LifeCare Chiropractic

The Best Chiropractic Care in Mesa, Arizona

epidural

Steroid Injection Epidurals For Spinal Stenosis–Boon or Bane?

by

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…).

Had Spinal Injections? You’re Twice As Likely to Accept This

by

As I have written in past articles that there is a time and place for surgical intervention for low back pain.  The same is true for interventional pain management like epidural spinal injections.

I currently have an older male patient who has a pretty textbook case of lateral recess stenosis (for those of you less familiar with medical terminology, it means that arthritis in his spine has begun to choke off the nerves of his lower back as they exit the spine, leading to pain down the leg, especially with standing or walking).  Generally, our office does exceedingly well with these types of patients using a technique called Flexion Distraction.  But there are a very small percentage that do not respond.

This recent patient, after 3 treatments, is fitting into this category.  He has not noted any difference despite the treatment we have done.  The likelihood of him responding goes down precipitously from here.  On the last visit, we discussed the potential for epidural spinal injections if he does not respond within one more visit.  In our office, this patient is a clear candidate for spinal injections.

However, this treatment pathway is not altogether typical.  I have seen patients treated with interventional pain management (trigger point injections, epidural spinal injections, etc..) that wer not good candidates and did not respond well.

But here’s where things get interesting.

I remember a meeting several years back with one of the nation’s larger health insurance carrier.  On a conference call, one of the big wigs mentioned that merely having an MRI or an epidural spinal injection would increase that patient’s likelihood of having spinal surgery.

At first thought, this seemed crazy.  I mean..how could merely having an MRI increase your risk of having surgery??  Or even an epidural spinal injection?

Regardless of how much it does or does not make sense, the relationship is clear and has been documented in multiple studies.  Personally, I have always felt that, once patients are sent to an MRI that they shouldn’t have had, they are told that something tangible is wrong with his or her back.  Pay no attention to whether or not that disc bulge or arthritis is causing your pain–there is something wrong!

This starts the patient on a trajectory based on a potentially false set of information.  In today’s version of mainstream medicine, far too often this is the only trajectory the patient will ever experience.  If someone is convinced that there is an actual problem found on an MRI that needs to get fixed, the thought of an epidural or surgery naturally follows.

As it turns out, I may not have been too far off.  This particular study helps give some additional insight into the relationship between epidural spinal injections and spinal surgery.

Patients were asked about his or her likelihood to undergo spinal fusion surgery when faced with 3 potential complications (nerve damage, wound infection, and nonunion of the fusion) and educated on the likelihood of experiencing symptom relief.  For each scenario, the patient indicated whether he or she would or would not undergo spinal fusion.

Here’s what they found:

  1. Patients were more likely to accept spinal fusion with lower risks and better outcomes (no big shocker here…).
  2. Greater low back pain intensity made patients more accepting of higher surgical complication risks.
  3. Greater leg pain intensity had a weak correlation to opting for spinal fusion.
  4. One of the strongest factors of undergoing surgery despite a higher risk of complications was a history of spinal injections (almost twice as likely to opt for surgery) (Tweet this).

To sum it up, if someone had a spinal injection at some point, he or she was twice as likely to still say yes to a surgical fusion despite a higher risk of complications.  This is a pretty darn strong difference.  Pain severity, age, education status, duration of pain symptoms….all of this was less important then whether or not someone had spinal injections.

Slipped Disc in Back: Common Sciatic Nerve Treatment Falls Short

by

MRI finds a slipped disc in back. Options are short, but you decide on a common sciatic nerve treatment from your doctor’s suggestion. But what’s the best option?

The task of deciding what options are the best seems daunting. Medications, injections, chiropractic (my personal favorite), acupuncture, massage, physical therapy and probably 10 others I’m forgetting.

But before you decide on a treatment, we need to back up a little. The conversation needs to start with where you got your diagnosis. The diagnosis of a disc problem (slipped disc, disc bulge, disc herniation – the actual description is quite technical, but you get the idea) can be make quite accurately in a competent physician’s office. Rarely is an MRI needed to diagnose a disc problem, and the guidelines clearly state, that in the absence of red flags, any imaging needs to wait until 4 weeks of conservative treatment. Despite this mainstream medicine seems to want to order MRIs and CT scans at the first sign of back problems.

This is were the problems begin. Numerous studies have confirmed that early MRIs are a bad thing, driving expensive, dangerous and unneeded treatments. But let’s say you made the mistake of not going to a chiropractor first for your back pain and you did get an MRI or CT scan. And this MRI or CT shows that you have some type of problem with the intervertebral discs of your lumbar spine.

Here comes the big question. Do you have leg pain or not? And is this leg pain scleratogenous, radicular or radiating? I don’t really expect you to answer that question, but hopefully you can begin to see that just because your back pain is accompanied by leg pain this does NOT mean that you have sciatica. I can’t tell you how many times I’ve seen patients with leg pain that, after some targeted soft tissue work on his or her low back and glut region (gluteus maximus, posterior hip, rump, derriere–you get the idea), the leg pain gets better or is gone.  There is no way a slipped disc in back would respond that fast.

