporarily more irritated following the procedure. This can cause increased burning, shooting, tingling, or radiating pain for a short period. Persistent or progressive neurological symptoms should be evaluated.

No. The corticosteroid does not necessarily provide immediate relief. It may take several days before its anti-inflammatory effects become noticeable. [1,4]

New or progressive neurological problems are among the most important warning signs. Significant weakness, sensory loss, bowel or bladder dysfunction, or numbness around the saddle area should receive urgent medical attention.

Contact the physician if the pain is unexpectedly severe, continues to worsen rather than stabilize, remains substantially worse after several days, changes character significantly, or is accompanied by new neurological or systemic symptoms.

Pain becoming worse after an epidural steroid injection can be alarming, especially when the whole purpose of the procedure was to reduce pain.

But a temporary increase in discomfort does not automatically mean something went wrong.

The injection itself can temporarily irritate already sensitive tissues. The local anesthetic may wear off before the corticosteroid begins working. An inflamed nerve may also react temporarily to the medication being placed around it.

For many patients, symptoms are somewhat worse for the first one to three days before beginning to improve. [1,2,3]

The key is to watch the pattern.

Pain that resembles your usual symptoms and gradually begins settling is generally more reassuring.

Pain that continues escalating, feels completely different from your usual pain, or occurs with new weakness, significant numbness, fever, drainage, severe positional headache, loss of bladder or bowel control, or other neurological symptoms should not simply be written off as a normal steroid flare.

When symptoms fall outside the expected recovery pattern, contacting the physician who performed the injection is the safest approach.

References: