Alternatives to Epidural Steroid Injections – Why do patients still get epidurals?
Ross Hauser, MD, Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
Danielle R. Steilen-Matias, MMS, PA-C, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
David Woznica, MD, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Alternatives to Epidural Steroid Injections
It is very likely you are reading this article because:
1. You already had the injection(s) and you have been told that the next step is surgery. OR,
2. You have tried the epidural and it did not help as much as you thought it would and you are exploring whether to get another injection. OR,
3. You have been newly suggested to get the injection and you were advised of the benefits and risks and you are looking up information on the Epidural Steroid Injections.
Typically we will get an email or a patient will tell us in the office that they were recommended to get an epidural, and, doing what most people do, they went right to internet to look up what an epidural steroid injection is, what are the side-effects of an epidural steroid injection, and how much does it really help? It does not take long for someone to discover enough information about epidural steroid injections to want to explore an alternative. The challenge is finding a suitable alternative.
Some people have had great success with Epidural Steroid Injection. Some people even had a few of them. These are the people we typically do not see in our office. We see the ones who had the less than desired results or failure of the treatment.
Epidurals, sometimes referred to as epidural nerve blocks or epidural blocks, can be delivered as:
- interlaminar epidural injections (which delivers the injection over a wider area of the back),
- transforaminal epidural injections, (more targeted to a specific nerve – some call this an epidural nerve block or epidural block injection),
- and caudal techniques (delivery into the extreme lumbar spine).
The goal of this injection is pain relief through a reduction of inflammation and swelling in the epidural space.
Numerous research studies have found it challenging to determine whether one technique is superior to the other, especially when considering multi-level disc related pain.
Overall long-term effectiveness of treatment with epidural corticosteroid injections
Here is a recent study. Let’s look at the list of leading universities who participated in this study: University of Washington, Oregon Health and Science University, Brigham and Women’s Hospital and Spine Unit, Harvard Vanguard Medical Associates, University of Texas, Stanford University Medical Center, University of Colorado, the University of Pittsburgh, Columbia University Medical Center, New York, and let’s add the Mayo Clinic, Henry Ford Hospital in Detroit, and Kaiser Permanente Center for Health Research. Clearly, there is a lot of knowledge behind this research.
Published in the journal Archives of Physical Medicine and Rehabilitation, August 2017, (1) these researchers came up with these conclusions concerning the overall long-term effectiveness of treatment with epidural corticosteroid injections for lumbar central spinal stenosis and the effect of repeat injections, including crossover injections of lidocaine alone, on outcomes through 12 months.
“For lumbar spinal stenosis symptoms, epidural injections of corticosteroid plus lidocaine offered no benefits from 6 weeks to 12 months beyond that of injections of lidocaine alone.”
Here is the result of this research:
- “For lumbar spinal stenosis symptoms, epidural injections of corticosteroid plus lidocaine offered no benefits from 6 weeks to 12 months beyond that of injections of lidocaine alone in terms of self-reported pain and function or reduction in the use of opioids and spine surgery.
- In patients with improved pain and function 6 weeks after initial injection, these outcomes were maintained at 12 months. However, the trajectories of pain and function outcomes after 3 weeks did not differ by injectate type. Repeated injections of either type offered no additional long-term benefit if injections in the first 6 weeks did not improve pain.”
- So for some people, the epidurals worked up to 12 months.
For some, epidurals did not work beyond 6 weeks or at all, and for those patients, further injections did not offer benefit.
- So for some people, the epidurals worked up to 12 months.
Epidural steroid injections “do not repair damage and long-term clinical improvement is lacking”
In a recent study, published in the medical journal Schmerz (Pain), (2) German 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 an MRI scan looking for back pain. 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 our 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. This agrees with the above research on the lack of long-term effectiveness.
The only best use of epidural steroid injection is to provide pain relief until spinal surgery can be performed?
In agreement with the previous study that epidural steroid injection does not repair damage and long-term clinical improvement is lacking, is a study published in the Hong Kong Medical Journal, (3) where doctors suggest that the only best use of epidural steroid injection is to provide pain relief until spinal surgery can be performed. What do they base this on?
- In this study, the immediate response rate to transforaminal epidural steroid injection was 80.2% in patients with clinically diagnosed lumbar radiculopathy and magnetic resonance imaging of the lumbar spine suggesting nerve root compression.
- Of patients with single-level radiculopathy and multiple-level radiculopathy, 80.3% and 78.6% expressed an immediate response to transforaminal epidural steroid injection, respectively.
- The analgesic effect lasted for 1 to 3 weeks or less in 15% of patients
- for 3 to 12 weeks 15.9% patients,
- and for more than 12 weeks in 92 (39.7%) patients.
- Of the 232 patients in this study, 106 (45.7%) were offered surgery, with 65 (61.3%) undergoing operation, and with 42 (64.6%) requiring spinal fusion in addition to decompression surgery.
Conclusions: The immediate response to transforaminal epidural steroid injection was approximately 80%. 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.
