Wednesday, 11 July 2012

Steroid injections for low back pain


The Cochrane review on injections for low back pain concludes: “There is insufficient evidence to support the use of injection therapy in subacute and chronic low-back pain”. The injections contain corticosteroid (‘steroids’, ‘cortisone’) mixed with local anaesthetic and are injected into the epidural region or the facet joints of the lumbar spine. The injections have been compared to placebo injections and to other treatments and, without going in to all the detail, they basically don’t work.

But that’s back pain you say. What about radiculopathy, where patients have a “pinched nerve”? Surely the corticosteroids will reduce swelling and reduce pain? Well yes, most patients do get better after these injections. But again, they are no more likely to provide relief than a placebo injection (here).

But surely some studies show a benefit to these injections? Again, yes, but those studies are usually not ‘blinded’ and do not use a true placebo, so we are not allowing for the placebo effect and the other reasons why people get better without treatment.

Other studies of steroid injections into the spine have compared different injection techniques (here), different types (here) or different doses of steroid (here), and when they find no difference between the treatment groups they conclude that both treatments are equally effective, without considering the possibility that both treatments are equally ineffective.

How big is the problem? There are hundreds of thousands of back injections performed each year worldwide. It is routine practice for general practitioners and spine specialists, and it is big business for interventional radiologists. In the US, the rate of epidural injections in the Medicare population increased more than three-fold between 1994 and 2001 (here) and more than doubled in the 10 years leading up to 2006 (here). The increase in costs per injection means that the cost of spinal injections has increased several hundred percent (here). Graphs like this one highlight the problem (reference):
















We are witnessing an increasing divergence between the growing evidence that these injections do not work, and the growth in the number of these injections being performed. There are many likely explanations. Firstly, it is standard practice, so it is easy to justify; if everyone is doing it, then you cannot be criticised for doing it. Also, as I have said before, patients want some kind of treatment and at least the doctors feel as if they are “doing something”. Most doctors probably believe (from what they see, from tradition, and from wishful thinking) that the injections work. Like Bruce Willis in The Sixth Sense, doctors are ‘seeing what they want to see’. They give the injections and some patients feel better afterwards, and they impute cause-and-effect. Very human of them, but not very scientific. The science tells us that they were just as likely to get better with a placebo. Also, of course, a lot of people are making a lot of money from these injections.

26 comments:

  1. This comment has been removed by the author.

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  2. Not all injections are the same though. Your reference for radicular pain only refers to caudal epidurals. Transforaminal injections have been subject to a systematic review
    http://www.painphysicianjournal.com/2009/january/2009;12;233-251.pdf
    which showed them to be very beneficial. Your reference with regards techniques http://www.ncbi.nlm.nih.gov/pubmed/21914118 merely compared epidural to transforaminal injections, and found good pain relief for both, but no difference between them. Extrapolating my two studies would suggest that transformational and epidurals may both be better than placebo.

    Is the picture clear? Not yet, but the evidence is strong that transformational injections for radicular pain are very effective, and that's not counting the diagnostic information they provide as well. Your blog did not address this.

    I think it's not very fair to dismiss them on the basis of practitioner's income, and in fact quite unfair.

    John

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    1. Thanks John, but I disagree.
      I think the equivalent therapeutic effect of epidural and transforaminal injections fits with the other studies. Epidurals are no better than placebo, and according to the systematic review to which you refer, transforaminal injections provided no lasting benefit over placebo (the placebo actually did a little better in the long term). The non-placebo studies showed mixed results.
      My conclusion has not changed. All of these injections work; I agree that there is strong evidence that they provide post-injection improvements. My point is that none of them provide improvements greater than placebo injections.
      As for financial incentives influencing medical practice, I am simply offering one (of many) reasons to explain continued practice in the face of conflicting evidence.

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  3. Thanks Dr Skeptic, I really enjoyed this article. In my point of view, Most practitioners will also agree that, while the effects of the injection tend to be temporary - providing relief from pain for one week up to one year - an epidural can be very beneficial for a patient during an acute episode of back and/or leg pain. And Epidural steroid injections (ESIs) are a common treatment option for many forms of low back pain and leg pain.

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    1. Thanks, I don't think there is any doubt that many patients improve after these injections, but given that the effect is no greater than placebo, should we continue to use it?

      ESIs are clearly common, and in fact they are increasingly being used. I just have a problem with using placebo treatments and rationalising their use with pseudo-scientific explanations.

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  4. Hi There, I just spent a little time reading through your posts, which I found entirely by mistake whilst researching one of my projects. Please continue to write more because it’s unusual that someone has something interesting to say about this. Will be waiting for more!

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  5. Does this blog post also apply to such injections given in the cervical spine area? My neck is a mess and my orthopedic surgeon said that the injection is the only other option before we resort to surgery at this point if the pain reaches the point of becoming intolerable. (I've done PT and it helped a lot) I really don't want the injection if it's not even going to do anything. I am opposed to sticking things into areas that may injure my spinal cord and if these injections don't even work, I don't see how the risk can be justified. If they don't work, I'll just suck it up and suffer, as I do NOT want surgery. Thank you for any response.

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    1. Most of the studies, and most of the injections, are lumbar. The theory in the neck is the same (reduce swelling, reduce inflammation etc.). Even if the theory is accepted without proof, it can only lead to a temporary improvement and I would not recommend it. Certainly not at this point in time in NE USA (see http://www.cbsnews.com/8301-204_162-57530886/steroid-injections-tied-to-meningitis-outbreak-may-cause-joint-infection/).

