Marc Darrow MD,JD
As the availability of elective surgery maybe become less available, many people who decided to move forward with surgery find themselves on a prolonged and delayed waiting list for the surgery and are now back on treatments that did not help them in the past. For people with chronic, persistent back pain, this would include another round of epidural or steroid injections to help hold them over until their surgical turn comes up.
Regardless of the current situation. Epidural steroid injections do not heal a bad back or neck. Some researchers consider epidural steroid injections to be, at best, a very short-term painkiller that sometimes prevents a patient from getting the proper treatment for his/her back pain.
The one thing that surgeons and regenerative medicine specialists agree on is the question being raised in the medical literature asking whether patients have been informed of the poor likelihood of long-term epidural injection treatments success for disability.
Here is what was published in the surgical journal (1) Surgical neurology international.
It is well documented that epidural spinal injections of steroids have significant risks and complications without any long-term efficacy.
“Therapeutic epidural spinal injections of steroids are one of the most common nonsurgical management modalities employed for alleviating pain due to chronic persistent lumbar spinal disease. However, it is well documented that they have significant risks and complications without any long-term efficacy. Epidural spinal injections of steroids may result in epidural empyema (the development of pus) which may be difficult to diagnose with delays resulting in significant permanent neurological (disease or injury).”
In the research below from some of the leading medical universities in the world, we see that the goal of epidurals and surgery is to provide pain relief. Unfortunately improving disability and function may not be an attainable goal with these treatments.
Just a little better than placebo, but only in the short-term
A study published in November 2020 (2) compared the effectiveness of Epidural corticosteroid injections. The findings were simply:
- Epidural corticosteroid injections were probably more effective than placebo in reducing short-term leg pain in sciatica patients
- Epidural corticosteroid injections were probably more effective than placebo in reducing short-term disability
- Epidural corticosteroid injections may be slightly more effective in reducing short-term overall pain
- Epidural corticosteroid injections are effective, although the effects are small and short-term. There is uncertainty on safety.
How many epidurals can I get?
This is one of the concerns patient’s and doctors have. An orthopedist or neurosurgeon has suggested a cervical or lumbar surgery. The patient is put on a waiting list and may need to wait months, maybe longer for the surgery. The patient needs help managing their pain and disability until they can get the surgery. The question then becomes, How many times can we give an epidural?
There is a concern these injections can alter the hypothalamic–pituitary–adrenal axis. What does this mean?
A study (3) in May 2020 offered grave concerns that many doctors fall under the spell of “myths,” concerning the safety of these injections. These are the myths:
- Myth #1: Epidural steroid injections (ESIs) can be repeated without concern regarding the duration of time between injections.
- Myth # 2: A “series” of ESIs is sometimes required regardless of the clinical response to a single ESI.
This is the published “FACT.”
- “Fact: After an Epidural steroid injection, a period of up to 14 days may be needed to assess the clinical response. Systemic effects on the hypothalamic–pituitary–adrenal (HPA) axis may last three weeks or longer. These factors must be considered when determining if or when another ESI is indicated. There is no evidence to support routine performance of a “series” of repeat injections without regard to the clinical response.
The concern here is that doctors wait up to 14 days to see if there are adverse side effects. However, some side effects do not appear until after. One of the side effects is a negative impact on the hypothalamic–pituitary–adrenal (HPA) axis causing hypothalamic–pituitary–adrenal dysfunction. This would be a suppression of natural cortisol production which could lead to among other problems, reduced immune response, digestive problems, fatigue, and increased pain in the back and legs.
Can epidurals prevent surgery? Is surgery just better?
It is probably safe to say that most people would like to avoid a spinal surgery. For some people this is an achievable goal, for others the degenerative condition of their spine would put surgery as the most realistic option. This would be in patients with advanced neurological defects, like the inability to urinate, loss of circulation or sensation in the legs, among other symptoms.
“…epidural steroid injection cannot alter the need for surgery in the long term.”