Concern: Epidural stopgap until surgery
How about evidence that the epidurals are only masking pain and could be making your situation worse?
Here is a piece of research from doctors at the University of Arizona that makes a very good point that the only best use of epidural steroid injection is to provide pain relief until spinal surgery can be performed. It was published in 2016 in the journal Clinical Biomechanics.(5)
The researchers looked at people with degenerative facet arthritis who were treated with medial or intermediate branch nerve block injection.
Then they asked these people about their pain and measured these people with standardized scoring systems for a health condition, disability, objective motor performance measures (gait, balance, and timed-up-and-go) at pre-surgery, immediately after the injection, one-month, three-month, and 12-month follow-ups.
- Results showed that average pain and disability scores improved by 51% and 24%, respectively among patients, only one month after injection.
- Similarly, improvement in motor performance was most noticeable in one-month post-injection measurements; most improvements were observed in gait speed (14% normal walking) and hip sway within balance tests, and turning velocity within the timed-up-and-go test.
Interpretations of study:
- Spinal injection can temporarily (one to three months) improve motor performance in degenerative facet osteoarthropathy patients.
- Motor performance showed maximum improvements in one or three months after spinal injections; motor performance deteriorated after these maximum points toward baseline values. (The patient was back where the started from).
The next part the researchers found interesting and so did we.
Patients had a significant pain reduction immediately after injection with a similar reduction of more than 50% observed one month after the injection. This suggests that patients’ perceived pain reduction immediately after spinal injection; however, the pain relief was not reflected in a significant immediate improvement in motor performance.
The epidural masked the back pain but did not improve the degenerative disease condition and can put the patient at risk for hurting themselves because they feel less pain and think their back is getting better. This is not so. This is why some surgeons suggest epidurals should not be given at all, the patient should just go right to surgery.
“Unnecessary multiple epidural steroid injections delay surgery for massive lumbar disc herniation”
There are numerous research papers that suggest 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. So here the recommendation is to forget the epidural steroid injections altogether – go right for the surgery.
In the Spine Journal, doctors from Massachusetts General Hospital, Northwestern School of Medicine, Johns Hopkins University School of Medicine / Walter Reed National Military Medical Center, suggested that 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)
Dr. Nancy Epstein writing in the journal Surgical neurology international:
- Epidural steroid injections, transforaminal lumbar epidural steroid injections, transforaminal epidural steroid injections, are the most commonly performed procedures in the United States for managing chronic low back pain.
- The procedures are not Food and Drug Administration (FDA) approved for this application and are associated with major risks and complications.
- These steroid injections have been shown to be equally effective as intramuscular steroids, epidural saline or interlaminar saline injections, have no demonstrable long-term benefits, and have not reduced the need for surgery.
- Pain specialists, typically including anesthesiologists, physiatrists, and radiologists, are neither trained in neurology or in spinal surgery but are increasingly performing Epidural steroid injections/variants for patients with surgical spinal lesions.
- Even more recently, and these physicians who are not spine specialists are performing percutaneous diskectomies resulting in major morbidity/mortality.(7)
This brings us to another interesting point: Delay of treatment, any treatment.
Researchers at Penn State University writing in the medical journal Clinical spine surgery sought out to determine what factors could or could not predict which patients would benefit most from caudal epidural steroid injections in managing chronic low back pain and radiculopathy.
Among the findings:
- The duration of the patient’s symptoms was found to be negatively significantly related to lesser pain improvement.
- For each week of the duration of symptoms, the percentage of improvement decrease.
The longer the patient waited for treatment, the less likely the caudal epidural steroid injections would work.(8)
The reason comprehensive Prolotherapy is favored in our practice over epidurals is that Prolotherapy injections repair damaged tissue. In the above research, the pain is being caused by spinal tissue that needs repair, epidurals do not repair this tissue. The longer the patient waits for treatment, the more damage occurs and the greater the likelihood of surgical intervention. Prolotherapy can help patients repair damage and avoid surgery.
Epidural Steroid Injections Risks and Concerns
Concern: What is that cortisone doing to your whole body?
Researchers at Vanderbilt University Medical Center published a December 2019 study in the journal Current Physical Medicine and Rehabilitation Reports. (9) What they were questioning is what were the side effects of “systemic absorption of corticosteroids occurs following epidural administration.”
Side-effects group 1:
Central steroid response,
- including sleeplessness,
- non-positional headache,
- and increased radicular pain, represents some of the most common immediate or delayed adverse event related to epidural steroid injections
Side-effects group 2:
The systemic effects of corticosteroids themselves. These include:
- hypothalamic-pituitary-adrenal axis suppression,
- decreased bone mineral density, and others.
Suppression of the hypothalamic-pituitary-adrenal axis can can impair digestive functions, the immune system, cause sexual dysfunction, problems of mood and emotional swings, and possible impairment of the body’s energy producing systems that will lead to excessive fatigue.
