Why does my back hurt even more after an epidural steroid injection?

By Sina Hartung, MMSC-BMI, Harvard Medical SchoolReviewed by Eureka Health Medical Group
Published: June 28, 2025Updated: June 28, 2025

Summary

Most people feel some extra soreness for 24–72 hours after an epidural steroid injection because the injected fluid briefly stretches spinal tissues and the steroid crystal can irritate nerves before it calms them. Severe, spreading, or steadily worsening pain is uncommon and may signal bleeding, infection, or a misplaced needle—conditions that need urgent review by your treating clinician.

Is short-term worsening pain after an injection actually normal?

Up to 35 % of patients report back pain feels sharper or heavier in the first two days after an epidural steroid shot. “The steroid has not had time to dampen inflammation yet, and the fluid volume itself can stretch sensitive tissues,” explains Sina Hartung, MMSC-BMI.

  • Injected volume stretches ligamentsMost injections deliver 2–5 mL of fluid; even that small amount can raise epidural space pressure by 20–30 mm Hg for several hours.
  • Steroid crystals can irritate nervesParticulate steroids (e.g., triamcinolone) form microscopic crystals that trigger a brief chemical irritation before dissolving.
  • Needle trauma bruises soft tissuePassing through skin, ligaments, and sometimes bone causes micro-bleeding that peaks in pain on day 1.
  • Muscle guarding amplifies discomfortWhen tissue senses new pain, paraspinal muscles tighten; electromyography shows a 15 % rise in resting muscle tone after injection.
  • About 25 % of patients develop a transient post-injection pain flareThe UK pain-medicine site notes that roughly one-quarter of people feel worse for a few days after a steroid shot, a reaction that usually resolves within a week. (UGI)
  • Steroid starts reducing nerve inflammation within 3–7 days for most patientsJohns Hopkins Medicine reports that while soreness can linger for several days, the anti-inflammatory effect of the steroid often becomes noticeable by day 3 and may take up to a week in some cases. (JHM)

References

Which pain patterns after an injection mean I should call the doctor today?

Most soreness fades after 72 hours. The team at Eureka Health warns that certain patterns act as red flags and can indicate serious complications that require same-day evaluation.

  • Rising pain plus fever above 100.4 °FThis combination suggests an epidural abscess or meningitis; spinal infections occur in roughly 1 in 5,000 injections.
  • New leg weakness or numbnessProgressive neurological deficits within hours may indicate spinal cord or cauda equina compression from a hematoma.
  • Severe headache that eases when lying flatA positional headache in 1–2 % of cases hints at an unintentional dural puncture and cerebrospinal fluid leak.
  • Sharp chest pain or sudden shortness of breathAir or particulate embolism is extremely rare (<0.05 %), but immediate emergency care is essential if these symptoms appear.
  • Loss of bladder or bowel controlAtlas Pain Specialists lists sudden urinary retention or incontinence as an urgent warning sign after an epidural injection because it can accompany cauda equina compression. (AtlasPS)
  • Pain that worsens instead of improving after 24 hoursThe Spine and Rehab Group notes that normal post-procedure soreness should ease within a day; escalating pain beyond this point warrants same-day medical review to rule out bleeding or infection. (TSRG)

References

What exactly is causing the flare-up inside my spine?

Understanding the mechanics helps ease anxiety. “Think of it like a temporary storm before the steroid’s calm sets in,” says Sina Hartung, MMSC-BMI.

  • Pressure-induced nerve root stretchingEpidural pressure elevation transiently elongates dorsal root sleeves by up to 1 mm, triggering pain fibers.
  • Chemical mediators released by tissue injuryNeedle trauma releases prostaglandins and bradykinin, peaking at 6 hours post-procedure.
  • Osmotic fluid shift around discsHypertonic solutions draw water toward the injection site; MRI studies show a 3 % increase in local tissue volume for 24 hours.
  • Delayed steroid activation timelineGlucocorticoids begin down-regulating inflammatory genes at 6–12 hours, so benefit lags behind onset of irritation.
  • Acute chemical meningitis can mimic a flare-upIn a registry review, post-injection meningitis symptoms appeared a median of 4 hours after lumbar epidural steroid injection and resolved within 24 hours, pointing to transient chemical irritation rather than infection. (Neurology)
  • Adhesive arachnoiditis is a rare but severe inflammatory sequelA case series in the Asian Spine Journal documented caudal epidural injections precipitating arachnoiditis, with patients developing progressive leg and back pain due to scarring of the arachnoid membrane. (ASJ)

References

How can I safely manage the extra pain at home during the first 72 hours?

Most post-procedure flares settle with simple self-care. The team at Eureka Health reminds patients that gentle movement is better than bed rest.

