Interventional Diagnostics – Steroid injections

Report on epidural steroid injections efficacy raises doubts, but critics argue report is wrong

Do epidural steroid injections effectively treat radicular pain?

The American Academy of Neurology says it finds little in the way of high-quality evidence to support that notion.

However, that flies in the face of the positions held by a number of other medical societies and the federal government.

For example, epidural steroid injections (ESIs) have been endorsed by the American Spine Association and by the Agency of Healthcare Research and Quality of the U.S. Department of Health and Human Services – both of which contend that ESIs represent an integral part of non-surgical management of radicular pain from lumbar spine disorders.

Further, the Department of Physical Medicine and Rehabilitation at the University of Medicine and Dentistry of New Jersey notes in a paper published in 2007 that “ESIs have been recommended to deliver steroids in a more localized fashion to the area of affected nerve roots, thereby decreasing the systemic effect of the administered steroids.”

That same paper said ESIs also can have significant diagnostic worth. “ESIs may help identify the region of potential pain generation through pain relief after local anesthetic injection to the site of the presumed anatomic pathology,” the researchers wrote. “In addition, if the patient receives several weeks or more of pain relief, then it may be reasonable to assume that an element of inflammation was involved in his or her pathophysiology. This last element of diagnostic information is the therapeutic element. Since prolonged pain relief is presumed to result from a reduction in an inflammatory process, it is also reasonable to assume that, during the prolonged pain relief, the afflicted nerve roots are relatively protected from the deleterious effects of inflammation.”

Controversial assessment

The American Academy of Neurology made its controversial assessment of ESIs in an article appearing in the March 6 2007 issue of the journal Neurology.

It began by agreeing with the well-established fact that back pain is one of the most common disabling conditions in the developed world today. (According to an article published in The Permanente Journal Fall 2007 edition, low back pain is the fifth-most common problem that leads patients to seek medical attention.)

 “The economic impact of back pain is as important as its clinical impact, contributing by any measure an enormous sum to the total healthcare expenditure in the U.S.,” wrote the authors of the Neurology article. “In particular, the cost of treating spinal pain is significant and growing yearly. Epidural steroid injections are generally considered to be an important part of the standard conservative therapy for back pain. However, the role and efficacy of epidural steroid injections continues to be debated.”

The authors conclude that, in general, epidural steroid injection for radicular lumbosacral pain “does not impact average impairment of function, need for surgery or provide long-term pain relief beyond three months.”

In addition, they found insufficient evidence to recommend either cervical epidural steroid injections or radiographic guidance of those injections.

Opposing view

Edgar Ross, MD, director of the Pain Management Center at Brigham and Women’s Hospital and an assistant professor of anesthesia at Harvard Medical School, Boston, took the American Academy of Neurology to task with a rebuttal published in the April 17, 2007 issue of Journal Watch Neurology. He wrote: “The authors rightly highlight the paucity of studies that fit their strict inclusion criteria and that can be used to assess efficacy of epidural steroid injections for radicular spinal pain. However, does this mean that epidurals do not work and should not be used, or that the four studies included are the only relevant ones that can be used to assess this question? Is the practice and opinion of pain management physicians in treating these patients irrelevant?

“Observational studies and expert opinion have a role in evaluating clinical practice. The authors would have produced a better and well-balanced guideline by including high-quality observational studies, with the appropriate caveats that observational studies with negative results often lack important information, and that a paucity of controlled studies can reflect the difficulty of doing such studies rather than the efficacy of the procedure. However, the question that these guideline authors attempted to answer is important and clearly must be addressed in further research.”

Ross’ argument is buttressed by the University of Medicine and Dentistry of New Jersey. In  the above-referenced work by that school, ESIs may be indicated earlier in the treatment algorithm and for more than radicular pain associated with a herniated nucleus pulposus. Other indications include: lumbosacral disc herniation; spinal stenosis with radicular pain (central canal stenosis, foraminal and lateral recess stenosis); compression fracture of the lumbar spine with radicular pain; and facet or nerve root cyst with radicular pain.

The university also contends that ESIs can be used in a cervical approach. Indications include: pain associated with acute disc herniation and radiculopathy; postlaminectomy cervical pain; cervical strain syndromes with associated myofascial pain; and postherpetic neuralgia. Meanwhile, thoracic ESIs have been reported in the medical literature as treatment for pain associated with the following conditions: acute thoracic disc pathology; thoracic radicular pain secondary to disc herniations; postherpetic neuralgia; trauma; diabetic neuropathy; degenerative scoliosis; idiopathic thoracic neuralgia; thoracic compression fracture.

A relatively recent study in Chang Gung Medical Journal even found success with transforaminal ESIs. Its authors concluded this approach is a relatively simple, effective and low-risk alternative to surgical decompression for the treatment of lumbar disc herniation in selected cases.

Conclusions

ESIs have been used to successfully treat low back pain for many decades and now are in widespread use in many countries.

The rationale behind injecting steroids into the epidural space adjacent to the spinal nerve is that it will combat the inflammatory response associated with acute disc herniation and thus reduce pain.

There have been numerous randomized trials examining the efficacy of ESIs. However, ESIs are now a controversial matter because the American Academy of Neurology has questioned their efficacy, although the academy’s position runs counter to that of most other medical specialist societies and the federal government.

Here at Oregon Pain Associates, our position on ESIs is that they play an important role in both the diagnostic and therapeutic aspects of conservative management of back pain. Moreover, we believe that it amounts to a disservice if patients are given ESIs without first having undergone comprehensive evaluation and trialing: Our philosophy is to not take a cookie-cutter approach but to make certain that the treatment delivered is the most appropriate possible for the individual patient.

Oregon Pain Associates has over the years acquired a well-deserved reputation for providing genuine life-changing relief to those who suffer pain, be it in the low back or someplace else. It is the reason so many area physicians refer to us – particularly when it involves cases of an exceptionally challenging, time-consuming nature.

When you send your patients to us, our goal is to return them to you well satisfied by the diagnostic and/or interventional services we provide.

For more information, please call Oregon Pain Associates in Portland or Salem at 503.238.7246 or toll-free 866.785.7246.

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