Marc Darrow MD,JD

Epidural steroid injections do not heal a bad back. Some researchers consider epidural steroid injections to be, at best, a very short-term painkiller that sometimes prevents a patient from getting the proper treatment for his/her back pain. Epidural steroid injection is the most frequently performed pain procedure. It is becoming clear that epidural steroid injections for various spinal conditions are best used for a patient who is in pain and waiting for back surgery. If you have decided that you are getting a spinal surgery, then an epidural may be the procedure you want prior to surgery.

The one thing that surgeons and regenerative medicine specialists agree on is the question being raised in the medical literature asking whether patients have been informed of the poor likelihood of long-term epidural injection treatments success for disability. The same question is also being raised about spinal surgery.

In the research below from some of the leading medical universities in the world, we see that the goal of epidurals and surgery is to provide pain relief. Unfortunately improving disability and function may not be an attainable goal with these treatments.

Epidural steroid injections can provide modest pain relief

In one study doctors found that epidural steroid injections do provide modest pain relief. The immediate response to transforaminal epidural steroid injection was approximately 80%. The researchers of the study conclude:  Transforaminal epidural steroid injection is a useful diagnostic, prognostic, and short-term therapeutic tool for lumbar radiculopathy. Although transforaminal epidural steroid injection cannot alter the need for surgery in the long term, it is a reasonably safe procedure to provide short-term pain relief and as a preoperative assessment tool. However transforaminal epidural steroid injection cannot alter the need for surgery in the long term.(7)

As pointed out by Thomas Jefferson University, Rothman Institute researchers, for some, the epidural steroid injections did not work at all. “Patients with lumbar disc herniation treated with epidural steroid injection had no improvement in short- or long-term outcomes compared with patients who were not treated with epidural steroid injection.”(15)

Latest research

Comparing PRP and Transforaminal steroid injection

Let’s make a few explanatory remarks first.

PRP treatments are injection treatments. The treatments are derived from your own healing and growth factors found in your blood. These healing and growth factors are collected from a standard, like a lab test, blood draw. The collected platelets are then injected back into the injured area of the back to stimulate healing and regeneration to the soft tissue structures that stabilize the spine. We do not inject into the spinal canal. The goal of our treatment is to inject into the facet joint areas where spinal instability develops. The goal is to heal damaged tissue.

Transforaminal steroid injections are put into the spine in the space between the spinal cord and the vertebrae. The goal here is to reducing inflammation that may come from herniated disc or spinal instability. The goal here is to mask pain and reduce inflammation and as we will see in the research below, many doctors do not believe this is the best treatment option for patients with long standing back pain.

A June 2021 study in the Journal of neural transplantation & plasticity (1) compered PRP injections to steroid. Here are the results:

“Transforaminal steroid injection is extensively used as a treatment in cases of herniated disc, but it is associated with complications. In comparison, platelet-rich plasma (PRP) injection has been used in musculoskeletal disorders and could be another option. This study is aimed at comparing the efficacy and safety aspects between ultrasound-guided transforaminal injections of PRP and steroid in patients who suffer from radicular pain due to lumbar disc herniation.”

Two groups of patients were given ultrasound-guided transforaminal injections of either PRP (61 patients) or steroid (63 patients).

Two groups of patients were given ultrasound-guided transforaminal injections of either PRP (61 patients) or steroid (63 patients). Patients were assessed by various pain, function and disability scoring system at 1 week, 1 month, 3 months, 6 months, and 12 months after treatment. Intergroup differences during follow-ups over a period of 1 year were not found to be significant in all the above assessment between the PRP and steroid groups. No complications were reported. The results showed similar outcome for both transforaminal injections using PRP and steroid in the treatment of lumbar disc herniation, suggesting the possible application of PRP injection as a safer alternative.”

In this study PRP was substituted for steroid, administered in the same way and provided similar results.

Injecting into the epidural space.

As pointed out in a September 2021 paper (2), “injecting into the epidural or spinal space comes with its own risks. Epidural steroid injections (ESIs) are a commonly utilized treatment for lumbosacral radicular pain caused by intervertebral disc herniation or stenosis. Although effective in certain patient populations, Epidural steroid injections (ESIs) have been associated with serious complications, including paralysis and death. In 2014, the US Food and Drug Administration (FDA) issued a safety warning on the risk of injecting corticosteroids into the epidural space.”

