Why Perform Spinal Injections at All? Evidence is Weak

International Society for the Advancement of Spine Surgery (ISASS17) Meeting Highlight

A particularly engaging panel discussion at the 17th Annual ISASS Conference was moderated by Pierce Nunley, MD, Director of the Spine Institute of Louisiana in Shreveport and focused on Pain Management: Why Do We Do Injections at All?

Peter G. Whang, MD, FACS, an Associate Professor of Orthopaedics and Rehabilitation at Yale School of Medicine, opened the symposium with a review of the literature regarding epidural injections in the treatment of lumbar stenosis. He first noted that the participating panelists are all spinal surgeons and thus admittedly have an inherent bias. Dr. Whang noted that the majority of patients with lumbar spinal stenosis (LSS) can be successfully managed with non-operative care.
Woman holding her neck and low backDr. Whang noted that the majority of patients with lumbar spinal stenosis can be successfully managed with non-operative care.Dr. Whang cited evidence demonstrating that the rate of lumbar epidural injections (LEIs), using either steroids or local anesthetics, increased by 665% from 2000 to 2011. In fact, epidural steroid injections are the most widely used pain management procedure in the world, despite a lack of systematic evidence supporting their efficacy.

Furthermore, Dr. Whang noted the wide variability in injection techniques, locations, and dosing frequencies. In general, available evidence indicates LEIs (with steroids or anesthetics) generally afford only “fair” efficacy for spinal stenosis. In addition, steroid injections may lead to increased use of opioids and a more rapid need for surgery.

Further, evidence suggests a significantly higher risk of surgical site infection in patients who received an injection in the 3 months prior to surgical intervention. He concluded by noting, “The long-term efficacy of LEI for alleviating symptoms of LSS, improving function, and/or avoiding surgery have yet to be established.”

Yu-Po Lee, MD, an orthopaedic surgeon with UC Irvine Health (CA), then addressed the data regarding cervical epidural injections. He noted that cervical injections may, in fact, prevent cervical surgeries, but wondered why that is considered a benefit—given that cervical surgeries have such a high rate of effectiveness and safety!

Dr. Lee discussed the three types of patients generally considered appropriate candidates for cervical epidurals—specifically, patients with loss of sensation, motor weakness/gait imbalance, or radiculopathy. Of these, he noted, steroid epidurals will only provide benefit for patients with radiculopathy. In addition, since the benefits are of short duration, patients must undergo additional injections, which can reduce bone mineral density and lead to osteopenia or even osteoporosis.

As the rebuttal presenter had bowed out prior to the symposium, the final presenter was Daniel K. Park, MD, an Associate Professor in Orthopaedic Spine Surgery, serves as Director of Minimally Invasive Orthopaedic Spine Surgery at William Beaumont Hospital-Royal Oak, Michigan. His topic was on the hype surrounding facet injections, medial branch blocks, and rhizotomies for lower back pain (LBP).

Dr. Park explained that LBP is one of the most common reasons to visit a healthcare professional, and noted that it generally resolves with time (without interventions). Approximately 5% to 15% of patients with LBP have facet joint pain, although referred pain from a variety of other sources can manifest as facet pain. Recognizing the challenges associated with diagnosing facet joint syndrome—specifically, physical examination and history are unreliable, and there is no reliable clinical test. Dr. Park noted that facet injections or medial branch blocks can be used as both diagnostic tools and treatments.

However, studies have reported no significant differences in effectiveness between intra-articular injections versus sham injections, and medial branch blocks afford benefit for approximately 15 to 19 weeks, but then require additional injections. In contrast, medial radiofrequency ablation (RFA), which is the gold standard, can afford longer-lasting pain relief (~11 months) and is associated with success in 85% of cases.

Studies have demonstrated a large placebo effect among patients with chronic pain. Dr. Park also reviewed some of the challenges associated with rhizotomies, including nerve regeneration, incorrect placement of electrode, anatomical variations and incomplete ablation. Audience participants discussed the difficulties of finding the nerve for injections to work. Dr. Park concluded there is no strong data to prove that injections and blocks are very effective, and while there is some good data, it’s not convincing. “We prescribe injections/blocks because we don’t have another solution, not because it is a great treatment.”

Audience Discussion
An audience member then posed the following question to the panel and the audience: “If the patient is not a surgical candidate, would you and do you send that patient for pain management?” The overwhelming consensus was that patients who are not (yet) surgical candidates are, in fact, being referred for pain management—often because clinicians/surgeons do not want to tell these patients that there is nothing they can offer them (at this time).

However, some clinicians did recommend that the spine surgeons assume responsibility for the injections, as they may be the most qualified specialty to administer them, instead of referring patients to other clinicians for ongoing pain management.

Updated on: 02/08/18
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