Epidural Steroid Injections effective?

[mmglobal]

From www.orthosupersite.com

wow... $50 million / year from Medicare?

__________________________________________________ ___

Epidural steroid injections limited in treating back pain, neurology society advises

Literature review finds epidural steroid injections have no impact on average functional impairment or on the need for surgery.


1st on the web (March 30, 2007)
March 2007

Epidural steroid injections play only a limited role in providing short-term relief to patients with radicular lumbosacral back pain, according to a guideline developed by the American Academy of Neurology.

"While some pain relief is a positive result in and of itself, the extent of leg and back pain relief from epidural steroid injections, on the average, fell short of the values typically viewed as clinically meaningful," said lead investigator Carmel Armon, MD, MHS, in a press release from the organization.

Armon is chief of the division of neurology at Baystate Medical Center in Springfield, Mass., and professor of neurology at Tufts University School of Medicine, Boston. He is also a member of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.

Armon and colleagues performed an evidence-based literature review focusing on fluoroscopically guided transforaminal epidural injections. Of 37 articles identified, only four met the strict predetermined inclusion criteria for the study. The researchers' conclusions, based on these four studies, comprise the guideline, which is published in the journal Neurology.

The researchers found that epidural steroid injections provide some short-term pain relief between 2 and 6 weeks postinjection. However, "The average magnitude of effect is small, and the generalizability of the observation is limited by the small number of studies, limited to highly selected patient populations, the few techniques and doses studied, and variable comparison treatments," the investigators reported.

"In general, epidural steroid injections for radicular lumbosacral pain have shown no impact on average impairment of function, on need for surgery, or on long-term pain relief beyond 3 months," they wrote. "Their routine use for these indications is not recommended."

In addition, the researchers found insufficient evidence to make any recommendations regarding the use of epidural steroid injections for treating radicular cervical neck pain.

The authors noted that the review was limited by the small number of high-quality scientific studies available, and further well-designed studies are needed to determine the effectiveness of steroid injections.

"The use of epidural steroid injections to treat chronic back pain is increasing over time despite limited quality data," Armon said in the release. "Recent figures show 1999 Medicare Part B claims for lumbar epidural steroid injections were $49.9 million, for 40.4 million covered individuals."

For more information:

Armon C, Argoff CE, Samuels J, Backonja MM. Assessment: Use of epidural steroid injections to treat radicular lumbosacral pain: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2007;68:723-729.

[Poncho]

Boy, I would like to have a look at these studies - especially the stats...

My impression is that one needs to view this information with a critical eye and keep in mind who the "key players" are re: sponsors of the article.

In my case, the epidurals helped a little bit - but not significant enough.

Anyone else care to comment on their experiences?

[sahuaro]

I had a series of 3 epidurals for an extrusion of C5/C6. I did not notice any significant effect except I would like to believe that they contributed (along with other conservative measures) to some resorption of the extruded material. Nonetheless, I have gone on to have increased nerve damage from foraminal stenosis and am now told that surgery is no longer elective. The neurologist who did my last EMG which showed changes from previous studies, suggested another series of epidurals. I could not see the purpose; plus I am cynical enough at this point to see more steroid injections as a threat to my bone density and therefore to my surgical choices. However, I do know of cases, both cervical and lumbar, that were significantly helped by ESI's.

[mmglobal]

IMHO, epidurals are much like many other treatments (traction therapies, enbrill injections, etc...) They have the potential to have a long term benefit in a small percentage of the population and they often have some short term benefit. However, what I see is that SOME, NOT ALL of the purveyors of the technology overuse it in a very gross fashion. I've spoken to too many people who've gotten ZERO relief from 2 ESI's and have still been given a third in the same location. I've spoken to too many people who've gone to VAX-D or DRX-9000 traction therapy and told that their case is so bad that they'll really need to complete all 20 treatments to realize any benefit... oh yes... it may make you worse at first... that'll be $4,000 out of pocket please.

I know a few people with good results, but for every one I know that has a good result, I know many, many more without.

Having said that... I believe that intelligently applied, ESI's are an appropriate tool in the arsenal and some of my 8 ESI's were of great short-term benefit. When I was in the situation where my pain was episodic, ESI's saved vacations and allowed me to function better and recover from a flare-up more quickly. Once you get to the point where the DDD is advanced and there are real structural problems., it's just a symptom masker... but of benefit for some.

I know a couple of people with good result from traction, but in my experience, these successes are few and far between.

Also... when the choice is between fusion and conservative treatment, we'll do more conservative treatment before pulling the trigger on surgery. As our surgical options improve, hopefully it will become a more reasonable option to fix the problem and not let things get worse, earlier in the degenerative cascade.

Just my 2 cents... all the best,

Mark

[Maria]

Lumbar ESIs saved my ARSE for quite some time~ I've had around 21 all together or some such number!!! Was asking for one recently and Utilization Review denied due to no real documentation as to the benefit as well as denying my Methadone since it's not proven that Methadone is actually helpful for pain relief as it's primary/proven use is for withdrawl from Heroin. I'm paraphrasing but pretty much this was what was said in 6 pages of UR BS.

Again, Lumbar ESIs helped me greatly, esp. transforaminal approach (caudal worked as well but seemed less effective at certain levels).

[mmglobal]

I had 8 ESI's over 2.5 years. 7 were done by one old doc with no flouroscopy... never hurt... never made me worse... 5 of 7 produced relief for days or weeks. (remember that my pain was episodic, so I may have gotten better anyway.) The one caudal ESI I had with a young physiatrist (again, no flouroscopy), really set me off.

Upon going back to the old guy when I told him about ESI causing many days of severe pain, he said, "I bet he ran into bone and had to back up and try again." He was absolutely correct.

Mark

[Maria]

All but the first was done under flursocopy and the the first was BRUTAL!
The rest were a walk in the park and done at outpatient surgery centers with the first few years w/local anesthetic only. In Florida the doc would NOT do them with local only. Since then, I just prefered not knowing when it was done (go ahead, knock me out)~ the effects usually were within a day to three (calming of pain) and last up to 1 month at least. Sometimes longer relief up to 3=4 months but maybe just broke the pain cycle~ Maybe that's what happened this time.
All I know is that my back has been hurting since this foot surgery and I'd have been pleased to have an ESI to calm things down. Guess I'll just have to start walking and getting it together on my own. Hopefully~

[marijo]

It didnt give me any relief at all. Not even one day. I think all my probs come from a crooked pedicle screw, which encroaches about 20% of my spinal canal.

[Maria]

Marijo,
Sorry to hear the ESI didn't give any relief, I need one now as they are helpful to me but Work Comp is denying since surgery was approved tho I canceled for now...

Has anything been suggested/offered re the crooked pedicle screw?? That sounds like a bear~