Spinal injections for stenosis may worsen condition

Epidurals are handed out like candy in this country. We assume that, much like surgery and medications, that there are hordes of research studies documenting the effectiveness of this intervention.

Regular readers of the Rantings and any chiropractor out there will tell you this couldn’t be further from the truth.

Yet this doesn’t seem to stop primary care doctors from referring patients out for epidurals long before they would consider a referral to a chiropractor (data from a major insurance company in the US notes that a measly 6.6% of non-surgical spine episodes that do not begin with a chiropractor will ever be referred to one for care, and even then this is VERY late in the episode).

Possibly this lack of referral is because primary care doctors don’t think there is research supporting chiropractic care (not true).  But this doesn’t seem to halt the referral to pain management centers to perform expensive, invasive procedures with evidence actually against their use that carries a much higher risk than manipulation.

Just seems strange to me.

That’s not to say that I don’t believe epidurals have a place in medicine, because I do. I have referred non-responsive patients out for them in the past, but they are few and far between and always for leg pain that is consistent with a disc herniation.  This scenario is a far cry from what is happening in the arena of low back pain in mainstream medicine today.

I can’t tell you how many times I’ve had patients sent for epidurals for isolated low back pain with no leg pain involvement.  Ugh!!

But what about leg pain associated with spinal stenosis-a condition where advanced arthritis of the spine begins to choke off the room for the nerves going into the leg?

Just recently I had just such a case.  After the 2nd visit using Flexion-Distraction he had absolutely no response to treatment.  So on the 3rd visit I really ramped up the agressiveness of the treatment with instructions to only return for additional treatment if he noted improvement after this visit.

I was fully expecting to have a discussion about a referral to pain management for this patient.  Luckily, that last treatment broke through the barrier and he had a pretty substantial improvement.  His outcome is going to be good.

But what if it wasn’t?  What if the 3rd visit didn’t help?  I’ve had stenosis patients in the past who did not have a strong response.  They are few, but they happen.  An epidural would seem to me to be a better option than referring that patient out for a surgical consult.

At least that’s what I thought until I came across this particular article.

The premise of this study was that the use of an epidural spinal injection for spinal stenosis patients would lower the need for, or at least delay, surgery.  Boy, were they surprised.

In looking at a group of patients who had an epidural spinal injection in the first 3 months of the trial versus those who did not, there were some enlightening findings:

1. Those who received the epidurals had a much higher preference for avoiding surgery (62% versus 33%).
2. In those who got the epidural but ultimately ended up in surgery there was a 26-minute increase in operative time and an increased length of stay by 0.9 days.
3. Over 4 years, there was 34% less improvement in overall quality of life (measured using the 36-Item Short Form Health Survey (SF-36) Physical Function) among the epidural patients that ended up having surgery.
4. There was less improvement in the epidural patients (56% less on Body Pain and 64% Physical Function).
5. Of the patients who were initially in the non-surgery group, those who had an epidural were 45% more likely to switch to the surgical group.
6. On the only positive note, the patients who were originally in the surgery group who got the epidurals were 1/3 less likely to actually follow through with surgery.

Wow!  Talk about nullifying a hypothesis!

I think that we, as a society, need to really rethink what steroids might be doing to our ability to heal, and accept the fact that the use of steroids applied directly to sensitive spinal structures may very well be doing far more harm than good.

Just my two cents (and a lot of medical research, too…).

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