Epidural Steroid Injections for back pain
Danielle R. Steilen-Matias, MMS, PA-C
In this article back pain treated with epidural steroid injections and Prolotherapy are compared. We will answer common patient questions such as do epidural injections help herniated, slipped, bulging discs? How long do epidural pain relief last?
In the medical journal Neurosurgery, a review of 1931 patients who either received spinal surgery or epidural steroid injections for back pain were compared to see which treatment was superior.
After years of collecting data from thousands of patients and condensing the results down to 161 patients who met the criteria for comparison, the doctors found that for various problems of the spine, surgery is superior to epidural steroid injections for improving quality of life and pain.
This difference does not hold for disability level 1 year after treatment, however. What does this mean? For some patients who had either epidural steroid injections or spinal surgery, two mainstays of conservative care – one year later there was no improvement in disability levels.1
Ineffectiveness of surgery or epidural steroid injections starts at the diagnosis
In a recent study, doctors made a significant discovery. Chronic lumbar pain syndromes without neurological (nerve and muscle) deficits can be caused by many problems not just what shows up on a scan. In many cases a diseased intervertebral disc is found on radiological examination but the clinical relevance of these findings is not clear.
- What the study says is that an MRI or scan is showing disc problems but it is unclear if that is causing any problems. See Ross Hauser, MD’s article on MRI for back pain as a risk of failed back surgery syndrome.
But there is a problem of inflammation. A transforaminal epidural injection (the injection near the nerve root inflammation) into the lumbar region can reduce inflammation and therefore improve temporary treatment outcome, but it does not repair damage and long-term clinical improvement is lacking. 2 This agrees with the above research on the lack of long-term effectiveness.
Another study suggests that the only best use of epidural steroid injection is to provide pain relief until spinal surgery can be performed.3 So here there is no point to even compare – use the epidural injections to comfort the patient until surgery can be scheduled.
So clearly no healing is occurring. In fact one paper suggested that the use of epidural steroid injection subjects patients to complications by withholding surgery and that spinal surgeons should actively take back patients who could benefit more from surgery.4 So here doctors are saying forget the epidural steroid injections all together – go right for the surgery.
The reason comprehensive Prolotherapy is favored in our practice over epidurals is because Prolotherapy injections repair damaged tissue that cause inflammation – it reduces inflammation not by suppression, but by rebuilding.
Epidural Steroid Injections Risks and Concerns
Concern: Spinal pain after epidural shot
It is clear that Epidural Steroid Injections are a cause of concern to patients and doctors. Recent reseacrhy cites multiple case reports of neurological complications resulting from epidurals have led the Food and Drug Administration (FDA) to issue a warning, requiring label changes, warning of serious neurological events, some resulting in death. The FDA has identified 131 cases of neurological adverse events, including 41 cases of arachnoiditis. A review of the literature reveals an overwhelming proportion of the complications are related to transforaminal epidural injections, of which cervical transforaminal epidural injections constituted the majority of neurological complications.5
Concern: Epidural stopgap until surgery
In a related study to the one mentioned above, in the medical journal Spine, doctors said, Epidural steroid injections may provide a small surgery sparing effect in the short term compared to control injections , and reduce the need for surgery in some patients who would otherwise proceed to surgery.6
In the Journal of Alternative and Complementary Medicine, doctors said: “Intra-articular prolotherapy provided significant relief of sacroiliac joint pain, and its effects lasted longer than those of steroid injections”7
So if epidurals provide a small surgery sparing effect, then Prolotherapy must provide a large surgery sparing effect.
But why do patients still get epidurals?
A recent study from John Hopkins suggested that 75% of patients they monitored who were treated with epidural steroids reported 50 percent or greater leg pain relief and felt better overall after one month compared to those who received saline (50 percent) or etanercept (acting as an anti-inflammatory 42 percent).
On a pain scale of 0 to 10, with 10 denoting the worst pain, those who received steroids reported, at one month, an average pain score of 2.1 compared with 3.6 in the etanercept group and 3.8 in the group injected with saline.
Those in the steroid group also reported lower levels of disability (21 percent) than those in the saline group (29 percent) or etanercept group (38 percent).
Sounds good for the epidural against saline or anti-inflammatory – BUT after six months, however, slightly more patients in the saline (40 percent) and etanercept (38 percent) groups had a positive outcome than those in the steroid group (29 percent).8
Saline injections better than steroid in the long-run?
Epidural steroid injections are one option commonly presented to people with neck pain, thoracic pain, and low back pain. The goal of this injection is pain relief through a reduction of inflammation and swelling in the epidural space. The injection consists of inserting a needle into the epidural space of the spine and injecting a long lasting steroid.
- Many health professionals agree that the results are temporary and have no long-lasting effect.
This research supported a recently published work in the British Medical Journal that looked at the effectiveness of caudal epidural steroid or saline injections which are often used for chronic lumbar radiculopathy. They looked at the patients’ responses at 6 weeks, 12 weeks, and 52 weeks. It was a multi-centered trial, blinded, randomized and controlled.
They found no statistical or clinical difference between the groups over time. At the one year follow-up after epidural steroid injection, pain and disability improvement was reported at 36% and 43% of patients respectively. However, this was no different from the natural recovery without treatment.9
Epidural steroid injection and bone loss
- Recent research says epidural steroids for back pain robs postmenopausal women of bone.
