Epidural Steroid Injections Could Cause More Harm Than Good

For many with chronic back pain, epidural injections are the only reliable source of relief.  However, a recently published study suggests that consistent administrations of steroid could result in more harm than good.  In the following article, Dr. Michael Omidi discusses the study, as well as the possible complications that could arise from the steroid treatments.

The recent fungal meningitis outbreak was caused by a tainted batch of injectable steroids (methylprednisolone acetate) meant for the treatment of chronic back pain. Now, according to a new study, it seems that the back problems that the steroid was meant to relieve might actually be made worse by the epidural injections [1].

In a study that was recently published in the journal Spine, a group of physicians followed 276 patients from the ages of 53-75 with more or less similar degrees of chronic back pain for four years. Of the 276 subjects, 69 received epidural steroid injections as a part of pain management therapy, while the remaining 207 did not. The authors of the study expected to see a wider variation of painful symptoms in the subjects who had not had epidural injections versus those who did. Instead, it seems that the subjects that underwent epidural injections displayed considerably less improvement after corrective surgical procedures than those who did not. 

The study was too small to draw any concrete conclusions, but it does seem that the steroid injections might hamper the healing process post surgery.

The subjects were all suffering from spinal stenosis, a condition wherein the open spaces within the spine gradually narrow, putting pressure on the spinal cord and causing sometimes extreme pain. The steroid injections ease the pain temporarily by surrounding the conflicted nerves.

Because spinal stenosis is a degenerative condition, the addition of the steroids may facilitate that degeneration, making the prognosis after surgery more grave than if the treatment was never administered.

Epidural injections are only recommended for patients who suffer from crippling back pain that may also spread to the arms, legs and head. These injections are not meant to cure the condition; only to make the symptoms more bearable. However, it is estimated that only approximately half of all the patients who receive epidural injections for treatment of back pain derive significant pain relief.

It should be noted that steroid injections should be viewed as a last resort in the event that other physical therapies and medications prove ineffective.

The injectable steroid used in such epidural injections that caused the fungal meningitis outbreak was methylprednisolone acetate, a steroid that was obtained through compounding pharmacies because FDA-regulated drug manufacturers do not make a version of the drug without preservatives.  The compounding pharmacy that was responsible for the contamination of the drug that was distributed to thousands of clinics throughout the nation has since declared bankruptcy.

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[1] Bakalar, Nicholas: Back Pain Unrelieved By Steroid Shots New York Times 3/5/2013 http://well.blogs.nytimes.com/2013/03/05/back-pain-unrelieved-by-steroid-shots/?ref=health

Meningitis Epidural Shot Risks

Epidural Steroid Injections

Unfortunately, fungal meningitis hasn’t been the only condition that has resulted from the tainted batch of compounded medications from the New England Compounding Center, and it isn’t the first that has arisen from the practice of injecting steroids near the spinal column. Physicians are of differing opinions about whether the use of epidural steroid injections is ethical or even safe, and the recent health crisis is causing many regulatory bodies to look more closely at the practice.

Risks of Epidural Steroid Injections

Although steroid injections are approved for pain relief in joints, epidural injections of steroids aren’t endorsed by the FDA. However, it is common practice for physicians to recommend or use drug treatments that are not specifically intended for a particular purpose, and many patients report significant or total relief from crippling back pain, which sometimes spreads into the arms and legs. It is generally believed that epidural injections are safer than surgery or even drug treatments, which can lead to prescription pain medication addiction. Nevertheless, performing injections near the spinal column is a very tricky business; the physician risks causing permanent nerve damage, depriving the site of oxygen and even injecting the drug directly into the spinal fluid. There have been cases of chronic complications, including arachnoiditis (an inflammation of the membrane of the spinal column that leads to numbness, incontinence, sexual dysfunction and even paralysis) and even death.

Sufferers of chronic and debilitating back pain due to herniated discs are considered the appropriate recipients of epidural steroid injections, but a study in 2007 revealed that they make up less than half of the patients who receive this treatment. According to Dr. Laxmaiah Manchikanti, chairman of the International Society of Interventional Pain Physicians, only 20 percent of doctors performing this procedure have received the appropriate training.

Financial Incentive for Performing Epidural Steroid Injections

There might also be a financial incentive to perform these treatments as well. Medical insurers and Medicaid pay sometimes hundreds of dollars per injection, and there are clinics around the nation that are devoted to exclusively providing epidural steroid injections for back pain management.

It is believed by many physicians that steroids that are free of preservatives are less risky to patients than their counterparts. However, because preservative-free epidural steroid injections are not manufactured by drug companies, clinics and physicians must use compounded drugs, which are not heavily regulated and, as we have seen with the recent meningitis and tainted drug crisis, are vulnerable to contamination.

Sufferers of chronic back pain should seek multiple opinions on the best treatment course, and only submit to epidural injections after different therapies have been exhausted. The potential complications from epidural injections are scary, to say the least, it should be noted that they occur in only one in 10,000 cases, according to Dr. James P. Rathmell, who is involved in an FDA review of catastrophic neurological damage from injections.