Epidural Steroid Injections

Epidural steroid injections are a commonly recommended procedure for patients with back pain with or without leg pain (sciatica).  I have personally seen this procedure work effectively in some cases when surgery was being considered as an option and I would certainly prefer to see patients avoid surgery.  On the other hand, I have seen a number of patients for whom these injections did not help at all.  It should be noted that many medical physicians who treat such patients with back pain think of treatment as a continuum starting with pain medications and possibly a short course of physical therapy, chiropractic, or acupuncture, followed by one or three epidural steroid injections if the pain meds and therapy fail, followed by surgery if pain meds and the injections fail to relieve symptoms.  But are such injections a good idea?  Let’s examine the scientific evidence.

Did you know that epidural steroid injections are not approved by the FDA as a treatment for back pain or sciatica?  According to Dr. Epstein, in an editorial in Surgery Neurological International  in 2013 “although not approved by the Food and Drug Administration (FDA), injections are being performed with an increased frequency (160%), are typically short-acting and ineffective over the longer-term, while exposing patients to major risks/complications.”(1)  The biggest risks are infections from contaminated steroids, such as what happened in 2012 when a batch of steroids (methylprednisolone acetate) that tested positive for fungus (Aspergillus fumigatus) killed and sickened thousands of patients across the US with a fungal meningitis.   But there are other significant risks associated with these injections.  As Dr. Epstein points out, there are a number of  recent reports that have cited contaminated epidural steroid injections resulting in meningitis, stroke, paralysis, and death. “The Center for Disease Control (CDC) specifically identified 25 deaths (many due to Aspergillosis), 337 patients sickened, and 14,000 exposed to contaminated steroids. Nevertheless, many other patients develop other complications that go unreported/underreported: Other life-threatening infections, spinal fluid leaks (0.4-6%), positional headaches (28%), adhesive arachnoiditis (6-16%), hydrocephalus, air embolism, urinary retention, allergic reactions, intravascular injections (7.9-11.6%), stroke, blindness, neurological deficits/paralysis, hematomas, seizures, and death.”

What about the effectiveness of epidural steroid injections?  While some studies have shown some benefits in terms of pain relief with epidural steroid injections(2), other studies have shown that the benefits are only short term–lasting 3 weeks or so.(3,4)  A recent meta-analysis published in Annals in Internal Medicine  showed very little benefit for patients suffering with sciatica.(5)  Researchers reviewed 23 different clinical trials and concluded that epidural steroid injections had a small short term benefit (2-12 wks) for a decrease in leg pain but no benefit for long term relief of leg pain as compared to placebo.

References:

1. Epstein NE. The risks of epidural and transforaminal steroid injections in the spine: Commentary and a comprehensive review of the literature. Surg Neurol Int. 2013; 4(Suppl 2): S74–S93.

2.  Ahadian FM, McGreevy K, Schulteis G. Lumbar transforaminal epidural dexamethasone: A prospective, randomized, double-blind, dose-response trial. Reg Anesth Pain Med. 2011;36:572–8.

3. Carette S, Leclaire R, Marcoux S, Morin F, Blaise GA, St-Pierre A, et al. Epidural corticosteroid injections for sciatica due to herniated nucleus pulposus. N Engl J Med. 1997;336:1634–40.

4. Arden NK, Price C, Reading I, Stubbing J, Hazelgrove J, Dunne C, et al. A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: The WEST study. Rheumatology (Oxford). 2005; 44:1399-406.

5. Pinto RZ,  Maher CG,  Ferreira ML et al. Epidural Corticosteroid Injections in the Management of Sciatica: A Systematic Review and Meta-analysis. Ann Intern Med. 2012;157(12):865-877.