Steroid Injections for Back Pain
Data reported in the journal SPINE (Volume 32, page 1754) suggests that older people with back pain are receiving steroid injections for a growing number of conditions, despite limited evidence about how well the steroid injections actually work and limited agreement on when they should be used.
According to a Johns Hopkins University Health Alert in most cases, back pain resolves quickly, regardless of the type of treatment. In fact, about 90% of cases improve on their own. Fewer than 5% of people with back pain have a major medical problem that requires either intensive care or surgery. But if you experience severe back pain that doesn't improve after a couple of days of bed rest, or if your back pain is recurring or is accompanied by pain, numbness, or tingling that radiates into the buttocks or legs, it is important to see a doctor.
Researchers report that, at least part of the reason for the rise may be profit related. They note a 32% increase per year in steroid injections at ambulatory surgery centers, which are reimbursed at a higher rate than injections administered in a hospital or doctor's office.
A panel of experts for the American Pain Society make the following recommendations.
- Recommendation 1. Discography may show signs of degenerative disc disease, but that doesn't mean the patient's pain is coming from the disc. Therefore, provocative discography is not recommended. During discography, contrast medium is injected into the disc and the patient's response to the injection is observed. In theory, pain that is similar to the patient's current back pain suggests that the disc might be the source of the pain. But there are too many false positives to trust the test. And patients with a positive test who had surgery didn't have better results than those who didn't have surgery.
- Recommendation 2. Anyone with chronic low back pain who has not gotten better with conservative (nonoperative) care should be managed by a team of clinicians especially including a psychologist or behavioral specialist. This is called interdisciplinary rehabilitation. Best results occur when cognitive/behavioral therapy is combined with a prescriptive and supervised exercise program.
- Recommendation 3. The evidence does not support injections with BOTOX, steroids, and prolotherapy. Nerve blocks, intradiscal electrothermal therapy (IDET), and intrathecal therapy with narcotics or other opioid medications can't be recommended either based on the data available so far. There just isn't enough evidence to support the use of injections or other interventional therapies. Either the evidence was insufficient or the results were no better than when sham treatments were given.
- Recommendation 4. Nonradicular back pain responds as well to conservative (nonoperative) care as it does to surgery, so surgery should be considered a low-priority option. Patients considering surgery should be told about the risks and possibility that the results will be less than satisfactory. Intensive interdisciplinary rehabilitation is always recommended first before surgery.
- Recommendation 5. Artificial disc replacements still aren't proven better than spinal fusion. Yes, they preserve motion at the involved vertebral level. But they can loosen and migrate or sink down into the bone causing problems. Patients may end up getting a fusion when the device fails. And just like with a fusion, patients with disc replacements still develop facet (spinal) joint arthritis and degenerative changes at the adjacent (next) vertebral level.
- Recommendation 6. Steroid injections for radiculopathy due to disc herniation give short-term relief only. There are no long-term benefits of this treatment. There isn't enough evidence to recommend or reject this treatment for spinal stenosis. If one injection doesn't do the trick, should another be given? What's the best timing for injection(s)? These questions still haven't been answered fully yet (insufficient evidence).
- Recommendation 7. Anyone thinking about spinal surgery for herniated disc or spinal stenosis should know that pain relief is possible in the short-term. But the final results (one to two years later) aren't any different with or without the surgery. So, the cost of the procedure and possible risks should be factored against the possible short-term benefits before going ahead with the operation. There is still much to be studied when comparing one type of surgery over another. Timing of surgery and patient selection are two other factors that might make a difference but for which there isn't enough data to make recommendations.
- Recommendation 8. What can be done for patients who have had unsuccessful back surgery? This is called failed back surgery syndrome. Spinal cord stimulation may be an option. The risks associated with this treatment (e.g., infection, device-related problems, wound breakdown) must be weighed against the benefits for each candidate. Studies are needed to compare spinal cord stimulation with intensive interdisciplinary rehabilitation.