Another study is raising questions about the value of epidural steroid injections. New research at the Johns Hopkins University School of Medicine suggests that it may not be the steroids in spinal shots that provide relief from lower back pain, but the introduction of any fluid – even just saline solution — in the space around the spinal cord.
In recent decades, epidural steroid injections (ESI) have become one of the most common treatments for back pain, with nearly 9 million spinal injections in the U.S. in 2011. Studies have shown the procedure often gives only short term pain relief and have high failure rates for conditions such as sciatica.
In addition, questions have also been raised about the safety of steroids, particularly after a fungal meningitis outbreak caused by contaminated steroids killed 64 people and sickened hundreds in 2012. Steroid injections have also been found to increase the risk of spinal fractures.
Johns Hopkins anesthesiologist Steven Cohen, MD, and his colleagues reviewed dozens of published studies on epidural steroid shots and found something unexpected. Epidural injections of any liquid — such as saline solution or a local anesthetic like Lidocaine — work just as well as steroids.
“Just injecting liquid into the epidural space appears to work,” says Cohen, a professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine. “This shows us that most of the relief may not be from the steroid, which everyone worries about.”
The Johns Hopkins review covered medical records of over 3,600 patients from 43 studies comparing ESI’s to other sorts of epidural and intramuscular injections. The Johns Hopkins study is being published in the October issue of the journal Anesthesiology.
The researchers say they’re not recommending that patients stop receiving epidural steroids, but their analysis suggests that smaller steroid doses could be just as beneficial.
“Our evidence does support the notion that, for now, reducing the amount of steroids for patients at risk may be advisable,” said lead author Mark Bicket, MD, an anesthesiology and critical care medicine chief resident at The Johns Hopkins Hospital.
Cohen says the new analysis also raises questions about the value of many clinical studies on epidural steroid injections, because saline or anesthetic injections were commonly used as a placebo treatment during the studies.
“It’s likely that those studies were actually comparing two treatments, rather than placebo versus treatment,” Cohen said. “Researchers may be wasting millions of dollars and precious time on such studies.”
Patient advocates say the Johns Hopkins study ads to the growing body of evidence that epidural steroid injections can be risky.
“ESI’s are dangerous and overused, and a lot of new studies are coming out that state this,” said Walt Davis, who has suffered from back pain for 30 years and is a patient advocate for the Arachnoiditis Society for Awareness and Prevention (ASAP).
“I am not saying that all ESI’s are bad. There is a very small patient population that actually benefit from their use, but that percentage is as low as 20 percent, and even those that might benefit still run the very real risk of complications like arachnoiditis,” Davis wrote in an email to National Pain Report.
“And honestly, I have had well over 20 epidural injections, and the very first one caused my pain to get worse. None of them ever relieved any pain ever. I had blown disks and a fractured spine. The placebo effect is a very real factor here, if you tell a patient that it will help, then to some it does.”
Davis and Terri Anderson, another patient advocate for ASAP, believe any type of injection into the spinal area is risky and can cause complications. One of the most severe is arachnoiditis, an inflammation of the spinal membrane that they both suffer from.
“I had a ruptured lumbar disc and the dozens of ESI’s that I endured never ever helped me to avoid back surgery, in fact I believe they screwed up the surgical results, as the surgeon reported to me that the nerve rootlets ‘were a mess’ following dozens of steroid injections,” Anderson said.