Articles by JCS
Word count: 1741
Too often many of our patients come to chiropractors after opioid painkillers and epidural steroid injections failed to help them. Little do these patients realize the dangers and ineffectiveness of these two standard medical treatments for back pain, both of which find little support in research.
Foremost, the public does not realize epidural steroids injections (ESIs) are used “off-label” for back pain because they have never been approved by the FDA for back pain and recently found to be no better than placebo, but pain management physicians are not telling unsuspecting patients of these facts.
As of July, 2014, injectable corticosteroids must carry a new label warning about the risks of severe adverse effects from epidural injections including death, stroke, and permanent blindness and paralysis according to the FDA. The agency decided that such a warning is needed after reviewing numerous reports in the medical literature and its own adverse event database.
"Serious adverse events included death, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, stroke, seizures, nerve injury, and brain edema," the FDA said in announcing the warning.
"Many cases were temporally associated with the corticosteroid injections, with adverse events occurring within minutes to 48 hours after the corticosteroid injections. In some cases, diagnoses of neurologic adverse events were confirmed through magnetic resonance imaging or computed tomography scan. Many patients did not recover from these reported adverse events."
Cash Cow for Needle Jockeys
In recent years a gigantic industry has grown up around invasive but nonsurgical treatments for back problems. It is split across several larger nondrug disciplines: radiology, anesthesiology, physiatry, and neurology that often fall under the guise of “pain management.”
These physicians generally refer to themselves as “spine interventionalists.” Most are better known among medical professionals simply as “needle jockeys,” who do other expensive procedures as well:
Nothing on this list is under $600 under private insurance and many of these procedures are repeated every month or two, and sometimes every week or two. ESIs are one of many procedures, including implants of spinal cord stimulators, on which Americans spent $23 billion in 2011, up by 231 percent from 2002.
The Cleveland Clinic’s Richard Rosenquist, chairman of the pain management department, said another problem is the fact that most any doctor can become a needle jockey to give spinal injections. “The unsuspecting public has no idea someone might have gone to a weekend course and on Monday morning is testing out their brand new skill on you. It’s horrible.”
Why wouldn’t any MD bill himself as a “pain management” specialist? Steroid shots have become the most popular and profitable way physicians in the U.S. treat neck and back pain, which takes just a few minutes to administer and bring doctors huge reimbursements from Medicare and private insurers despite the research questioning their safety and effectiveness.
Medicare pays about $200 for a typical epidural steroid shot if given in an office, about $400 if done at a surgery center, and about $900 if performed at a hospital. The cost of the equipment, supplies and staffing needed for a typical shot can be as low as $120.
According to a study, Pain Management Injection Therapies for Low Back Pain, between 1994 and 2001, use of epidural injections increased by 271 percent and facet joint injections by 231 percent among Medicare beneficiaries. Total inflation-adjusted reimbursed costs increased from $24 million to over $175 million over this time period. More recent data indicate continued rapid growth in use of spinal injection therapies among Medicare beneficiaries, with an increase of 187 percent in use between 2000 and 2008.
The volume of patients is also shocking: 8.9 million Americans received ESIs in 2010. Some pain management “interventionalists” allegedly do 5000 per year for a chemical band-aid that is temporary at best and deadly at its worst.
The reported median salary for needle jockeys who do not practice anesthesiology is $340,506, and those who practice pain medicine with anesthesiology report an average of $502,024 per year. Not bad for giving placebo treatments to unsuspecting patients.
“Need Steroids? Maybe Not for Lower Back Pain”
Technically known as corticosteroids, ESIs are usually mixed with a local anesthetic, but their anti-inflammatory effect offers short-term temporary respite, if any at all. The surge in steroid injections has also brought an increase in severe and unexpected complications, including paralysis and death.
“We used to say this is so safe,” said James Rathmell, chief of pain medicine at Massachusetts General Hospital in Boston who alerted the FDA to cases of such shots causing harsh complications. “It is a very rare event, but it is not zero, and it’s devastating.”
