More often than not, patients presents to a chiropractic clinic as a last resort for their lower back pain. Even more frequent, are the revelation of patients being advised to opt for a corticosteroids injection directly on to the painful area, the so called 'epidural injection'. However, when asked about its effectiveness, doubts start to raise as the medical and scientific evidence on this topic is shockingly poor considering the frequency with which this procedure take place in modern practice.
Lower back pain is a condition that is often encountered and treated by doctors of chiropractic, so it is necessary to take a critical look at this procedure.
Looking in to the available literature it was found that there had been a dramatic increase of this procedure being carried out, despite the fact that studies have failed to demonstrate valid evidence for its clinical use. Other studies actually suggest that it may actually be dangerous. In fact, as in any invasive medical procedure there are always risks and/or side-effects. In the case of spinal injections, these includes infection, bleeding, nerve damage and dural puncture. Other side effects of steroids medications per se are transient decrease in immunity, high blood sugar, stomach ulcers, avascular necrosis (mainly in the hip joint), cataracts and increased risk of fracture.
- In 2012, a meta-analysis review was carried out to investigate the effectiveness of epidural corticosteroids for sciatica. 23 randomized trials involving more than 2000 patients in which epidural corticosteroids injections were compared to placebo for sciatica. Epidural steroids injections produced small, statistically insignificant short-term improvements in leg pain and disability (but not less back pain) compared to placebo. The improvement also was only over a short term period of time (two weeks to three months). Beyond 12 months, there was no significant difference between groups, (Pinto RZ, et al.).
- In 2012, an outbreak of fungal meningitis sparkled in 23 states of USA following corticosteroid back injections, reporting a conservative estimate of more that 14000 possible infections (later on, 751 cases were confirmed including 64 deaths).
- In 2013, a retrospective study published in the Journal of Bone and Joint Surgery looked at lumbar epidural steroid injection (LESI), and the potential impact on bone fragility and vertebral fractures (spinal fractures). Researchers identified a total of 50,345 patients who had medical diagnosis codes involving the spine; within that group, a total of 3,415 patients had received at least one LESI. Three thousand patients were randomly selected from the 3,415 injected population and 3,000 additional patients were selected from the non-injected group as a control group. There was no significant difference between the injected and non-injected groups with respect to age, sex, race, hyperthyroidism or corticosteroid use. When incidence of vertebral fractures was assessed, researchers discovered that an increasing number of injections was associated with an increasing likelihood of fractures, and each successive injection increased the risk of spinal fracture by 21 percent, (Mandel S, Schilling J, Peterson E, et al.). Based on this evidence, LESIs clearly exacerbate skeletal fragility. They promote deterioration of skeletal quality similar to the use of exogenous steroids, which is the leading cause of secondary osteoporosis. In fact, the rate of vertebral fracture following epidural steroid injections may be underestimated.
- Both European, (Airaksinen O, Brox JI, Cedraschi C, et al.) and American, (Chou R, Rosenquist R, Loeser J.) guidelines, based on systemic reviews, conclude that epidural corticosteroid injections may offer temporary relief of sciatica, but do not reduce the rate of subsequent surgery, (Armon C, Argoff CE, Samuels J, Backonja M). This conclusion is based on multiple randomized trials comparing epidural steroid injections with placebo injections, and monitoring of subsequent surgery rates, (Arden NK, Price C, Reading I, et al.). Facet joint injections with corticosteroids seem no more effective than saline injections.
- Despite the limited benefits of epidural injections, Medicare (a national social insurance program, administered by the U.S. federal government since 1966) claims show a 271 percent increase during a recent seven-year interval.7 Earlier Medicare claims analyses also demonstrated rapid increases in spinal injection rates. For patients with axial back pain without sciatica, there is no evidence of benefit from spinal injections; however, many injections given to patients in the Medicare population seem to be for axial back pain alone, (Friedly J, Chan L, Deyo R.). Charges per injection have risen 100 percent during the past decade (after inflation), and the combination of increasing rates and charges has resulted in a 629 percent increase in fees for spinal injections, (Friedly J, Chan L, Deyo R.). Yet during this time, the Medicare population increased by only 12 percent.
In conclusion, a few clinical pearls could be drawn:
1) Epidural steroid injections have little clinical benefit (short or long term) and are associated with significant risks.
2) Steroid injections cause deterioration of bone quality, elevating the risk of spinal fracture.
3) Use of epidural steroid injections has increased dramatically despite lack of evidence to justify the procedure.
So, it all begs the question:
Why such a huge increase in the use of a procedure that has limited benefit?
Patients need to be informed about treatment options including the best evidence for effectiveness, uncertainties and risks, so they can take an expanded role in decision-making.
Pinto RZ, et al.
Epidural corticosteroid injections in the management of sciatica: A systematic review and meta-analysis.
Ann Intern Med, 2012 Nov 13; [e-pub ahead of print].
Mandel S, Schilling J, Peterson E, et al.
A retrospective analysis of vertebral body fractures following epidural steroid injections.
J Bone & Joint Surg, 2013 Jun;95(11):961-964.
Armon C, Argoff CE, Samuels J, Backonja M.
Assessment: use of epidural steroid injections to treat radicularlumbosacral pain. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.
Arden NK, Price C, Reading I, et al.
A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: the WEST study.
Airaksinen O, Brox JI, Cedraschi C, et al.
European guidelines for the management of chronic nonspecific low back pain.
Eur Spine J, 2006;15(Suppl 2):S192–S300.
Chou R, Rosenquist R, Loeser J.
ACP-APS Guidelines for Surgical and Interventional Procedures for Chronic Low Back Pain.
Presented at Symposium 312 of the American Pain Society’s 27th Annual Scientific Meeting, Tampa, Fla., May 8, 2008.
Friedly J, Chan L, Deyo R.
Increases in lumbosacral injections in the Medicare population: 1994–2001.