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 And the injections offer no significant relief for pain related to
narrowing of the spaces around the spinal cord, the researchers say.
Some earlier studies have reached similar conclusions, but others
have shown some benefit. Meanwhile, the use of epidural steroid
injections has been increasing in the face of contradictory
guidelines for physicians.
To clarify this confusing situation, Dr. Roger Chou from Oregon
Health & Science University in Portland and colleagues sorted
through the evidence from 63 published reports about the use of
epidural steroid injections for treating low back pain from ruptured
discs or spinal narrowing.
“I think the important thing is for patients and clinicians to be
able to make informed decisions,” Chou told Reuters Health by email.
“Epidural corticosteroid injections are perceived as being more
effective than they are.”
Spinal steroid injections brought immediate relief of pain and
improvement in function in patients with ruptured discs, but not in
patients with spinal narrowing, or stenosis, the researchers
reported in Annals of Internal Medicine.
Injections also seemed to reduce the need for disc surgery in the
short term.
But in the long term, the effects of injecting steroids epidurally
were no better than the effects of a placebo, the researchers say,
and there was no reduction in the need for surgery.
It didn’t seem to matter what specific injection technique or which
particular steroid was used.
Serious complications of the injections were rare in this study,
according to the authors. Minor complications included blood clots,
bleeding, and nerve root irritation.
If patients and clinicians understand that benefits of these
injections are small and short-lived, they may sometimes still
decide to try them, Chou said.
“Unfortunately, there are not a lot of great treatments for these
conditions besides surgery, so the options for treatment are
limited,” he added. “I do let patients know that the natural history
for both of these conditions is for improvement over time.”
The new analysis seems unlikely to settle any controversies,
however.
Dr. Zack McCormick, who specializes in physical medicine and
rehabilitation at Northwestern University Feinberg School of
Medicine in Chicago, told Reuters Health by email that because the
studies available for analysis by Chou’s team were of low quality,
the conclusions “cannot be applied to the realistic day-to-day
practice of spine medicine.”
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“The goal of epidural steroid injection is not for long term ‘cure,’
but rather to (improve) symptoms in order to allow restoration of
sleep, quality of life, and tolerance of physical therapy,”
McCormick said.
“Epidural steroid injections should not be used as an isolated
therapy,” he added. “More studies are needed which show outcomes of
epidural steroid injections in conjunction with a multi-modal
approach that includes physical therapy, oral medications, and other
adjunctive treatments, as this represents true clinical practice.”
Dr. Laxmaiah Manchikanti from the University of Louisville,
Kentucky, who is CEO and Chairman of the Board of American Society
of Interventional Pain Physicians, was also skeptical, and he told
Reuters Health by email that patients with lower back pain from a
ruptured disk or spinal stenosis should talk to their physician
rather than trust the new conclusions.
“Over a million people receive epidural injections either with
steroids or with local anesthetic alone per year and at least 60% of
them receive significant relief,” he said.
Dr. Steven P. Cohen, a pain specialist at Johns Hopkins School of
Medicine in Baltimore, Maryland told Reuters Health by email, “I do
not think we should categorically discontinue epidural steroid
injections for either of these conditions, but we need to limit
their use to those people who are most likely to benefit, and to
only repeat them if patients obtain clearly defined improvements in
function and quality of life. Otherwise, the costs and risks may
outweigh the benefits.”
SOURCE: http://bit.ly/1i46lF7 Annals of Internal Medicine, online
August 24, 2015.
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