Epidural Steroid Injections ‘No Benefit’ for Spinal Stenosis

Epidural Steroid Injections ‘No Benefit’ for Spinal Stenosis

Another study is raising questions about the value of epidural steroid injections in treating chronic back pain. Researchers at the Agency for Healthcare Research and Quality (AHRQ) say the addition of a corticosteroid to a common anesthetic used in epidural injections does not enhance pain relief in patients with lumbar spinal stenosis.

Over 10 million epidural injections are performed annually in the U.S. to treat spinal stenosis, sciatica and other types of back pain. The practice has become more common in recent years, in part because of a growing reluctance by physicians to prescribe opioid pain medication to their patients. It is also a more lucrative procedure for doctors to perform.

bigstock-Hand-holding-hip-with-visible--29205395A research team led by Janna Friedly, MD, an assistant professor in the Department of Rehabilitation Medicine at the University of Washington, studied 400 patients with lumbar stenosis being treated at 16 hospitals in the United States. Half of the patients received epidural injections of lidocaine combined with a corticosteroid, while the other half received injections of the anesthetic without a corticosteroid.

The researchers found that patients who received a combination of corticosteroids and lidocaine were more likely to report side effects, and were more likely to absorb the corticosteroid into their bloodstream. Repeated injections of corticosteroids can also result in reduce bone density, increased risk of bone fracture and immunosuppression.

“This is the first large, multicenter randomized trial to look at epidural steroid injections for spinal stenosis, and we found that injection with corticosteroids and lidocaine provided these patients with minimal or no additional benefit over lidocaine injections,” said Friedly, whose study is being published in the New England Journal of Medicine.

Lumbar spinal stenosis is caused by gradual changes in the spine that cause the spinal canal to narrow and press against nerves. This leads to lower back and leg pain, a tingling sensation in the legs and muscle weakness. Stenosis is the leading reason for back surgery in older adults.

“The pain associated with lumbar stenosis can be excruciating, and patients are understandably looking for relief,” said AHRQ Director Richard Kronick, PhD. “This study raises questions about the benefits of combining corticosteroids with an anesthetic for patients with lumbar stenosis, and it will help patients and their physicians make better informed decisions about treatment options.”

The combination of an anesthetic with a corticosteroid in an epidural has been hypothesized to relieve pain by reducing nerve swelling and increasing blood flow. Rates and associated costs of the injections have increased nearly 300 percent over the last two decades.

“Although many injections are used for indications other than spinal stenosis, epidural injections have become almost an expected part of a comprehensive nonoperative treatment protocol in patients with this condition. Yet, evidence to support this practice is incomplete and conflicting,” wrote Gunnar B.J. Andersson, MD, in an editorial also published the New England Journal of Medicine.

In April, the Food and Drug Administration issued a warning about epidural steroid injections, saying they “may result in rare but serious adverse events, including loss of vision, stroke, paralysis, and death.”

The FDA began investigating the safety of the injections after concerns were raised by physicians and patient advocates, and after reviewing its own adverse event database. The agency said an advisory committee will also be formed later this year to discuss the benefits and risks of epidural injections, and whether further FDA action is needed.

Several recent studies have found that epidural steroid injections raise the risk of spinal fractures and often do little to control back pain.

Authored by: Pat Anson, Editor

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my stenois is very narrow they Doctors been told give him the shots, i refuse, on national news it was reported 2nd week in july, this year steriods do no good for this type of problem.So why are the doctors not told to stop. I dont know anyone that said it helped with spinal stenois ..I find what one doctors comment was he injects saline with great results, odd!!

Johnna Stahl

I know how hard it is to share these tragic stories, so I really appreciate your doing so. Just wanted to say that I was getting some good results from medical cannabis, when I could afford it, so you might want to explore this avenue of treatment, if possible in your state.

Johnna Stahl

Thank you, Dr. Elman, for making that distinction about lidocaine, which I was not aware of. I am going to check my records for the contents of my injections — not that it will make a difference at this point. It seems many treatments for pain have been shown to do more harm than good, and that has created a whole new population of intractable pain patients, like me.

Sandra L. Weidner

I have gotten epidurals off and on since 1993. They have helped with my back pain. I would get them every few months, once I got to the point of no pain relief, the Dr and I decided on next route to go. I have had a spinal fusion and so far it is effective. I don’t have the sharp burning pain going down my legs, and I am not needing to take opoid pain medications. I have even managed during all this to keep my fibromyalgia in check.

Daniel S. Elman, M.D., Board Certified in Anesthesiology

This study is terribly flawed. The ejection of lidocaine into the epidural space should never be performed. Lidocaine causes permanent nerve injuries when injected into the epidural space and it is obvious that this study should never have been published if it was review by an anesthesiologist practicing in pain medicine. the authors are to be condemned for practicing unsafe medicine and probably causing nerve damage and increased pain to their patients in this study. Shame on the New England Journal of Medicine for publishing this study.
I was the recipient of the journals Senior Medical Student essay contest in 1951 and now i am no longer proud of this since the editorial board is so incompetent now.

donnie davis

Just want to say one epidurial changed my life forever. No fluoroscopy was used and I was forced to take it because I was told if I didnt it would mean my position with the company I had worked years and long hours to get up the ladder to a tool makers position. No way of recorse sense the workers comp attorney’s and insurance companies are all sleeping together. He missed!!! Been in the worst pain for 20 years now. Oh ya lost the position anyway when I came off the table with the needle still in my back and had to be hospitalized where morphine drip would not take the pain, just made me forget who I was. Lost 31 year marriage, two homes and everything I had worked for. Ya I contacted congress people, everyone I could. No reply from anybody. All over a slip and fall which broke my tailbone. Truth!!!!! Its a joke and the people suffer!! oh ya took 7 years just to get to court. That is even a bigger joke!! And yes they know they are doing these things but money has no laws.!!!! Am I just a random case? No way!! I have met many with about the same story. Even one man losr his wife that I grew up with over a simple female procedure they used an epidurial ejection and paralyzed her. She died a few months later due to kidney failure.