Concern: Spinal pain after the epidural shot
It is clear that Epidural Steroid Injections are a cause of concern to patients and doctors. Recent research 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.(10)
Italian pain specialists writing in the Polish medical journal Anaesthesiology intensive therapy simply said this:
“We concluded that even if epidural steroid injection is one of the most widely- -used techniques to treat radicular pain, it must be administered cautiously, with careful monitoring for systemic side effects. At the very least, a standardised protocol is necessary.”(11)
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).
Patients still get epidurals because they provide pain-relief and as noted below, relief from disability challenges.
- Continuing with this cited study, 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).(12)
This research was cited in a supportive study published by a Chinese research team in the International Journal of Clinical & Experimental Medicine. Here, a systematic literature search was conducted to examine studies comparing the effect of local anesthetic with or without steroids. This meta-analysis confirms that epidural injections of local anesthetic with or without steroids have beneficial but similar effects in the treatment of patients with chronic low back and lower extremity pain.(13)
In research from Penn State already cited in this article, doctors found that patients with pain with lumbar extension (most commonly a popular exercise where patients “stretch” their spine by bending backward) was negatively and significantly related to the length of relief duration from the caudal epidural steroid injections. The average length of relief duration is 38.37 weeks for individuals without painful lumbar extension and 14.68 weeks for individuals with painful lumbar extension. The mean length of relief following a caudal injection is reduced by 62% in patients who exhibit pain with lumbar extension.(8)
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 the epidural steroid injection, pain and disability improvement were reported at 36% and 43% of patients respectively. However, this was no different from natural recovery without treatment.(14)
Side Effect: 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 the bone mineral density of the hip. Enough so that doctors should be considering options when contemplating treatment for radiculopathy.
Writing in the medical journal Spine, (15) doctors noted:
“A single Epidural steroid injection in postmenopausal women adversely affects Bone Mineral Density of the hip. . . . Our findings show that epidural administration of corticosteroids has a deleterious effect on bone, which should be considered when contemplating treatment options 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.”
In other words, for some women, the temporary relief from back pain can lead to hip fracture.
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 researchers from South Korea wrote in the journal Pain Physician.(16)
- “(Our) 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.”
So the findings do not include long-term high dose steroid use. After further review another South Korean group of researchers came back and published in the journal Pain Physician:(17)
“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, and that study group was too small to provide an assessment.
An Alternative to Epidural Steroid Injections is 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.
In 2013, doctors at the Hadassah Medical Center in Jerusalem began recruiting patients to test the long-term effects of epidural steroid injection versus Prolotherapy in patients with low back pain. Registered with the US National Institutes of Health US Library of Medicine, the Israeli doctors’ hypothesis is that in the treatment of low back pain radiating to the leg, the long-term results of prolotherapy are more effective than those of the current conventional treatment: epidural steroid injections (ESI). This research is expected to be published in 2020.(18)
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.
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”(19)
In 2017, research from Prolotherapy doctors including Liza Maniquis-Smigel, MD; Kenneth Dean Reeves, MD; Howard Jeffrey Rosen, MD; John Lyftogt, MD; and David Rabago, MD; published in the journal Anesthesiology and Pain Medicine, found that among participants with chronic low back pain and either buttock or leg pain, 10 mL of dextrose injected in the caudal epidural space, compared with injection of 10 mL of normal saline, resulted in substantial, consistent, and significant analgesia within 15 minutes that lasted at least 48 hours.
These findings suggest for the first time that 5% dextrose injected in the caudal space may confer a pain-specific neurogenic effect at the dorsal root level.(20)
There is plenty of research to support the use of Prolotherapy for back pain (especially lumbar pain), here are some of the research summaries.
- University of Manitoba, Winnipeg, Manitoba, Canada. The Journal of Alternative and Complementary Medicine
- One hundred and ninety (190) patients were treated between, June 1999-May 2006.
- Both pain and Quality of Life scores were significantly improved at least 1 year after the last treatment.
- This study suggests that prolotherapy using a variety of proliferants can be an effective treatment for low back pain from presumed ligamentous dysfunction for some patients when performed by a skilled practitioner.(21)
- Harold Wilkinson MD, in the journal The Pain Physician
Citing our own Caring Medical and Rehabilitation Services published research in which we followed 145 patients who had suffered from back pain on average of nearly five years, we examined not only the physical aspect of Prolotherapy but the mental aspect of treatment as well.
- In our study, 55 patients who were told by their medical doctor(s) that there were no other treatment options for their pain and a subset of 26 patients who were told by their doctor(s) that surgery was their only option.
- In these 145 low backs,
- pain levels decreased from 5.6 to 2.7 after Prolotherapy;
- 89% experienced more than 50% pain relief with Prolotherapy;
- more than 80% showed improvements in walking and exercise ability, anxiety, depression and overall disability
- 75% percent were able to completely stop taking pain medications.(23)
If our study, mentioned above, was solely based on getting 75% of patients off their pain medications, that would be wildly successful in itself. But the fact that Prolotherapy was able to strengthen the patient’s spines and decrease overall disability and return these people to a normal lifestyle. That is not pain management, that is a pain cure.
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