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.

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.

Latest research

A July 2021 study (1) 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.(2)

“…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.(3)

From The Chinese University and Prince of Wales Hospital in Hong Kong:

  • The immediate response to transforaminal epidural steroid injection was approximately 80%. . . However transforaminal epidural steroid injection cannot alter the need for surgery in the long term.(4)

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.”(5)

A February 2019 study (6) 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.”(7)

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.”(8)

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.”(9) 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.

Dr. Darrow injecting the patient’s spinal ligaments to relieve discomfort.

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.

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

 


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11645 WILSHIRE BOULEVARD SUITE 120, LOS ANGELES, CA 90025

PHONE: (800) 300-9300 or 310-231-7000

References:

1 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.
2 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.
3 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.
4 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.
5 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
6 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 J Bone Joint Surg Am. 2012 Jun 27. doi: 10.2106/JBJS.K.00341. [Epub ahead of print]
7 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.
8 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
9 Stout A. Epidural steroid injections for low back pain. Physical Medicine and Rehabilitation Clinics. 2010 Nov 1;21(4):825-34.

 

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