Johnna Stahl

While more non-invasive treatments for pain are obviously needed, after having three rounds of these injections (which, by the way, I found to be very invasive), I very easily came to the same conclusion as this study. However, I did not have this treatment until my pain had reached intractable levels, wasting time and money (and hope that it might work) in the process.

Perhaps this article should have also mentioned the scandal and tragedies over compound pharmacies providing doctors with toxic steroids?

(The FDA – always a day late and a dollar short.)

Joseph Carr

Gina,

This study is terribly flawed. It is clear that the NEJM has a bias against interventions. Remember their flawed study about vertebroplasty compared to a “sham” procedure?

Problems with study include:

1) Level of Stenosis isn’t discussed. Patient’s with mild to moderate lumbar stenosis would obviously do better than patient’s with severe stenosis. Often, mild to moderate stenosis doesn’t progress to severe stenosis. Surgery is only really indicated for severe stenosis with neurological deficits. Patient’s have very poor results with fusion surgery for pain control alone. Furthermore, patient’s often get worse after fusion surgery.

2) LESIs performed once by themselves are not used for a comprehensive approach towards this issue. LESIs (multiple) should be combined with PT and medications. Often, PT is unable to be performed due to severe pain from the stenosis condition. LESIs allow the patient to undergo PT in the future. Patient’s that have failed PT treatment due to pain, would get great benefit from LESIs, so that they could undergo further PT treatment.

Michael describes his own case as basically “instability” of the spine, which should be an indication for fusion surgery. For these cases, obviously, surgery should be undertaken rather than conservative treatments. Fortunately, significant instability of the spine is quite rare.

Fusion surgeries are notoriously bad.

When Independent workman compensation groups from Ohio and Washington State compared fusion surgery with conservative care, it was shown that FEWER fusion surgery patients get back to work compared with conservative care. Furthermore, their narcotic usage increased by 41% on average. There was also a high rate of re-operation.

Therefore, proceeding to fusion surgery for these patient’s would be very foolish from a financial standpoint. Patients should undergo all conservative care before considering a fusion. Fusion surgery should be a last resort option.

Gina speaks about the “costs” of LESIs.

Lets compare the costs of LESis vs fusion surgery. It would require about 30-40 years of LESIs to equal the cost of one multi-level fusion surgery. Therefore, its a no brainer that if we can prevent a decent amount of surgery, it would be cost savings to the healthcare system as well.

Every pain management physician has TONS of patient’s that are on high dosages of Oxycontin or other narcotics after multiple spinal fusion surgeries. Trust me, surgery isn’t the answer for the vast majority of patients.

Sir
It is undertreatment giving only steroid in epidural asit cannot work on all adherent nerve fibres in spinal canal stenosis, therefore any study will have similar results. I as pain specialist for 32 yrs. have used saline in so many cases with slight more force, it gives wonderful results. My all cases are very happy,the first pt. was treated 32 yrs. back,she is still bringing other cases to me.
Further, saline nerds only one time inj.,rarely twice against many inj. Of steroids. Further, the side effects talked about May be due to stenosis itself.if millions had no side effects study of only few thousands has no significance, that too even this study had very rare side effects.
It is difficult to believe only lidocaine can give any long term results.

Joseph Carr

Gina,

Depends on the severity of the stenosis you are speaking about. If it is very severe, then yes LESI would not benefit.

However, LESI are beneficial for patients with mild to moderate stenosis when added to PT and medications. This can prevent surgery for a good amount of these patients, considering many don’t progress to severe stenosis.

Furthermore, Fusion surgery is NOTORIOUSLY bad. How many patients get fusion surgeries only to get worse? If you think an LESI is bad, wait until you get a multi-level fusion surgery. Then come back and discuss real pain.

After you get about 3 to 4 of these surgeries, due to worsening of your back pain when the above segments go bad, you’ll be placed on Oxycontin for life.

Ohio Workman compensation in 2013 showed that far fewer people get back to work with fusion surgeries vs conservative care with the same diagnoses.

Wonder if the surgeons would like the LESI to fail so that they can increase fusion surgeries?

Also, if 11 million ESI are done a year, how many wind up with complications?

How many people are fusion surgeries wind out with complications? Far MORE than Fusion surgical patients.

JEFF G

Hello, I have had several injections for my back and yes no relief. This went on for about 10 years. I then met a young DR. and we talked he then said he would like to give me an injection in the area of my left hip around the joint. For years I had this pain down my legs RT. and LF and into my growing. He gave me the injection in the hip and about 2 to 3 days it was golden it was the best I have felt in all of those years and it lasted for around 3 to 4 years, I will take those odds anytime. So now when it flares up I will have them do the injection. I mean what do you have to lose ? Jeff I still thank him when I see him and that has been or course just over 10 years ago. Back no Hip yes for me!!

I totally without any hesitation AGREE with this article. I have and still do suffer horrible pain. I’ve had several series of injections and only 1 time did I see an improvement. But one thing was definite, I had increased pain after EVERY single procedure.
They perform these very painful injections with no local IV sedation.
Sad is most insurance companies force u to suffer and go through the injections before they will pay for surgery. Totally confused as to how they can do this when these injections are not even approved by the FDA!!!!

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Gina Lewis, RN