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Low Return for Spinal Steroid Injections

back_pain_lowerA recent article published in the Medical Journal Of Australia has caused more than a little stir regarding the effectiveness of Spinal Steroid Injections.

The article, also picked up by Rheumatology Update states that steroid injections in the spine for low back pain should not be subsidised since the procedure is no better than placebo.

This is a significant issue in the orthopaedic community as there has been a doubling of the use of the procedure without research data to back it up.

The cost to the community is also significant. But, hey it goes on our medicare bill so why worry about it?

I often wonder with these types of procedures that if patients had to pay the full cost, and the effectiveness so low, how many would actually have it done, given the inherent risks outlined in the study below.

It is interesting because I usually see patients, who are really motivated to have this procedure, looking for a ‘quick fix’, rather than committing to care, participating in their recovery and following through on their rehab.

My question is always, after the injection wears off, what is being done to address the underlying joint and disc damage?

Steroid injections in the spine for low back pain should not be subsidised since the procedure is no better than placebo, argue two Australian experts.

Writing in the MJA, Professors Ian Harris (UNSW) and Rachelle Buchbinder (Monash University), pointed to a 2008 Cochrane review that found no benefit of steroid injections for subacute or chronic low back pain.

Other reviews had concluded that, at best, injections may provide short-term benefits lasting two to four weeks.

But studies in which a local anaesthetic was used with the placebo (as it normally is with steroid injections) had shown no difference between treatment groups for disc herniation or spinal stenosis, they noted.

Despite these findings, the number of procedures carried out in Australia had more than doubled in the past decade, the authors said.

The likely explanation was patient preference and a placebo effect observed by the doctor, they speculated.

Although rare, serious complications had been reported including cases of cauda equina syndrome, septic arthritis, discitis, paraspinal abscesses, arachnoiditis, encephalopathy and paraplegia.

Recent reports of deaths from meningitis due to fungal contamination of the steroid prepared in the US should also give pause for thought, the authors said.

Given the lack of evidence for a benefit over placebo and the small but real risk of harm, there was little justification for continued use of spinal steroid injections, the authors concluded.

“In our opinion, withdrawal of public funding for spinal steroid injections of therapeutic substances (including steroid) for low back pain and/or radiculopathy in Australia should be considered,” they said.

 

Following on from this article was another published in Pub Med last year regarding the effectiveness of lumbar transforaminal injection of steroids.

One of the authors, Professor Nikola Bogduk, who’s work I have admired over the years, published a comprehensive review with systematic analysis of the published data regarding lower back steroid injections.

Whilst this review is often touted by the orthopaedic community as very positive for patients with lumbar radicular pain caused by contained disc herniations, it does help their pains but does not necessarily resolve the problem.

The actual results show:

  • For miscellaneous conditions, the available evidence is limited and is neither compelling nor conclusive.
  • For disc herniation, the evidence is sufficiently abundant to show that lumbar transforaminal injection of steroids is not universally effective but, can help a proportion of patients.
  • For disc herniation, the injections appear to be better than a placebo.
  • Success rates are higher in patients with contained herniations that cause only low-grade compression of the nerve.
  • So the worse you are the less likely the injections work.

 

Bottom line, prevention and rehab.

 

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