Does PRP injection directly into the disc help?

This is a very debated subject. An April 2021 study (3) examined patient outcomes in treating people with back pain by injecting PRP directly into the disc. This is a systematic review and meta-analysis stuyd meaning that the researchers examined outcomes of previously reported results in peer-reviewed papers.

  • 13 studies involving 319 patients were included in the meta-analysis.
  • A single-arm meta-analysis (simply did the people in the study get results or not) showed a beneficial effect of the intervention in terms of pain relief outcomes while such improvement was not seen in functional outcome measures. No structural improvement in magnetic resonance imaging was observed.

The researcher’s conclusion: “There is a paucity of high-quality studies to give conclusive evidence on the benefits of intradiscal PRP for lumbar disc disease. Although intradiscal PRP injection has shown some beneficial effect in controlling pain for lumbar disc disease, we could not find structural or functional improvement from the included studies. Hence, we recommend large double-blind double-arm randomized controlled studies to analyze the benefits of the intervention being analyzed.”

Intradiscal PRP injections as a possible future remedy once more studies are reviewed

Further along these lines of research is a  2019 paper (13) where researchers suggested intradiscal PRP injections as a possible future remedy once more studies were reviewed. The paper notes that while intradiscal cells can be grown in the laboratory and that animal studies have shown structural changes (IVD height) and improving the matrix integrity of degenerated IVDs as evaluated by magnetic resonance imaging (MRI) and histology, more research and clinical evaluation should be considered before recommending this treatment. They write: “Clinical studies for evaluating the effects of the injection of PRP into degenerated IVDs for patients with discogenic low back pain have been reviewed. Although there was only one double-blind randomized controlled trial, all the studies reported that PRP was safe and effective in reducing back pain. While the clinical evidence of tissue repair of IVDs by PRP treatment is currently lacking, there is a great possibility that the application of PRP has the potential to lead to a feasible intradiscal therapy for the treatment of degenerative disc diseases.”

 

Epidural Steroid Injections on lumbosacral radicular syndrome-related symptoms

A July 2021 study (4) assessed the clinical relevance (is this a treatment that will help people) of Epidural Steroid Injections on lumbosacral radicular syndrome-related symptoms: The researcher’s observations in this study are as follows: “Epidural steroid injections can be used to reduce lumbosacral radicular syndrome related pain. The clinical relevance of Epidural steroid injections are currently unknown.”

“On the basis of the analyses (the study authors) conclude there is insufficient evidence that Epidural steroid injections for patients with lumbosacral radicular syndrome are clinically relevant at any follow-up moment. High-quality studies utilizing a predefined clinical success are necessary to identify potential clinically relevant effects of Epidural steroid injections. Until the results of these studies are available, there is reason to consider whether the current daily practice of Epidural steroid injections for patients with lumbosacral radicular syndrome should continue.”

From Vanderbilt University:

  • When studied side-by-side against many different lumbar disc problems, surgery is superior to epidural steroid injections for improving quality of life and pain, however after a year neither the surgery or the epidural steroid injections significantly helped improve the patient’s disability.(5)

“…epidural steroid injection cannot alter the need for surgery in the long term.”

Epidural steroid injections do not prevent surgery, they provide pain relief until the day of surgery. From Johns Hopkins School of Medicine, Walter Reed National Military Medical Center, University of Toronto researchers:

  • Epidural steroid injections provide modest pain relief up to 3 months in patients with lumbosacral radicular pain caused by herniated disks, but they have no impact on physical disability or incidence of surgery.(6)

From the Department of Orthopedic Surgery, Thomas Jefferson University, Rothman Institute

  • For some epidural steroid injections did not work at all. “Patients with lumbar disc herniation treated with epidural steroid injection had no improvement in short or long-term outcomes compared with patients who were not treated with epidural steroid injection.”(8)

A February 2019 study (9) from Stanford University School of Medicine wrote this:

  • “Lumbosacral epidural steroid injections (ESIs) have increased dramatically despite a narrowing of the clinical indications for use. One potential indication is to avoid or delay surgery, yet little information exists regarding surgery rates after epidural steroid injections.  The purpose of this research was to determine the proportion of patients having surgery after lumbar ESI for disc herniation or stenosis and to identify the timing and factors associated with this progression.”

