Epidural steroid injections have become one of the most commonly used pain treatments in modern medicine. In the U.S., we perform an estimated 10-11 million of these procedures each year, with about 20 percent of those coming in the more elderly Medicare population. In fact, I would say that this very procedure is what helped launched the specialty of pain management, also referred to as pain medicine, some 30+ years ago. You see, anesthesiologists are trained on how to position special needles within the epidural space of the spinal canal in order to anesthetize the body for surgery or to treat labor pain. There is a special technique required to perform epidural blocks appropriately, and using this procedure to deliver medications like corticosteroids (cortisone) to alleviate spinal pain was one of the first treatments developed to treat pain as an entity or a disease, as opposed to a symptom. As a result, the subspecialty of pain management grew out of the practice of anesthesia, with a strong emphasis on being able to perform procedures that could effectively treat pain.
Despite the history surrounding spinal injections and the large volume of them that now get performed each year, it has been difficult to find rousing scientific support for their benefit. The New England Journal of Medicine has just published a new study from the University of Washington examining epidural steroid injections. This particular study looked specifically at patients with spinal stenosis in the lumbar region who had sciatica, also known as radicular pain. Spinal stenosis is typically an age-related narrowing around the spaces of the spinal canal, and this narrowing can exert pressure on the spinal nerves, which can cause pain, numbness, or weakness in the legs. They compared a study group injected with corticosteroids to a group injected with only lidocaine, and after six weeks, they found no significant differences in pain levels or disability scores between the two groups. They concluded that the epidural steroid injections “offered minimal or no short-term benefit” in comparison.
This published study is typical of others done on epidural injections for spinal pain that frequently find either only short-term or limited benefit from the procedure. But these types of proclamations raise the ire of many vested patients and doctors who continue to see them as valuable treatments that provide subjective benefit. What was interesting about this latest study is that the epidural steroid injection group did show a statistical advantage when it came to satisfaction with their treatment and had greater improvement in their depression. In other words, these patients seemed happier with their respective situations even though their pain symptoms or level of function did not change any more than the group who just an injection of local anesthetic. I think this makes evaluating the quality of the treatment more complex. Isn’t patient satisfaction really important and something we should all strive for?
The answer to that may be “yes” and “no” depending on the situation. I think at a fundamental level, patients are going to be more satisfied with their treatment if they feel their doctors are engaged with them and trying to do things to help, regardless of the results. Patients often want to hear that their physician is going to “do something” when they are hurting. But what if doing something may have risks involved, is costly, or just isn’t likely to help? Not to mention that in some cases doctor approval ratings go up or down depending on how much pain medications they prescribe, regardless of how successfully they treat the problem. There are ramifications to bad outcomes, whether we are talking about dangerous medical complications or over-burdening the national deficit with extra treatments.
As a pain physician with an anesthesia background, I must say that I have performed this procedure thousands of times over a span of two decades. Many of my patients have been grateful for having it done, and they usually are the ones actively seeking it out, as opposed to me selling it to everyone who walks through the door. I try to take a comprehensive, integrated approach with all of my patients, which means I offer a wide assortment of recommendations to them with a goal of creating better health along the way. The mantra “do no harm” really resonates with me. In spite of everything, there still seems to be a useful place for a procedure that scientific studies have struggled to endorse. Maybe the studies are too flawed or we just don’t have a good way to measure outcomes when it comes to pain? In other words, sometime the science of medicine just plain lags behind the art of healing. Perhaps we need better patient selection to see better outcomes? Or maybe pain treatments are like honey, where the more I do the more patients I attract?
It would be great to hear your feedback on this topic. Have spinal procedures improved your quality of life? Helped you function better? What results have you seen with your family members or friends who have had epidural injections?