There Is a Role for Epidural Spinal Injections
Interview with Jianguo Cheng, MD, PhD
Despite controversy over epidural steroid injections (ESI), the intervention does have a place in the treatment of back and neck pain. “It is not a panacea to treat everything and it is not a cure. But it does provide better quality of life and better pain control,” Jianguo Cheng, MD, PhD, professor and director of the pain fellowship program at the Cleveland Clinic, told a packed room at the World Congress of the World Institute of Pain in New York City, May 29, 2016.
The procedure, which involves injecting corticosteroids into the epidural space around the spinal cord and nerves, has been under a lot of scrutiny, not only because it is the most common interventional pain procedure performed worldwide, but because research has been mixed on its effectiveness and safety.
Some believe it’s overused. In 2015, the Agency for Healthcare Research and Quality (AHRQ) published a review of 78 randomized controlled trials of ESI, and found that the benefits were small and not sustained, nor did the injections reduce a person’s odds of having surgery down the road.1
But in response to that report, 14 societies in the United States, collectively known as the Multisociety Pain Workgroup, wrote a letter to the AHRQ, with a list of rebuttals of the report.2 For starters, the letter said that the trials reviewed in the statement had flawed methodologies.
Dr. Cheng, on the side of the workgroup, described why he believes the AHRQ report was inaccurate. First, by relying only on randomized controlled trials, many of which were 15 to 20 years old, it excluded any observational studies that include subgroup analysis. One of the flaws of randomized trials is that they can have improper patient and treatment indications, inadequate treatment technique, and weaker outcome measures than a solid observational trial, says Dr. Cheng.
“There was no clear diagnoses. As we all know, back pain does not always respond to injections because it has many different etiologies,” said Dr. Cheng.
Secondly, many of the procedures were performed blindly with no imaging. “If you do the procedure without imaging, you have no certainty your target is reached,” he says. Even in an expert’s hand, the blind approach often misses the target, he says. If the target is not reached, it can, of course, skew the results of the study. “It’s no surprise that the outcomes were not good,” he said.
Dr. Cheng pointed to a number of observational studies and reviews that included observational studies that demonstrated a benefit of ESI.3-5 One review concluded that ESI was effective in reducing pain, restoring function and reducing the need for other health care and avoiding surgery. The authors also said that the results would not have been as compelling if the review was limited to randomized controlled trials.5
ESI can cause serious adverse events, including neurologic injury, embolization, bleeding, and infection, though the risks are thought to be rare. A recently study examined more than 16,500 consecutive ESIs performed based on evidence‐based guidelines and found no major adverse events.6
Dr. Cheng pointed out that though there are risks to ESI, there are also risks to alternatives to ESI, such as opioids, which has led to at least 19,000 fatal overdoses in 2014. There are also risks associated with NSAIDS, which has lead to more than 100,000 hospitalizations due to gastrointestinal issues.
Surgery is not always an option, and has its own set of contradictions and risks. “Needles are dangerous, the knife is dangerous, medications are dangerous,” said Dr. Cheng. “If epidural is put into the epidural space, it’s safe, but if it’s put in the wrong place, it can cause a problem. It’s not the product per se, it’s the delivery of the drug.”
ESI should only be used when conservative treatment, such as physical therapy and medications have failed. Surgery can be contraindicated due to other health conditions or age, and entails a higher incidence of risks. After discussing the risk benefit ratio of spinal injections compared to other treatments, it’s critical to follow certain standards and conventions:
- ESI should only be used when there is a clear diagnosis for selected conditions, such as radiculopathy. It’s not meant for generalized back pain or facet joint pain.
- Image guidance is highly recommended. Data shows that even in expert hands, ESI performed without image guidance, may not reach the epidural space, increasing its risk and reducing its effectiveness.
- Injections should not be repeated frequently. Follow a patient for at least a month or two, and depending on how he responds, make a decision if it’s worth repeating. In many cases, one injection can provide relief for several months or a year. If the patient needs another injection in two weeks, it’s probably not effective, said Dr. Cheng.
Like any other procedure, ESI is no exception. It has to be used for the right indication for the right patient.