Results:

  • Within six months, 12.5% of epidural steroid injections patients underwent lumbar surgery.
  • By 1 year, 16.9% had surgery,
  • and by 5 years, 26.1% had surgery.
  • Patients with herniation had surgery at rates of up to five-fold to seven-fold higher, with the highest rates of surgery in younger patients and those with both herniation and stenosis.

Conclusions:

“In the long term, more than one out of every four patients undergoing epidural steroid injections for lumbar herniation or stenosis subsequently had surgery, and nearly one of six had surgery within the first year.”

Also from Stanford University

“Despite a high success rate at 6 months, the majority of (patients) experienced a recurrence of symptoms at some time during the subsequent 5 years. Fortunately, few reported current symptoms, and a small minority required additional injections, surgery, or opioid pain medications. Lumbar disc herniation is a disease that can be effectively treated in the short-term by transforaminal epidural steroid injections or surgery, but long-term recurrence rates are high regardless of treatment received.”(10)

Epidural steroid injection the most frequently performed pain procedure, dangerous?

In a review published by Dr. Epstein from the Albert Einstein School of Medicine in the medical journal Spine, Epidural steroid injections were not only questioned for lack of effectiveness, but also called dangerous:

  • “(Epidural steroid injections) are typically short-acting and ineffective over the longer-term, while exposing patients to major risks/complications. . .Although the benefits for epidural steroid injections may include transient pain relief for those with/without surgical disease, the multitude of risks attributed to these injections outweighs the benefits.”(11)

Epidural steroid injection side effects

Epidural steroid injections are given to reduce inflammation in the nerves that pass through the spinal canal. Many pain management specialists believe that nerve inflammation is the root cause of the patient’s discomfort and the cause of radiating pain and numbness down the patient’s legs. Patients with these problems are often diagnosed as having “Sciatica,” a term to describe injury or compression of the sciatic nerve. Dr. Alison Stout of the Spine and Musculoskeletal Medicine, Rehabilitation Care Services, Veterans Administration said: “Epidural steroid injection has been used as a treatment for low back pain for over 50 years. In the last 10 to 15 years, there has been a significant increase in (their use) for the treatment of low back pain and radicular pain without clear improvements in outcomes.”(12) As chronic pain specialists we see many patients with radiating lower back pain. When we first examine these patients at least 25% of them will say that they have been diagnosed with sciatica. After the examination we find that many of these patients do not have sciatica at all and this is why epidural steroid injections have failed them.

When epidurals do not work

When epidurals do not work many physicians will move the patient unto surgery. Procedures will be recommended that will “stabilize the spine” such as spinal fusion, or surgeries or laser methods that will create more space for the nerves by removing bone from the vertebrae. This is why we see many patients with “Failed Back Surgery Syndrome,” a procedure was performed that did not address the cause of the patient’s pain ligament weakness or laxity.

Treatment options beyond epidurals and alternatives to surgery

In our clinic we offer our patients options that treat the cause of their pain and functional problems with stem cell therapy. Use the form below and ask me your questions about your back pain.

A May 2022 study (14) examined the effects of a transforaminal injection with autologous platelet-rich plasma in lumbar disc herniation. The authors write: “Lumbar radiculopathy is a major health problem, which often treated by neurosurgery or guided lumbar epidural steroids for pain relief. We used autologous Platelet Rich Plasma (PRP) as a novel pharmaceutical agent that has strongly emerged in recent years to treat patients of lumbar disc herniation. ”

Study highlights

  • Twenty-five patients were enrolled and injected with 4 ml of autologous platelet rich plasma under fluoroscopic guidance via transforaminal epidural injection into area of affected nerve root.
  • Patients who received transforaminal injections with autologous PRP showed statistically significant improvements in pain and function scales. The improvements were sustained over twelve-month follow-up and there were no associated complications.
  • Transforaminal injection with autologous PRP helps patients relieve chronic pains and be able return to work. Besides, autologous PRP can be considered as a good alternative to epidural steroids in management of lumbar disc herniation. 

