Steroid injections are a common procedure done by physicians to reduce the inflammation that contributes to a variety of different joint pains. In the spine they are epidural steroid injections (ESI) because the injection takes place in the epidural space. The epidural space is between the dura and the ligaments that sit upon and are attached to bone tissue. The dura is a thick tissue that covers the spinal cord and nerves. It is quite common to see epidural steroid injections for leg pain but they can also be used in cases of spinal stenosis or cases of back pain. The use of these injections varies from physician to physician so it is important to understand a few points about this procedure to help determine whether or not you can benefit from it.
The number one thing to remember about epidural steroid injections is that they are used to reduce or eliminate inflammation. Where there is pain there is almost always inflammation but this inflammation is never present without some sort of causation. Treating the inflammation, only, will never fully treat what is causing the pain/inflammation in the first place. Epidural steroid injections should be combined with a physical rehabilitation program, like what we do here. We only recommend a patient for epidural steroid injections in one of two scenarios. One is a new patient who presents with pain so severe we cannot touch them, if we cannot touch them we cannot treat them. In this case the injection helps to reduce the pain to the point that the patient can move better and therefore undergo care. The second situation is a patient who fails to progress in a reasonable amount of time, in this case the patient gets a little better but plateaus so the injections reduce some pain and the patient typically gets past that plateau and responds more quickly to care. There are other ways to treat inflammation such as icing, oral steroids, or over the counter NSAID’s. We typically recommend icing because the other options have limited efficacy and side effects you might not want.
In the majority of cases, these patients have more than just back pain, they typically have pain radiating into the arms or legs. In rarer cases the patients have mild weakness in the upper or lower extremities. In the very rare cases of severe weakness or rapidly worsening pain in the extremities we immediately send those patients out for a consult with a surgeon. Some of those very rare cases might not end up needing surgery but it is prudent to get that consult just in case. Pain radiating into the arms or legs with or without neck or back pain is very treatable in our office, we do it every day. This radiating pain, in the majority of cases, is due to inflamed tissue placing pressure on a nerve. Since inflammation is involved sometimes an injection is warranted but not always. By improving joint motion, strengthening the surrounding muscles, and improving posture we can have a huge impact on the long term relief and possibly elimination of symptoms. I have a few posts in this blog about conservative care and how effective it can be to treat spine and spine related conditions. I also have a few blog posts that question the efficacy of surgical interventions and epidural steroid injections, this is actually one of these posts.
This current paper was published just September 2015 and is a review of 38 published studies on ESI’s for the treatment of leg pain related to the lumbar spine (30 papers) and spinal stenosis (8 papers). The authors looked at studies that compared ESI’s to a placebo or sham injection. They were able to conclude that epidural steroid injection for leg pain offered only a small benefit in the short term, two weeks past injection, but no long term benefit. The authors found that the short term benefit included a decreased risk for surgical interventions but that the risk for surgery increased over time. The authors noted that no single injection technique or injection location yielded better results than any other. For spinal stenosis the authors found that there is no short or long term benefit in using epidural steroid injections. They noted that since they only found 8 studies on spinal stenosis their findings could not be as conclusive as they are for leg pain. What does this mean for you?
I believe this study confirms how we utilize ESI in our practice. (To be clear we cannot perform steroid injections, we send the patient out to an MD or DO who does them.) It is best used in a very specific subset of patients who are already in or will be in a spinal care program such as ours. Patients who have leg pain and not necessarily just back pain, the pain might be severe enough that they have difficulty moving and engaging in care, or they might have plateaued about two weeks into starting care. I don’t believe this study means to not consider using injections for spine related conditions but you need to be very selective of when to use them to get the best benefit. Lastly I believe this study confirms our notion that injections should never be used for pain management, meaning you should never be getting injections in your spine regularly (several times a year) as your sole treatment. Surprisingly enough this is commonly done with patients who suffer from chronic back pain.
If you are considering epidural steroid injections for your leg pain, back pain, or spinal stenosis you really should be sure you meet the criteria for it’s best utilization. Make sure you are going to do it in conjunction with a spinal care program like the care we offer in our practice. If you have been getting them as your sole means of pain management you really need to reconsider what you are doing. There is no literature, that I’ve seen, that supports the use of injections in this way. Look forward to a post, possibly a video, about this patient who has getting injections regularly for years with no long term relief. The paper I mentioned in this post, definitely does not support the long term use of epidural steroid injections. If you have been suffering with leg pain, back pain, spinal stenosis for a few days or years you really need to see us. We offer care that is truly unique and on the cutting edge of conservative spinal care today plus it is backed by numerous studies in the literature.