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11 Articles in Volume 18, Issue #8
Challenges & Opportunities for Pain Management In Veterans
Chronic Pain and Psychopathology in the Veteran and Disadvantaged Populations
ESIs: Worth the Benefits?
Letters to the Editor: Recovery Centers Reject MAT, Cannabis for Chronic Headaches, Central Pain
Medication Management in the Aging
Pain Management in the Elderly
Pharmacists as Essential Team Members in Pain Management
Photobiomodulation for the Treatment of Fibromyalgia
Plantar Fasciitis: Diagnosis and Management
Slipping Rib Syndrome: A Case Report
What types of risk screening tests are available to clinicians prescribing opioid therapy?

ESIs: Worth the Benefits?

As steroids injected into the epidural space are not FDA-approved, clinicians must carefully outline the risks ahead of time.

with Leonard Goldstein, DDS, PhD, and Alfred Mauro, MD

While most board-certified pain specialists offer epidural steroid injections (ESIs), the risks of these injections have been known for a long time. Pfizer, the manufacturer of one such drug, Depo-Medrol, asked FDA to ban the treatment five years ago after receiving hundreds of complaints about injuries and complications related to the injections.

The Growth of ESIs and Their Risks

A review of FDA records showed that 2,442 serious problems, including 154 deaths, were reported from Depo-Medrol injections performed between 2004 and March of 2018. Most injuries occurred when the needle missed the epidural space and directly injured the nerves or deprived the spinal cord of blood. FDA further warned in 2014 that injections of corticosteroids into the epidural space of the spine may result in rare but serious adverse effects, including loss of vision, stroke, paralysis, and death. Yet, the number of Medicare providers giving ESIs increased 13% from 2012 to 2016.

Corticosteroids such as methylprednisolone, hydrocortisone, triamcinolone, betamethasone, and dexamethasone are FDA-approved for injection into muscles and joints. Nevertheless, they are commonly injected along with an anesthetic into the cervical and lumbar regions of the spine. Despite the fact that this application is considered off-label use, in June 2018, the US House of Representatives approved an increase in Medicare reimbursement for the procedure as part of legislation to help tackle the opioid crisis.

Source: 123RFEpidural steroid injections come with risks but may improve chronic pain management when conducted with a risk-management plan.

When and How to Use ESIs

“The use of epidural injections is very technique-sensitive and should only be utilized by practitioners with significant training,” said Leonard B. Goldstein, DDS, PhD, assistant vice president for clinical education development at AT Still University in Meza, AZ, and a PPM editorial advisor. Alfred Mauro, MD, director emeritus of anesthesia and pain medicine at Jersey City Medical Center in Jersey City, NJ, agreed, noting that “the most common negative outcome is the possibility of a post-lumbar puncture headache.”

Opioids and epidural corticosteroid injections should only be used after safer and more conservative options have been tried, according to Drs. Goldstein and Mauro. They recommend the following multidisciplinary approach:

  • History and complete physical examination
  • Proper imaging, including magnetic resonance imaging (MRI) when indicated
  • Conservative treatment, such as physical therapy, osteopathic manipulation, and acupuncture, for at least two weeks before using ESIs or opioids
  • Use of ESIs only after the underlying pathological condition is verified and life-threatening conditions such as pyogenic spondylodiscitis are ruled out.

Even so, Drs. Goldstein and Mauro caution that despite producing an immediate reduction in pain, the benefits of epidural injections are often small. “While both radicular and non-radicular pain may have etiology related to the disc, non-radicular back pain has no compromise to the nerve root that exits through the foramen. In a radiculopathy, we must ascertain the cause as well as the exact level and decide whether the use of the epidural corticosteroid injection will result in enough disc shrinkage to relieve the pressure/impingement on the nerve root as it exits the foramen,” they said. Some pain clinics are refusing to prescribe any opioids unless patients agree to receive the spinal injections. Drs. Goldstein and Mauro consider this a ploy to have patients accept a much more expensive treatment.

When it comes to low back pain (LBP), for example, recent guidelines published by the American College of Physicians reports that improvements in pain and function show little to no differences, compared to controls, whether patients receive pharmacological or nonpharmacological treatment. The guidelines also recommend moist heat, spinal manipulation, massage, and acupuncture, and if pharmacologic treatment is desired, NSAIDs and skeletal muscle relaxants. For chronic LBP, exercise, multidisciplinary rehabilitation, acupuncture, and mindfulness-based stress reduction are considered to have the best evidence base.

Since steroids injected into the epidural space are not an FDA-approved indication, clinicians recommending or performing such procedures must carefully outline the risks without minimizing them, especially for a vulnerable patient who may otherwise disregard such risks in the presence of unrelenting, intolerable pain. 

Last updated on: November 7, 2018
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