Epidural steroid injections do not prevent surgery, they provide pain relief until the day of surgery. From Johns Hopkins School of Medicine, Walter Reed National Military Medical Center, University of Toronto researchers:
- Epidural steroid injections provide modest pain relief up to 3 months in patients with lumbosacral radicular pain caused by herniated disks, but they have no impact on physical disability or incidence of surgery.(3)
From The Chinese University and Prince of Wales Hospital in Hong Kong:
- The immediate response to transforaminal epidural steroid injection was approximately 80%. . . However transforaminal epidural steroid injection cannot alter the need for surgery in the long term.(4)
From the Department of Orthopedic Surgery, Thomas Jefferson University, Rothman Institute
- For some epidural steroid injections did not work at all. “Patients with lumbar disc herniation treated with epidural steroid injection had no improvement in short or long-term outcomes compared with patients who were not treated with epidural steroid injection.”(5)
This is from Stanford University
“Despite a high success rate at 6 months, the majority of (patients) experienced a recurrence of symptoms at some time during the subsequent 5 years. Fortunately, few reported current symptoms, and a small minority required additional injections, surgery, or opioid pain medications. Lumbar disc herniation is a disease that can be effectively treated in the short-term by transforaminal epidural steroid injections or surgery, but long-term recurrence rates are high regardless of treatment received.”(6)
Does Epidural steroid injection help with lumbar stenosis? Even if it doesn’t help that much, is it still better than surgery?
In September 2020 in the journal Pain practice: the official journal of World Institute of Pain (7) researchers questioned the long-term effectiveness of Transforaminal epidural steroid injection in patients suffering from back pain caused by lumbar stenosis.
In this study of 90 patients who underwent Transforaminal epidural steroid injection for controlling lumbar spinal stenosis-induced radicular pain at least 5 years previously, 54 patients completed a phone interview on the effectiveness of the treatment.
- Results: Five to seven years after the initial Transforaminal epidural steroid injection, the numeric (pain 1-10) rating scale score had decreased from 6.7 to 3.7. Of the included patients, approximately 65% of the patients had a pain score of less than 3, although roughly 15% of patients reported complete resolution of the initial pain. Approximately half of the included patients were currently receiving repetitive Transforaminal epidural steroid injection every 2 to 6 months or were taking oral pain medications. Further, approximately 25% of the patients had undergone a surgical intervention; however, its outcome was poor.
Conclusion: The prognosis after Transforaminal epidural steroid injection for controlling lumbar spinal stenosis-induced radicular pain is thought to be relatively poor. However, considering poor long-term outcome and complications after surgery, (the researchers of this study) we believed that Transforaminal epidural steroid injection is worth considering.
Epidural steroid injection the most frequently performed pain procedure, dangerous?
In a review published by Dr. Epstein from the Albert Einstein School of Medicine in the medical journal Spine, Epidural steroid injections were not only questioned for lack of effectiveness, but also called dangerous:
- “(Epidural steroid injections) are typically short-acting and ineffective over the longer-term, while exposing patients to major risks/complications. . .Although the benefits for epidural steroid injections may include transient pain relief for those with/without surgical disease, the multitude of risks attributed to these injections outweighs the benefits.”(8)
Epidural steroid injection side effects
Epidural steroid injections are given to reduce inflammation in the nerves that pass through the spinal canal. Many pain management specialists believe that nerve inflammation is the root cause of the patient’s discomfort and the cause of radiating pain and numbness down the patient’s legs. Patients with these problems are often diagnosed as having “Sciatica,” a term to describe injury or compression of the sciatic nerve. Dr. Alison Stout of the Spine and Musculoskeletal Medicine, Rehabilitation Care Services, Veterans Administration said: “Epidural steroid injection has been used as a treatment for low back pain for over 50 years. In the last 10 to 15 years, there has been a significant increase in (their use) for the treatment of low back pain and radicular pain without clear improvements in outcomes.” As chronic pain specialists we see many patients with radiating lower back pain. When we first examine these patients at least 25% of them will say that they have been diagnosed with sciatica. After the examination we find that many of these patients do not have sciatica at all and this is why epidural steroid injections have failed them.