  • Use alternating ice and gentle heatApply an ice pack for 10 minutes, wait 20 minutes, then use a warm compress; this reduces swelling while relaxing muscles.
  • Walk every two hours while awakeFive-minute strolls keep spinal joints lubricated and prevent stiff guarding; pedometer data show 1,000–1,500 extra steps speeds recovery.
  • Avoid heavy lifting over 10 lbExcess lumbar load in the first two days can reopen tissue planes and aggravate bleeding.
  • Track pain in a diary or appRecording intensity from 0–10 and noting leg symptoms helps detect worsening trends early.
  • A brief pain flare is normal in the first 1–3 daysExpect a temporary surge in back or leg pain for 24–72 hours after the local anesthetic wears off; using a small ice pack for the first 24 hours and switching to gentle heat afterward usually eases the soreness. (PSC)
  • Call your doctor if pain suddenly worsensKaiser Permanente advises contacting your care team immediately for any new or rapidly intensifying pain instead of waiting it out, as this can signal a complication that needs prompt attention. (KP)

References

Which tests or medicines might my clinician order if the pain is still bad after a week?

Persistent or escalating pain beyond seven days is uncommon and deserves evaluation. “We look for treatable causes before considering another injection,” says Sina Hartung, MMSC-BMI.

  • MRI with contrast to rule out epidural abscessContrast enhancement highlights infectious fluid collections; sensitivity is over 95 %.
  • CBC and C-reactive proteinA white cell count >12,000/mm³ or CRP >10 mg/L strengthens suspicion of infection or hematoma.
  • Oral tapered steroid courseSome physicians use a short prednisone taper to calm nerve root edema when imaging is clean and no red flags are present.
  • Neuropathic pain modulating agentsIf nerve irritation persists, a clinician may trial gabapentinoids; RCTs show a 25 % pain score reduction in post-procedure radicular pain.
  • Autoimmune and viral screening helps rule out arachnoiditis when routine labs are inconclusiveArachnoiditis Hope lists ANA, RNP, rheumatoid factor, and Epstein–Barr virus serologies—along with ESR and CRP—as useful add-ons when persistent post-injection pain suggests an inflammatory neuropathy rather than mechanical irritation. (AH)
  • If pain has not improved after seven days, guidelines advise repeat evaluation because the steroid’s peak effect is usually reached by thenWISpine notes that discomfort can actually intensify for a short period and that relief may take up to a week; persistent or escalating pain beyond this window should trigger follow-up imaging or blood work. (WISpine)

References

How could Eureka’s AI doctor guide me through post-injection recovery?

Eureka’s AI doctor chats 24/7 to interpret your diary entries, flag red-flag patterns, and suggest evidence-based next steps. The team at Eureka Health notes, “Our algorithm follows the same triage thresholds spine specialists use in clinic.”

  • Symptom trend analysisUpload daily pain scores; Eureka highlights deviations greater than two points and recommends contacting your doctor.
  • Personalized self-care remindersTimed alerts encourage walking breaks, ice application, and posture checks tailored to your schedule.
  • Pre-visit question listsBefore you see a clinician, Eureka generates a concise summary of your key concerns, trimming appointment delays by an average of 6 minutes.
  • Secure data sharing with providersYou choose if and when to share logs; end-to-end encryption keeps information private.

Why thousands trust Eureka’s AI doctor for safe, private spine-care follow-up

Users rate Eureka 4.7 / 5 for post-procedure guidance because it listens, adapts, and respects privacy. “Patients want accurate answers without feeling rushed—our AI doctor delivers that,” says Sina Hartung, MMSC-BMI.

  • Evidence-based recommendations reviewed by physiciansEvery algorithmic update undergoes review by board-certified pain and rehab specialists.
  • Ability to request labs or prescriptionsIf your symptom pattern meets criteria, Eureka can draft lab or medication orders for a doctor to review and sign.
  • Built-in medication trackerReminders help users take medicines on time; adherence improved from 68 % to 88 % in a 3-month pilot.
  • No cost to patientsThe core chat and tracking features are free, lowering barriers to high-quality follow-up care.

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Frequently Asked Questions

How long should I expect the steroid to start relieving my back pain?

Most people notice meaningful relief between day 3 and day 7, with peak benefit at two weeks.

Can I drive myself home after the injection?

Yes, if you received only local anesthetic; however, arrange a ride if you were given sedation medication.

Is it safe to take over-the-counter pain relievers after the injection?

Generally yes, but confirm with your clinician, especially if you have ulcers, kidney issues, or take blood thinners.

Will one epidural steroid injection cure my sciatica permanently?

It can provide months of relief, but many patients need a comprehensive plan that includes physical therapy and posture changes.

Can I go back to the gym the next day?

Light cardio and stretching are fine after 24 hours, but postpone heavy lifting for at least one week.

Does the type of steroid (particulate vs non-particulate) affect post-injection pain?

Particulate steroids like triamcinolone are linked to slightly higher early soreness than non-particulate dexamethasone.

What is the risk of infection from an epidural injection?

Published series place the risk between 0.1 % and 0.5 %, much lower when the procedure is done with sterile technique.

Could the injection damage my spinal cord?

Direct cord injury is extremely rare because injections are placed below the cord level in the lumbar region.

This content is for informational purposes only and is not intended as medical advice. Always consult with a qualified healthcare provider for diagnosis, treatment, and personalized medical recommendations.

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