As a personal injury attorney, many of our clients deal with back injuries as a result of a motor vehicle accident. Steroid injections are used as a part of the pain control for our clients. Thus, this article was a very interesting read for me.
The addition of a corticosteroid to epidural injections of an anesthetic does not enhance pain reduction in patients with lumbar spinal stenosis, according to a study in the July 3 issue of New England Journal of Medicine. (http://bit.ly/1jVLSz9 New England Journal of Medicine, July 3, 2014) The findings come from the first major clinical trial comparing epidural injections of anesthetic with and without corticosteroids for spinal stenosis People who received the drug mixed with the painkiller lidocaine scored no better on measures of disability and leg pain after six weeks than patients in a control group who received lidocaine injection alone.
Lumbar spinal stenosis is a narrowing of the passageway surrounding spinal nerves in the lower back. The resulting nerve compression is painful and the number one reason older adults have spinal surgery. The combination of glucocorticoid steroids and an anesthetic is supposed to reduce nerve inflammation and swelling in the surrounding tissue. Roughly 550,000 procedures – at a cost ranging from $500 to $2,000 per injection – are done each year just among Medicare recipients.
Some physicians have read the results of this study and think it may be a little harder to justify doing those injections for spinal stenosis in patients. Other health care providers who have read the study and still think that the treatment can be somewhat effective but not curative.
The study team involved doctors at 16 sites in the U.S., who gave half the patients injections of lidocaine followed by one of four glucocorticoid drugs: triamcinolone, betamethasone, dexamethasone or methylprednisolone. The remaining patients got lidocaine alone, and all patients had the option of a second round of treatment. Before the injections, three weeks later and again at the six-week point, patients scored their pain level on a 25-point scale, with 25 being the worst pain. At the three-week mark, average pain scores among patients in the lidocaine group had dropped from 15.7 down to 13.1, and down to 12.5 after six weeks. People in the lidocaine-glucocorticoid group started out with a bit more pain – their average score was 16.1 – and they showed most of their improvement at the three-week mark, scoring 11.7 at that point and 11.8 at the six-week mark. The difference between the groups was not statistically significant, meaning it could have been due to chance. A similar pattern was seen for leg pain, where there was a slight difference at three weeks, but that disappeared by week 6. On a satisfaction survey, 67 percent of patients who received steroids plus lidocaine reported being very or somewhat satisfied with their treatment, as compared with 54 percent of those who received lidocaine alone, the researchers note in their report. The steroid recipients showed more improvement on a scale that measured depression, as well. But they also reported more adverse events per person than the control group. The most pronounced difference in side effects was in the category of fever, infection or both. The problem was seen in two patients in the lidocaine-only group but 10 patients who got lidocaine plus a steroid.
Mostly, steroid injections are safe, carrying small risks of infection, headaches and sleeplessness. But in April, the Food and Drug Administration warned that they may, in rare cases, cause blindness, stroke, paralysis or death, noting that injections have not been F.D.A. approved for back pain and their effectiveness has not been established.
Because many insurance companies require the injections before surgery is approved, the new finding, combined with the U.S. Food and Drug Administration’s warning that they can cause paralysis, nerve damage or death, some suggest that this requirement should be reconsidered.
There isn’t much to alternatives to this regimen of treatment. I would have liked to see some suggestions on other alternatives for those who suffer from this horrible pain. Hopefully, we will see that soon.