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Epidural Steroid Injections: Are the Risks Worth the Benefits?

New insight into this opioid alternative therapy may not have enough effective evidence for its use

With Jeffrey Fudin, PharmD, Leonard B. Goldstein, DDS, PhD, and Alfred Mauro, MD

Reviewing Epidural Injections

Epidural injections are becoming more common, as the push against opioids increases, according to Jeffrey Fudin, PharmD, clinical pharmacy specialist in pain management at the Stratton VA Medical Center in Albany, New York and Practical Pain Management Co-Editor-At-Large. While most board-certified pain specialists offer them, the risks of these injections have been known for a long time. According to a recent New York Times article,1 Pfizer, the manufacturer of one such drug, Depo-Medrol, asked FDA to ban the treatment five years ago. Pfizer had received hundreds of complaints about injuries and complications related to the injections.

A review of FDA records showed that 2,442 serious problems, including 154 deaths, were reported from Depo-Medrol injections performed from 2004 through 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 when placed into the spinal fluid or arteries.

“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 Alfred Mauro, MD, director emeritus of anesthesia and pain medicine at Jersey City Medical Center in Jersey City, NJ. “The most common negative outcome is the possibility of a post-lumbar puncture headache.”

Dr. James Patrick Murphy, an anesthesiologist and addiction specialist in Kentucky, said in the Times article that he believes the injections are an expensive procedure, especially when there is no promise of a cure. He believes that recent studies showing that the injections work no better than physical therapy for many patients are reason enough not to use them.

Indeed, FDA 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.2 The number of Medicare providers giving epidural steroid injections had increased 13% from 2012 to 2016. The number of Medicare beneficiaries receiving these injections had increased by 7.5%. Total sales of Depo-Medrol and its generic versions had grown 35% from 2015 to 2017.1

Risks Involved

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 the House of Representatives approved an increase in Medicare reimbursement for the procedure as part of legislation to tackle the opioid crisis.1

“The risks of epidural steroid injections have been known for a long time, but providers are fearful of prescribing opioids, and other medications, including gabapentin, pregabalin, SNRIs, and antidepressants, have multiple pharmacologic mechanisms that can be maximized for the individual patient,” Dr. Fudin told Practical Pain Management. “Pharmacotherapy could be optimized in the clinic by utilizing strategies and tools such as pharmacogenetic testing and the expertise provided by a well-trained PharmD.”

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 approach for use in a multi-disciplinary pain management center:

  • 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 epidural steroid injections or opioids
  • Use of epidural steroid injections only after the underlying pathological condition is verified and life-threatening conditions such as pyogenic spondylodiscitis are ruled out.

Eliminating Unnecessary Treatment

Even so, Drs. Goldstein and Mauro caution that despite producing an immediate reduction in pain, epidural injections are very technique-sensitive, and their benefits 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.1 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 report that improvements in pain and function show little to no differences, compared to controls, whether patients receive pharmacological or nonpharmacological treatment.3 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.3

According to Dr. Fudin, all interventions and medications come with risks that may be offset by variable levels of analgesic benefit. 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.

What’s your take? Email us at ppmeditorial@verticalhealth.com

Last updated on: July 30, 2019
Continue Reading:
The Safety of Epidural Steroid Injections: What You Need to Know
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