A Balanced Approach to Epidural Steroid Injections

By Paul Lynch, MD Board Certified Pain Medicine Board Certified Anesthesiology Founder, PainDoctor.com Founder, Arizona Pain Specialists Board of Directors, American Society of Interventional Pain Physicians – Arizona Chapter

Posted on | By Paul Lynch, MD

Epidural steroid injections are the most widely used pain management procedures in the world.1 So why all the criticism? Some would lead you to believe it is the most foolishly used procedure in the world. The truth, as it so often does, lies somewhere closer to the middle.

From This Episode:

Dr. Oz's Pain Clinic

A close analysis of the data, along with countless patient testimonials, tells us that injections of corticosteroids into the space around the spine (known as epidural steroid injections or ESIs) given to the right patient by the right doctor will usually yield a positive result with extremely low complication rates.

I have personally witnessed this, and heard from patient after patient that this procedure got them back to work, let them hike a mountain, or simply allowed them to pick up their kids. In short, it changed their life. Those are the real patient stories that cannot be ignored.

But as a physician, I am also taught to examine the scientific data. What does the data say and how should you, as a patient, make your decisions?

Let’s start with the obvious when it comes to choosing a physician: It’s confusing. There are so many choices, specialties and advertisements that make it difficult to distinguish the good from the bad. Let me provide a very clear idea of who I would send my own mother to see.

1. Credentials - Board certified, fellowship-trained physicians have invested the time to become knowledgeable about pain management and can most reliably provide care.

2. Clinic Model - The very best physician practices employ a comprehensive, integrated model using a multidisciplinary team of physicians and nurses to deliver care: chiropractic, physical therapy, bracing, diagnostics, behavioral health, interventional care and medication management should be incorporated into a unique treatment plan for each patient. If you are not being offered these things, you are not in the right place.

3. Conservative Care - In most cases, unless there is visible evidence of serious problem, physicians who jump straight to a procedure before exploring the most conservative care first are doing their patients a disservice. This is what I refer to as “the mom or dad test” – I wouldn’t send my mom or dad to such a physician, and I would strongly urge they get a second opinion.

4. Diagnosing the Problem - Industry-leading physicians are interested in the cause of your ailment, not just providing treatment. Make sure your provider is saying things like, “You’ve got a herniated disc at L5 confirmed by MRI,” not just, “An epidural will help your back pain.”

A Closer Look at the Data

Using the Global Pain Scale (GPS) in our practice at Arizona Pain Specialists has shown the following:

  • 61% of patients increase their activities of daily living
  • 58% are taking less medications
  • 51% sleep better
  • 48% have a decrease in pain scores

I assure you, not all of these patients are getting epidural steroid injections. They are being offered an array of treatment options based on the expertise of a team of providers focused on the best outcome for the patient.

For those who do have epidurals, there are dozens of studies that look at the safety and effectiveness of this procedure, and that data guides our decision-making.

Epidural Steroid Injections Can Help

 

From the early 1900s until 1953, epidural injections contained only a local anesthetic. After 1953, doctors switched to injecting corticosteroids, as these were considered more effective than local anesthetic alone. Over the past six decades, there have been over 45 placebo-controlled, scientific studies assessing thousands of patients to test the efficacy of epidural steroid injections.1 Most of these studies found that epidural steroid injections were effective in relieving pain (Review some of these studies for yourself.).

Some of the studies did not find epidural steroid injections to be more effective than the control treatment. However, many of those studies that found similar results for patients receiving ESIs and the control group did not simply give the control group a placebo treatment that had no therapeutic benefit. Instead they gave control patients local anesthetic injections – the standard treatment until the 1950s. Thus, rather than showing that ESIs don’t help, these trials appear to show that both treatments (local anesthetic injections and epidural steroid injections) are effective in reducing pain.

When are epidural steroids the right treatment?

Like any medical treatment, there is a right and wrong time to any intervention. Some patients’ back pain is the result of one or more bulging spinal disc(s). When the disc protrudes to the side, it can put pressure on the nerve roots that pass through the spine. Often, this occurs in the lower back and causes pain that radiates from the lower back down the legs. This is often called sciatica or lumbar radiculitis. The research is clear that epidural steroid injections can help reduce pain for such patients, in part because these injections reduce the inflammation, relieving pressure on the nerve roots.1

Are there other conditions that are helped by epidural steroids?

For other patients, their low back pain may result from narrowing of the spinal canal. Research has found that, though epidural steroid injections can help relieve pain from narrowing of the spinal canal, the benefit is smaller than it is for patients with bulging discs.

How long do the benefits last?