Research suggests that a single epidural steroid injection in postmenopausal women adversely affects bone mineral density of the hip. Enough so that doctors should be considering options when contemplating treatment for radiculopathy.
The resulting decrease in bone mineral density, while slight, suggests that epidural steroid injections should be used with caution in those at a risk for fracture.10
Therapy with glucocorticoids often results in bone loss and glucocorticoid-induced osteoporosis
Other researchers, however, disagree. While they agree that corticosteroids often result in bone loss and corticosteroid-induced osteoporosis, they say it has nothing to do with bone mineral density because no link has been made between epidural steroid injection and bone mineral density. Further smaller doses are okay. Here’s what they say:
“These data suggest that epidural steroid injection using triamcinolone (over 200 mg) for a period of one year will have a negative effect on bone mineral density in postmenopausal women treated for lower back pain. However, ESI therapy using a maximum cumulative triamcinolone dose of 200 mg in one year would be a safe treatment method with no significant impact on Bone Mineral Density.”
[Fortunately these researchers recognized their limitations]: First, this study is limited by the fact that it was retrospective. Second, this study did not consider the use of epidural steroid injection with high-dose corticosteroids. “Third, our study did not include any long-term assessments of the effects of epidural steroid injection on Bone Mineral Density.”11
So the findings do not include long-term high dose steroid use. After further review a similar group of researchers came back and said. “Therapy with glucocorticoids often results in bone loss and glucocorticoid-induced osteoporosis. However, the relationship between epidural steroid injection, bone mineral density, and vertebral fracture remains to be determined.” Confused? Read the research, it wasn’t the steroids – it was old age:
- “Older age and lower bone mineral density were associated with osteoporotic fracture in postmenopausal women treated for low back pain with epidural steroid injection. The epidural steroid injections were not associated with low bone mineral density or fracture.”
Again, the limitations were that this research was not valid for patients who received high-dose corticosteroids, that study group was too small to provide assessment.12
Prolotherapy for Back Pain
Temporary pain relief is not what pain patients should be seeking. Permanent healing and pain relief should be the goal. Maybe pain patients don’t believe there is a cure for their pain, so they seek as many pain relief options as possible. The problem is that many pain relief treatments include steroids and anti-inflammatory agents that can make the injury even worse. As the injury gets worse, a person is forced to look for stronger and more complex pain relief. It’s a vicious cycle.
Prolotherapy is the opposite of epidural steroid injections. Prolotherapy creates inflammation to bring blood flow and healing factors to the injured tissue. Any neck or back pain that is related to joint degeneration or ligament injury can be treated effectively with Prolotherapy.
1. 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. PubMed PMID: 27399440.
2. Niemier K, Schindler M, Volk T, Baum K, Wolf B, Eberitsch J, Seidel W. Efficacy of epidural steroid injections for chronic lumbar pain syndromes without neurological deficits : A randomized, double blind study as part of a multimodal treatment concept. Schmerz. 2015 Jul;29(3):300-7. doi: 10.1007/s00482-015-0020-6.
3. 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. [Epub ahead of print]
4. Epstein NE. Unnecessary multiple epidural steroid injections delay surgery for massive lumbar disc: Case discussion and review. Surg Neurol Int. 2015 Aug 31;6(Suppl 14):S383-7. doi: 10.4103/2152-7806.163958. eCollection 2015.
5. Manchikanti L, Hirsch JA. Neurological complications associated with epidural steroid injections. Curr Pain Headache 1. Rep. 2015 May;19(5):482. doi: 10.1007/s11916-015-0482-3.
6. Bicket MC, Horowitz J, Benzon H, Cohen SP. Epidural injections in prevention of surgery for spinal pain: systematic review and meta-analysis of randomized controlled trials. Spine J. 2014 Oct 13. pii: S1529-9430(14)01569-1. doi: 10.1016/j.spinee.2014.10.011. [Epub ahead of print]
7. Kim WM, Lee HG, Jeong CW, Kim CM, Yoon MH. A randomized controlled trial of intra-articular prolotherapy versus steroid injection for sacroiliac joint pain. J Altern Complement Med. 2010 Dec;16(12):1285-90. doi: 10.1089/acm.2010.0031.
8. Cohen SP, White RL, Kurihara C, et al. Epidural Steroids, Etanercept, or Saline in Subacute Sciatica. Annals of Internal Medicine April 17, 2012 vol. 156 no. 8 551-559.
9. Trond Iversen et al. British Medical Journal 2011:343:d5278 Effect of caudal epidural steroid or saline injection in chronic lumbar radiculopathy: multicentre, blinded, randomised controlled trial.
10. Al-Shoha A, Rao D, Schilling J, Peterson E, Mandel S. Effect of Epidural Steroid Injection on Bone Mineral Density and Markers of Bone Turnover in Postmenopausal Women. Spine. 37(25):E1567-E1571, December 01, 2012.
11. Kang SS, Hwang BM, Son H, Cheong IY, Lee SJ, Chung TY.Changes in bone mineral density in postmenopausal women treated with epidural steroid injections for lower back pain. Pain Physician. 2012 May-Jun;15(3):229-36.
12. Yi Y, Hwang BM, Son H, Cheong IY. Low bone mineral density, but not epidural steroid injection, is associated with fracture in postmenopausal women with low back pain. Pain Physician. 2012 Nov;15(6):441-9.
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