When epidurals do not work
When epidurals do not work many physicians will move the patient unto surgery. Procedures will be recommended that will “stabilize the spine” such as spinal fusion, or surgeries or laser methods that will create more space for the nerves by removing bone from the vertebrae. This is why we see many patients with “Failed Back Surgery Syndrome,” a procedure was performed that did not address the cause of the patient’s pain ligament weakness or laxity.
Treatment options beyond epidurals and alternatives to surgery
In our clinic we offer our patients options that treat the cause of their pain and functional problems with stem cell therapy. Use the form below and ask me your questions about your back pain.
Do you have questions? Ask Dr. Darrow
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References:
1 Brunasso L, Basile L, Iacopino DG, Gulì C, Graziano F, Pino MA, Nicoletti GF, Tumbiolo S, Maugeri R. All that glitters is not gold: A spinal epidural empyema following epidural steroid injection. Surgical Neurology International. 2020;11.
2 Oliveira CB, Maher CG, Ferreira ML, Hancock MJ, Oliveira VC, McLachlan AJ, Koes BW, Ferreira PH, Cohen SP, Pinto RZ. Epidural Corticosteroid Injections for Sciatica: An Abridged Cochrane Systematic Review and Meta-Analysis. Spine. 2020 Nov 1;45(21):E1405-15.
3 Mattie R, Schneider BJ, Smith C. Frequency of Epidural Steroid Injections. Pain Medicine. 2020 May 1;21(5):1078-9. [Google Scholar]
2 Sivaganesan A, Chotai S, Parker SL, McGirt MJ, Devin CJ. 161 Patient-Reported Outcomes After Epidural Steroid Injections vs Surgery for Degenerative Lumbar Disease: A Prospective, Matched Cohort Study. Neurosurgery. 2016 Aug;63 Suppl 1:164-5. doi: 10.1227/01.neu.0000489730.99853.c3.
3. Bhatia A, Flamer D, Shah PS, Cohen SP. Transforaminal Epidural Steroid Injections for Treating Lumbosacral Radicular Pain from Herniated Intervertebral Discs: A Systematic Review and Meta-Analysis. Anesth Analg. 2016 Mar;122(3):857-70. doi: 10.1213/ANE.0000000000001155.
4. Leung SM, et al. Clinical value of transforaminal epidural steroid injection in lumbar radiculopathy. Hong Kong Med J. 2015 Aug 14. doi: 10.12809/hkmj144310.
5. Radcliff K, Hilibrand A, Lurie JD, Tosteson TD, Delasotta L, Rihn J, Zhao W, Vaccaro A, Albert TJ, Weinstein JN. The Impact of Epidural Steroid Injections on the Outcomes of Patients Treated for Lumbar Disc Herniation: A Subgroup Analysis of the SPORT Trial J Bone Joint Surg Am. 2012 Jun 27. doi: 10.2106/JBJS.K.00341. [Epub ahead of print]
6 Kennedy DJ, Zheng PZ, Smuck M, McCormick ZL, Huynh L, Schneider BJ. A minimum of 5-year follow-up after lumbar transforaminal epidural steroid injections in patients with lumbar radicular pain due to intervertebral disc herniation. The Spine Journal. 2018 Jan 1;18(1):29-35.
7 Jang SH, Chang MC. At Least 5‐Year Follow‐up After Transforaminal Epidural Steroid Injection Due to Lumbar Radicular Pain Caused by Spinal Stenosis. Pain Practice. 2020 Apr 21.
8. Epstein NE The risks of epidural and transforaminal steroid injections in the Spine: Commentary and a comprehensive review of the literature Spine: 2013;3:74-93 6. Stout A. Epidural steroid injections for low back pain. Phys Med Rehabil Clin N Am. 2010 Nov;21(4):825-34.1156
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