Articles on our treatment options for back pain:

Platelet Rich Plasma therapy for chronic low back pain

Non-surgical treatment of degenerative disc disease

Stem Cell Therapy for sciatica like symptoms

Stem Cell Therapy and PRP for sacroiliac joint dysfunction

Do you have questions? Ask Dr. Darrow

 


A leading provider of stem cell therapy, platelet rich plasma and prolotherapy
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PHONE: (800) 300-9300 or 310-231-7000

References:

1 Xu Z, Wu S, Li X, Liu C, Fan S, Ma C. Ultrasound-Guided Transforaminal Injections of Platelet-Rich Plasma Compared with Steroid in Lumbar Disc Herniation: A Prospective, Randomized, Controlled Study. Neural plasticity. 2021 May 27;2021.
2 Cohen SP, Greuber E, Vought K, Lissin D. Safety of Epidural Steroid Injections for Lumbosacral Radicular Pain: Unmet Medical Need. The Clinical journal of pain. 2021 Sep;37(9):707.
3 Muthu S, Jeyaraman M, Chellamuthu G, Jeyaraman N, Jain R, Khanna M. Does the Intradiscal Injection of Platelet Rich Plasma Have Any Beneficial Role in the Management of Lumbar Disc Disease?. Global Spine Journal. 2021 Apr 12:2192568221998367.
4 de Bruijn TM, de Groot IB, Miedema HS, Haumann J, Ostelo RW. Clinical Relevance of Epidural Steroid Injections on Lumbosacral Radicular Syndrome-Related Complaints: Systematic Review and Meta-Analysis. The Clinical Journal of Pain. 2021 Apr 15.
5 Sivaganesan A, Chotai S, Parker SL, McGirt MJ, Devin CJ. 161 Patient-Reported Outcomes After Epidural Steroid Injections vs Surgery for Degenerative Lumbar Disease: A Prospective, Matched Cohort Study. Neurosurgery. 2016 Aug;63 Suppl 1:164-5. doi: 10.1227/01.neu.0000489730.99853.c3.
7 Bhatia A, Flamer D, Shah PS, Cohen SP. Transforaminal Epidural Steroid Injections for Treating Lumbosacral Radicular Pain from Herniated Intervertebral Discs: A Systematic Review and Meta-Analysis. Anesth Analg. 2016 Mar;122(3):857-70. doi: 10.1213/ANE.0000000000001155.
8 Leung SM, et al. Clinical value of transforaminal epidural steroid injection in lumbar radiculopathy. Hong Kong Med J. 2015 Aug 14. doi: 10.12809/hkmj144310.
9 Koltsov JC, Smuck MW, Zagel A, Alamin TF, Wood KB, Cheng I, Hu SS. Lumbar epidural steroid injections for herniation and stenosis: incidence and risk factors of subsequent surgery. The Spine Journal. 2018 Jun 26
10 Kennedy DJ, Zheng PZ, Smuck M, McCormick ZL, Huynh L, Schneider BJ. A minimum of 5-year follow-up after lumbar transforaminal epidural steroid injections in patients with lumbar radicular pain due to intervertebral disc herniation. The Spine Journal. 2018 Jan 1;18(1):29-35.
11 Epstein NE The risks of epidural and transforaminal steroid injections in the Spine: Commentary and a comprehensive review of the literature Spine: 2013;3:74-93
12 Stout A. Epidural steroid injections for low back pain. Physical Medicine and Rehabilitation Clinics. 2010 Nov 1;21(4):825-34.
13 Akeda K, Yamada J, Linn ET, Sudo A, Masuda K. Platelet-rich plasma in the management of chronic low back pain: a critical review. Journal of pain research. 2019;12:753.
14 Le VT, Dao LT, Nguyen AM. Transforaminal injection with autologous platelet-rich plasma in lumbar disc herniation: A single-center prospective study in Vietnam. Asian Journal of Surgery. 2022 May 28.
15 Radcliff K, Hilibrand A, Lurie JD, Tosteson TD, Delasotta L, Rihn J, Zhao W, Vaccaro A, Albert TJ, Weinstein JN. The impact of epidural steroid injections on the outcomes of patients treated for lumbar disc herniation: a subgroup analysis of the SPORT trial. The Journal of Bone and Joint Surgery. American volume. 2012 Aug 8;94(15):1353.

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