      Surgery is a much bigger decision, but remember that the severity of your symptoms and the lack of alternative treatments do not make the surgery any more effective, so they are not reasons for surgery. The decision should be made on the likelihood of gaining any benefit, over the likelihood of harm.

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    2. Thanks. Very good points. And I appreciate the shift you provided in my mindset at the end of your reply.

      Also, the meningitis story has definitely been on my mind. I remember the day that my surgeon misunderstood something I said and thought I wanted the injection... he left the room to go get it. I could have been one of those people. And I had no idea that the substance he would have injected is compounded by unregulated companies with potentially poor quality control. I thought it was a regular old drug made by a regular old drug company that is subject to the regular old rules and regulations. It's all just very scary. Thanks very much for your reply.

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    3. One other thing... I'd be interested in hearing whether you think the meningitis outbreak will reduce the number of providers who resort to these injections... and/or reduce the number of injections individual providers give.

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    4. Once the problem has been isolated and corrected, and possibly with more regulations in place, I see no reason why the rate will drop significantly. The same drivers are in place: perception of benefit, placebo effect, patient demand, doctor reliance on 'something', ease of use, low cost etc. etc. The only driver that wil dip in the short term is perceived safety.

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  6. Thank for sharing. Can you explain what are the side effects for the injection?

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    1. Side effects are uncommon, but rare cases of infection, discitis and even permanent neurological deficit have been reported. Currently, there is an outbreak of fungal meningitis from contaminated steroids in the USA which has caused 29 deaths at this stage (http://www.medpagetoday.com/Neurology/GeneralNeurology/35668?utm_source=breaking-news). Not really acceptable for a placebo in my opinion.

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  7. The complete lack of movement from every day to day life can lead to loss of muscle tone in the lower back which results in loss of stability in the spine.

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    1. Thanks, but you offer a biological explanation for ... what exactly? The definition of spinal instability is so vague as to be untestable. Back pain is just as common in lazy people as active people, and it is back pain we are interested in, not theoretical "instability" which has no clear clinical definition, let alone any link to back pain.

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  8. Thanks for the post. I had been looking for something related and found your web site in the process.. I will definitely be back for more.

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  9. Delighted that I found your site, fantastic info. I will bookmark and try to visit more frequently.

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  10. Interesting post about spinal injections. I am scheduled to have an injection today, as a matter of fact, to ease the pain being caused by a central protrusion of my disc between L4 and L5. In reading about side effects and now the fact that there is no evidence that the steroid injection is any better than a placebo, I'm considering cancelling the appointment. However, what are some of my alternatives to get relief. The pain in my hip, leg, and groin is becoming unbearable.

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    1. Thanks for your comment.

      It is not my place to offer individual advice on a patient that I have not seen, but your question is a common one: "If this treatment is not effective, what should I do?"
      Depending on the condition, sometimes there are no effective interventions beyond simple analgesics and modifying your activities to minimise the pain. For you particular condition, I recommend getting advice from your doctor.

      One thing I try to avoid is driving patients from one ineffective treatment to another. Remember that the failure of one particular treatment does not make the next treatment more effective. Each treatment should stand or fall on its own.

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  11. Good information shared about steroids injection.But Is it safe to take steroid injection every time if a patient is having back pain as their is a possibility of having back pain again.

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    1. Thanks James,

      Rather than repeating steroid injections, my point is that they should not e used in the first place. They have no specific (beyond placebo) therapeutic effect and carry a small risk of harm. There are safer and cheaper placebos available.

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  12. Interpreting research findings is an art in itself and it's clear that one must exercise caution whenever a study tries to investigate any intervention for 'back pain.' Without a diagnosis or identifiable tissue in lesion you don't even know what it is you have investigated.

    To wit injection procedures. If used in conjunction with a history, exam and a clinician who is up to date with the literature you can tell Mr Smith that the benefit will not be sustained (Cochrane) but will give us an opportunity to provide temporary relief, initiate conservative care and confirm a diagnosis (when this proves difficult). After all joint blocks gave us tremendously valuable clinical information so that we can reliably correlate the site of symptoms with the generator without resorting to invasion in the majority of cases. A recent study has suggested that steroid infiltration (early intervention (under 2 months) lateral recess) may reduce neural tethering of the exiting root (a common complication with annular lesions)) and lower the risk of the development of chronic pain. It appears (at this point) that it's use may be limited after the acute inflammatory phase.

    So yes if read one way the report appears to suggest a blanket rejection of injection but like one review of say 'spinal manipulation' we don't know what was done nor what conditions it didn't appear to work for nor those which responded because there was no diagnosis to begin with. As with the above we can misinterpret and throw the baby out with the bathwater.

    Regards

    Douglas Scown




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    1. Thanks Douglas, some good points. However, I disagree with the usefulness of local injections to localise disease. This is notoriously unreliable, and I think the saga of discograms has shown that. Also, if used for localisation of pathology, why not use local anaesthetic only, because I dont' think the steroids do anything?

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  13. Just discovered your site and blog...finally a much sought after intelligent rational discourse. Where does one find doctors who are guided by science and critical thought rather than their own game of questionable therapy? This is probably a rhetorical question.

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    1. I don't know exactly how to find them, but I can tell you that they are out there.

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  14. I have always heard about this but never gave it a second thought. I've suffered from back pain for years and have always been on edge when trying new things cause everything I have tried has failed. The only thing that has relieved me back pain was actually exercise. Thanks for sharing this information with us.

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