Sciatica refers to radicular pain that comes from chemical or pressure (from a disc) directly on the sciatic nerve. For those of you unsure of where the sciatic nerve goes, I’ll clarify. It goes into the leg. Despite this, I have seen patients spend tens of thousands of dollars for epidural injections for low back pain that doesn’t involve pain in the leg. I’m not sure there’s ever been an indication to use epidural injections in the lumbar spine for treatment of local back pain (without leg pain). It may be done all the time, but that doesn’t make it right.

Overall, this means that you need to see someone who understands all the nuances of back pain and leg pain. (hint, hint….a chiropractor). Anything short of that and you may get sent in the wrong direction.

Back to this particular article that looked at the effectiveness of epidural steroid injection as a common sciatic nerve treatment.

I have personally referred a small handful of patients out for epidural steroid injections over the years, but they are few and far between. I have never considered spinal injections as a stand alone therapy. At the most, they allow a small window of pain relief, where other options have failed, where other therapies can be used more aggressively.

So what happens if an epidural is the only therapy used? Basically, confirming other studies, these researchers found that they suck. Here are the specifics:

  • Researchers looked at 25 different studies.
  • Epidural corticosteroid injections improved leg pain 6.2 points (out of 100).
  • This was only noted in the short term (2 wks to 3 months).
  • Beyond 3 months, the benefits were even smaller–pretty much non-existent.

So basically, an epidural injection for sciatic pain is very expensive (I’ve seen bills as high as $5,000 per shot) and really does nothing but provide a small amount of pain relief for a short period of time. Worse, it may accelerate destruction of the disc and lead you to surgery. Of course, none of this takes into account the close to 400 cases of fungal meningitis on the East Coast from contaminated vials of the steroid used in this procedure, with almost 30 deaths so far.

Where do I sign up?

STEROID INJECTIONS FOR LOW BACK PAIN? DID YOU GET AN MRI FIRST?

by

Medicine has somehow managed to create a culture around low back pain.  Maybe it was unintentional.  Maybe it was ignorance.  Maybe it was willfully done to support the “system.”  Whatever the reason, it costs society massive amounts of money on waste.

Usually not a month goes by when some patient is told by their PCP that they should stop seeing a chiropractor (sometimes after only 1 or 2 visits) and see a PT or get an MRI or both.  Worse, there are many times that a chiropractor does not even become a part of the equation.  The costs when a chiropractor is NOT involved skyrocket.  Here in AZ, a patient seeing their PCP first may end up costing some 30% more.  If they manage to self refer to a PT, the costs are almost TRIPLE.

The reasons for this are multiple, but the bottom line is that we are experts at low back pain and are very good at controlling care.  This means that we infrequently order X-rays and rarely order MRIs.  I know that, in our office, if the patient’s low back pain and leg pain looks an awful lot like sciatica from a disc bulge, why the heck would I order an MRI if I already have a very good idea of what is going on?

This particular study has some interesting findings.  Researchers looked at patients getting an epidural for low back pain with leg pain (lumbosacral radiculopathy) and whether or not they actually needed an MRI before the procedure.  What???  Of course you need an MRI before someone sticks a very long needle into the most sacred of regions in your spine!!  Or do you..

Here are the findings when comparing 2 groups of patients, one group where the MRI was used to guide the epidural procedure and a second group where the MRI was NOT used:

  • Slightly less leg pain in the MRI group at 1 month
  • No differences in pain or function at 3 months
  • After 3 months, only 35% in group 1 and 41% in group 2 showed improvement
  • In non-MRI patients who received a different injection than that proposed by an independent physician (basically a 2nd opinion, but this doctor did actually look at an MRI of the patient), the outcomes were not quite as good as those whose procedure matched that the MRI findings
  • Collectively, 6.8% of patients did not (group 2) or would not have (group 1) received an epidural after the MRI was reviewed

So, the bottom line is that MRI made very little difference in the outcomes of the epidural.  Further, a little under 2/3 of the patients received no long term benefit from the whole process.  All for the price tag of around $10K.  Give a good chiropractor $10K to work with and we’ll have the vast majority of patients competing for the Ironman Triathlon in 6 months….

WHAT HAPPENED AFTER YOUR MRI?

by

It doesn’t happen all the time, but it is not uncommon for a patient to call our office to cancel an appointment because they went to their PCP, the PCP ordered an MRI and now they have to see a specialist. Sound reasonable?

There are multiple layers of “wrong” in this scenario. First and foremost is that, in most situations, we have already identified whether a disc bulge / sciatica was present based on talking to the patient and our exam finding. At this point, without any type of red flags, it is never, ever recommended to order an MRI this early in the treatment. Happens all the time, but apparently, those ordering the MRI are not reading the studies.

Not only is this a tremendous waste of resources, but it is well documented that this starts the patient on a MRI to epidural to surgery pathway, despite evidence that this is not the best pathway for the patient. It is also far too common for the PCP to steer the patient away from chiropractic care to a specialist–when chiropractic care is exactly what they need.

So what about the epidural’s effectiveness in the case of chronic (>12 weeks) radiculopathy (leg pain)? This particular study finds it worse than worthless—actually giving a small injection of saline was massively more beneficial than the steroid injection (Oswestry change after 52 wks– saline 14.3 points improvement, epidural 1.9 points worse). So basically, the epidural clearly made the patient worse as time went on.

The bottom line is that chiropractic care, for all musculoskeletal complaints, is the best place to go to get the best outcomes for your pain. Let the chiropractor decide if an MRI and epidural is appropriate.