New Evidence that Steroid Injections Fail to Fix Spinal Stenosis

Every year millions of patients are injected with epidural steroids to treat back pain, but now, new research suggests that many of those injections are completely unnecessary. In a study released Wednesday from The New England Journal of Medicine, researchers found that epidural steroid injections failed to produce any measurable benefits compared to lidocaine injections for spinal stenosis.

This isn’t the first study to question the effectiveness of epidural steroid injections for back pain. What makes this research unique is that it is the largest randomized trial conducted yet on the effects of the injections for spinal stenosis. This condition refers to a narrowing of the spine that causes sciatica as well as pain in the back and legs.

The study included 400 patients with spinal stenosis who received injections of either steroids or an anesthetic (lidocaine). After six weeks, both groups showed similar rates of improvements, leading researchers to conclude that steroid injections “offered minimal or no short-term benefit.”

The FDA has not approved these injections for the treatment of back pain, yet doctors routinely perform the procedure in everyday practice. Why? Because some patients report improvements and many insurance companies require patients to get the injections prior to receiving surgery.

One orthopedic surgeon at Rush University Medical Center in Chicago, Dr. Gunnar Andersson told  The New York Times, “It’s sort of become the thing you do. You see this abnormality on the M.R.I. and the patient complains, and immediately you send the patient for an epidural injection.” Dr. Andersson said the latest study will likely cause more physicians and patients to ask, “Should I really do this?’”

In answering that question, patients should consider the risks. Although the injections are generally considered safe, the FDA warned in April that in rare cases the treatment may cause blindness, stroke, paralysis, and even death. In 2012, contaminated steroid injections were linked to an outbreak of fungal meningitis with 751 cases, including 64 deaths. Many of those infected had received the injections for spinal stenosis and back pain.

The treatment also carry additional risks for the elderly: A study of patients over 50 years old found that every new injection of epidural steroids resulted in a 21% increase in a patient’s risk of vertebral fractures.

For seniors who don’t want to take those chances (however rare), chiropractic care can alleviate symptoms of spinal stenosis in many patients, research suggests. In fact, when it comes to disc herniation, one trial found that chiropractic was just as effective as epidural steroid injections in easing back pain, but without the costs or risks.

Written by: Marissa Luck on July 3, 2014.on July 7, 2014.

FDA Orders New Warning for Epidural Steroids

Injectable corticosteroids must now carry a new label warning about the risks of severe adverse effects from epidural injections including death, stroke, and permanent blindness and paralysis, the FDA said.
The agency decided that such a warning is needed after reviewing numerous reports in the medical literature and its own adverse event database.

"Serious adverse events included death, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, stroke, seizures, nerve injury, and brain edema," the FDA said in announcing the warning.
"Many cases were temporally associated with the corticosteroid injections, with adverse events occurring within minutes to 48 hours after the corticosteroid injections. In some cases, diagnoses of neurologic adverse events were confirmed through magnetic resonance imaging or computed tomography scan. Many patients did not recover from these reported adverse events."

Overall, the agency said, these events were rare, but their seriousness merited the label change.
It urged healthcare providers to discuss the risks with patients before giving injections and to instruct them to watch for adverse neurological effects such as loss of vision, numbness or tingling, severe headaches, or seizures.

The FDA emphasized that the warning is unrelated to the fungal contamination problem associated with steroids used in epidural injections in 2012 that resulted in a crackdown on compounding pharmacies.

The use of epidural injections, in my opinion, is a procedure over utilized.  Over the years I have seen both the good and bad outcomes from the procedure. Personally, I feel the best outcomes arise out of a combination of epidural with Chiropractic adjustments.  Having said that, it is rare that I recommend the procedure.  It leads to temporary reduction in inflammation without addressing the underlying mechanical issue.  Thus, many patients resort to multiple injections with the hope that the next one will CURE THEM. The delay in improving mechanical dysfunction further deepens the abnormal movement patterns giving rise to additional issues in the hips, knees and feet.  
As a society we are too quick in our judgement of treatment effectiveness.  I guess it comes from the reality that our lives are fast paced and with that comes a general disdain for anything that takes time.  Dr. Bruce Bond once said that if you are looking for quick and cheap relief you shouldn't be at a Chiropractor's office because the Medical community has quick and cheap relief down to a science.  But, if you desire true return to Health, Chiropractic has it all over Medicine.  

Dr David Marcon, DC