The evidence is clear that epidural steroid injections provide short-term benefits (lasting several months) for many patients that include reduced pain, the ability to return to work and resume normal life. The long-term benefits, over the course of years, appear to be smaller but some patients continue to get relief and are able to avoid more extreme treatments because of these injections.

Understanding the Risks and Limitations of Epidural Steroid Injections

Patients should be aware of the risks of epidural steroid injections and weigh their options before making the decision to use this treatment.

What are the risks and how common are they?

In medical school, doctors are taught the Hippocratic oath: “First do no harm.” By that measure, epidural steroid injections hit the mark. In a recent study of 4,265 fluroscopically ESIs performed in 1,857 patients, no major complications were found.2 Minor complications, such as increased pain or pain at the injection site, occurred in 2.4% of cases. More serious complications, including nerve injury, infection or death, have been reported, but are estimated to represent fewer than 1 in 100,000 patients receiving this procedure.3

Some fear of epidural steroid injections stem from an incident in 2012 in which contaminated drugs resulted in 733 cases of fungal infections and 53 deaths.4 This tragic and devastating outbreak was isolated to one pharmacy. An event like this is unprecedented in the 60-year history of this treatment, given that over 8 million epidural steroid injections are done in the US each year. Thankfully, even in the year of this tragic outbreak, fewer than 1 in 10,000 epidural steroid injections led to fungal infection, and fewer than 1 in 150,000 injections led to a fatal fungal infection.

How can we balance the benefits and risks of this treatment against other options?

Like any tool, once it is found useful, there is a risk that it will be overused. Responsible pain physicians rely on many tools, of which ESIs are just one. In our practice, we first pursue conservative care with patients. This means acupuncture, chiropractic care, physical therapy, behavioral therapy, holistic treatments and over-the-counter medications. If these treatments are not successful in alleviating a patient’s pain, we move on to low-risk medications, such as non-steroidal anti-inflammatory and neuropathic medications.

When patients’ symptoms are still not controlled by these treatments, the remaining options include surgery, opioid treatment and injection treatments, such as ESIs. Unfortunately, these treatments all carry risks. This is why these treatments are used only for patients who continue to suffer moderate to severe pain even after conservative care. Many surgical treatments have much greater risks and side effects than injection therapy. Some research indicates that, by receiving ESIs, patients are less likely to subsequently undergo riskier surgeries. Opioids such as Percocet, Vicodin, Lortab, Morphine and others not only carry a significant risk of addiction, but also caused over 16,500 deaths in 2010.5 When ESIs are compared to surgery or the use of opioids, the potential risks and benefits can be well justified.

Patient Education

Because doctors disagree about the best treatments for pain, patients must be actively involved in decisions about the care they receive. We are passionate about educating patients about pain. Patients’ ability to make informed choices depends on their understanding their condition and the treatment options available. We are passionate about educating patients about pain and, in that vein, we created Paindoctor.com to provide patients with information about pain conditions and medical treatments. Additional information about the research on epidural steroid injections can be found there.

Conclusion

Not every patient in pain needs an epidural, but the right patient will likely benefit from its effects. A conservative, comprehensive and integrated approach should be taken to diagnose and treat each patient in pain — this is what I would want for my own mom or dad. Within that context and with a full understanding of the risks and benefits, I am confident that ESIs are one of many useful tools that help patients get back on their feet.

References

  1. Cohen SP, Bicket MC, Jamison D, Wilkinson I, Rathmell JP. Epidural steroids: A comprehensive, evidence-based review. Reg Anesth Pain Med. 2013;38: 175-200.
  2. McGrath J, Schaefer M, Malkamaki D. Incidence and characteristics of complications from epidural steroid injections. Pain Med. 2011;12:726-31.
  3. Fitzgibbon D, Posner K, Caplan R, et al. Chronic pain management: American Society of Anesthesiologists Closed Claims Project. Anesthesiology. 2004;100:98-105.
  4. Centers for Disease Control and Prevention, Multistate Fungal Meningitis Outbreak Investigation. Available at: http://www.cdc.gov/hai/outbreaks/meningitis.html. Accessed May 3, 2013.
  5. Centers for Disease Control’s Primary Care and Public Heath Initiative Presentation. Prescription Drug Abuse and Overdose: Public Health Perspective. October 24, 2012. http://www.cdc.gov/primarycare/materials/opoidabuse/docs/pda-phperspective-508.pdf.

Article written by Paul Lynch, MD
Board Certified Pain Medicine Board Certified Anesthesiology Founder, PainDoctor.com Founder, Arizona Pain Specialists Board of...