Should I have epidural steroid injections?

This is the medical model for treating low back and leg pain that is caused by spinal stenosis (pictured, here) – a narrowing of the space that the spinal cord or nerve root passes through:

• Try exercises and physical therapy first.
• If you are still having more problems than you can deal with, try an epidural injection of steroids at the pain clinic.
• When that doesn’t help, surgery is then offered to open up the space.

A small study published in the February 2014 issue of the journal Spine suggests that the injections may do more harm than good!

The Spine Patient Outcomes Research Trial (SPORT) was a four year comprehensive study to look at different ways of treating low back and leg pain and how effective they were for patients, funded by the National Institutes of Health (NIH).  Some patients had surgery, others had non-surgical interventions, and the research published from the trial said, basically, that those who had surgery were, by and large, happier with their results one to four years later than those who didn’t.

Researchers with access to the SPORT database took a look at the results from a group of those non-surgical patients, specifically those patients with lumbar spinal stenosis, to see how the patients who received epidural steroid injection compared to those who didn’t.

There were 276 patients in the original SPORT study who had the diagnosis of lumbar spinal stenosis, and the data from this subgroup was analyzed to see how well the 69 who received the epidural steroid injections within the first 3 months of the study did, compared to the 207 who didn’t have the injections.

The conclusions? Pretty scary if you’ve already had the injections!

• Those patients who had epidural steroid injection were associated with significantly less improvement at 4 years among all patients with spinal stenosis in SPORT.
• Furthermore, for those who eventually had surgery, having epidural steroid injections were associated with longer duration of surgery and longer hospital stay.
• There was no improvement in outcome with epidural steroid injection whether patients were treated surgically or non-surgically.

In case you didn’t catch it:  At the end of four years, everyone who had the injections had significantly less improvement than those who didn’t have them (whether they ended up in surgery or not).

Okay.  Yes, this is a small study.  Yes, it only studied the people with one of the possible causes for low back/leg pain.  Do you really want to have such an injection IN CASE they find something different when they look at the rest of the population?

Should you have epidural steroid injections as part of the recommended course of treatment for your low back pain?  I think not.

I have a disc (bulge, herniation, rupture), but my surgeon sent me to . . .

This is really old news, but it came up in my personal life recently, so I’m putting it out there once again.

An article was published in the New England Journal of Medicine, in July, 1994, titled “Magnetic resonance imaging of the lumbar spine in people without back pain.”

They took 98 people who didn’t have low back pain and looked at their low backs with MRI scans.  36% had normal discs at all levels.  52% had a bulge at one or more levels (with 38% having more than one disc involved).  27% had a disc protrusion, and 1% had a disc extrusion.  They noted that the prevalence of bulges increased with age.

Their conclusion?

• “On MRI examination of the lumbar spine, many people without back pain have disk bulges or protrusions but not extrusions. Given the high prevalence of these findings and of back pain, the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental.” (emphasis is mine)

Some definitions might come in handy.  In this study,

• A disc bulge is defined as a circumferential symmetric extension of the disk beyond the interspace
• A disc protrusion is defined as a focal or asymmetric extension of the disk beyond the interspace
• A disc extrusion is defined as a more extreme extension of the disk beyond the interspace

These definitions are very basic, fairly vague, and non-universal.  The people who read MRI’s don’t have a universal language, so what one radiologist might call a protrusion another might call a herniation, someone else might call a prolapse, and yet another might call a rupture.  More information than even I want to read about the naming of this kind of radiographic finding can be found here.

I did find an article that gives a pretty balanced look at when it’s time to see the surgeon.  Take a look if you are considering this option.

And, that said, if you are experiencing pain that you cannot get away from (no position of comfort), if you are experiencing loss of bowel or bladder control, if you have foot drop . . . get evaluated sooner (like, now), not later.

Can We Predict Who Will Need Lumbar Spine Surgery?

This paper was published May 2013 in the journal SPINE:

Early Predictors of Lumbar Spine Surgery After Occupational Back Injury

Results From a Prospective Study of Workers in Washington State

Objective. To identify early predictors of lumbar spine surgery within 3 years after occupational back injury.

Results. . .  Reduced odds of surgery were observed for those younger than 35 years, females, Hispanics, and those whose first provider was a chiropractor. Approximately 42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who [first] saw a chiropractor. . .

Conclusion. . . There was a very strong association between surgery and first provider seen for the injury even after adjustment for other important variables.

SPINE Volume 38, Number 11, pp 953-964 ©2013