Recently, a study was published in the New England Journal of Medicine that focused on the efficacy of steroids in epidural spinal injections for spinal stenosis pain. We posted our response to the article earlier here.
The New England Journal of Medicine study suggested that the inclusion of a steroid in an epidural spinal injection does not improve the efficiency of the injection. To understand why this might matter to people suffering from spinal stenosis pain, it’s important to 1st understand the different variables at play, including the spinal condition that was treated.
Spinal stenosis is a narrowing of the spinal canal.
The spine, or backbone, is comprised of bones called vertebrae. The vertebrae are stacked on top of each other, forming the spinal column. Protected within the spinal column, a bundle of nerves travels along the spinal canal from the base of the spine to the base of the skull. This bundle of nerves is the spinal cord. The nerves from the rest of the body connect to the spinal cord, and it’s responsible for relaying information back and forth from the brain to the body.
Spinal stenosis usually occurs as a result of a degenerative disease, like arthritis, or conditions like bone spurs or bulging discs in the spine. Poor posture, excess weight, or an unbalanced gait can also contribute to the development of spinal stenosis. Sometimes, an individual is born with a narrow spinal canal, but this is much less common than spinal stenosis caused by degenerative conditions.
The narrowed spinal canal irritates the nerves in the spinal cord. Someone suffering from spinal stenosis might have difficulty walking, performing daily activities, or standing for long periods. He or she might also experience cramping in the lower back or aching pain extending into the legs or thighs. In severe cases of spinal stenosis, individuals might develop bowel incontinence, as well as weakness or loss of sensation in the lower extremities.
Overall, spinal stenosis is a severe back pain condition. Because of this, pain management is a primary concern in spinal stenosis treatment.
Since the pain from spinal stenosis can reach debilitating levels, the goal is often to relieve pain enough to allow people with this condition to resume their normal routines. In very extreme cases, surgery might be the best option. However, most physicians prefer to attempt less invasive methods of treatment first.
“Regular exercise can help you build and maintain strength in the muscles of your arms and upper legs (the hip adductors and abductors, quadriceps and hamstrings). This will improve your balance, ability to walk, bend and move about, as well as control pain.”
However, if a person’s spinal stenosis is advanced enough to cause significant pain, of the sort tested in the study, physical activity is not a realistic option for long-term pain management. There are a variety of non-surgical treatment options to consider for spinal stenosis, but many Arizona Pain doctors have suggested that since it’s a more severe back pain condition, epidural steroid injections may not be the best treatment option.
In his response to the piece in the New England Journal of Medicine, Dr. Lynch noted that:
“The study examined the use of epidural steroid injections for the specific condition of moderate to severe central canal spinal stenosis, which is a severe diagnosis. Patients with this condition are typically not the best candidate for epidural injections, and many patients with this condition need surgery. We typically do epidural steroid injections for conditions other than severe spinal stenosis–such as bulging discs or some other disc pathology, before surgery is necessary.”
The study reported in the New England Journal of Medicine also questioned the efficacy of steroids in epidural injections for spinal stenosis.
In the study, 400 spinal stenosis patients received epidural injections. Some received injections of an anesthetic only, while others received injections of an anesthetic plus a steroid. Patients received 1 or 2 injections, and the outcome evaluation was performed 6 weeks after the initial injection. The study concluded that the addition of steroids to the epidural injection provided “minimal or no short-term benefit”. However, several elements of this study have been called into question.
As noted, the focus of the study was on patients with moderate to severe spinal stenosis. Additionally, the injections were delivered to the interlaminar space, which is between the plate-like lamina of the vertebrae. Some research, though, has suggested that epidural steroid injections are more effective when delivered to the transforaminal space, which is the area surrounding a particular nerve root. Additionally, patients in the study received just 1 or 2 injections, even though many experts recommend a series of at least 3 epidural steroid injections to achieve the full effect.
Another major concern resulting from this situation is that a potentially-beneficial procedure for other types of back pain could be condemned prematurely. Physicians might opt out of offering epidural steroid injections, and insurance companies might deny coverage for epidural steroid injections. This procedure, while minimally invasive, does carry risks of course. However, all medications and medical procedures have potential risks.
Some physicians believe that the flaws in this study render it unable to conclusively judge the efficacy of steroids in epidural injections.
Dr. Lynch noted that:
“I’m shocked it was published in the first place and more shocked at the media’s spin on the story thus far. When a patient is a qualified candidate for an epidural steroid injection, comprehensive care should be provided in addition. For those who do not qualify for an epidural steroid injection, or for those who prefer not to receive one, we offer numerous other comprehensive and alternative treatment options that are highly effective for treating chronic back pain as well, and we have seen great success with the most severe cases of chronic back pain.”
Epidural steroid injections may be able to provide significant pain relief, perhaps even relief profound enough to delay or prevent corrective surgery. The Colombia Neurosurgeons, of Columbia University Medical Center, state that approximately 50% of patients experience pain relief from epidural steroid injections. For this reason, it can be hoped that more research is performed before epidural steroid injections are dismissed as part of a comprehensive pain management plan.
Have you discussed epidural steroid injections with your physician?
Image by winifredxoxo via Flickr