A survey of physicians reported in the journal Spine in 2007 uncovered 78 cases where patients who got shots in the neck suffered serious injuries; there were 13 deaths. An analysis of malpractice claims between 2005 and 2008 identified 31 cases in which patients who received the shots in the neck reported spinal cord injuries, and eight suffered strokes.
Saline as Good as Steroids
Now researchers from Johns Hopkins say the steroids in the spinal shots may not be what is easing the pain. Their analysis suggests saline shots may do just as well as steroids for lower back pain relief that could be the result of adding any fluid, such as anesthetics and saline, to the space around the spinal cord.
Anesthesiologist Steven P. Cohen, MD, a professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine and his colleagues reviewed dozens of published studies and found that epidural injections of any kind were also twice as good as intramuscular injections of steroids.
Cohen says concerns increased in 2012 when more than 740 people in 20 states became ill with fungal meningitis and 55 people died after getting epidural injections of contaminated steroids made by a compounding pharmacy. Although better oversight might allay that concern, Cohen notes that patients can only get a limited number of steroid injections each year, even if their pain returns.
Not only are ESIs controversial, dangerous and expensive, new research now deems them destructive. A 2015 study in “Clinical Orthopedics and Related Research” determined that corticosteroid injections were linked to joint deterioration. Experts also warn steroids are a less-than-ideal treatment for some as they can raise blood sugar in diabetic back patients, slow wound healing in those who need surgery, and accelerate bone disease in older women.
New Evidence Debunking ESIs
This cash cow of epidural steroid injections has recently hit another major bump after a review requested by the U.S. Centers for Medicare and Medicaid Services (CMS) found scant evidence for ESIs.
In 2015, a major review by Roger Chou, MD, et al. sponsored by the U.S. Agency for Healthcare Research and Quality (AHRQ) found the evidence in favor of spinal injections to be distinctly “underwhelming.”
In the review, Dr. Chou found 78 RCTs on epidural steroid injections, 13 trials on facet joint injections, and a single trial on sacroiliac injections. The data found some evidence for the effectiveness of epidural steroid injections for radicular pain only over the short term. Chou also admitted the magnitude of therapeutic effects was small and these injections did not provide “clinically important” pain relief. Nor did they correct the underlying cause of the pain.
The Chou study from the Agency for Healthcare Research and Quality concluded:
Despite these dramatic increases, use of injection therapies for low back pain remains controversial. Systematic reviews of injection therapies have come to conflicting conclusions regarding the benefits of injection therapies, and clinical practice guidelines provide discordant recommendations regarding their use.
Chou also could not find conclusive evidence that spinal injections were effective treatments for spinal stenosis, facet joints, sacroiliac joints, or non-radicular back pain.
The question now is: Will pain management physicians also tell their patients of the short term benefits, high cost, and serious adverse events from ESIs? Okay, stop laughing because that will never happen, nor will these needle jockeys refer LBP patients to chiropractors beforehand as the guidelines recommend.
Unfortunately, millions of patients are convinced these procedures are effective. And how would they know otherwise since most MDs are inept in MSDs, more likely to ignore recent guidelines, most likely to be “promiscuous prescribers” and more likely to suggest spine surgery than surgeons themselves.
Since most chronic back pain is episodic in nature that comes and goes to some extent, if they have an injection and their symptoms wane for a few days via simply masking the pain, natural regression or through the placebo response, they attribute the progress to the interventionalist's services despite the fact nothing has changed the underlying functional problem.
James Rathmell, MD, also admitted, “The problem with interventional pain is the majority of treatment is medical management. If you pay people to do stuff, they will do more stuff.”
From the escalating number of patients and the billions of dollars spent, it is obvious there have been millions of passengers on this wild ride subjected to too much medical “stuff” and it doesn’t appear to be slowing down, evident not only by the onslaught of ESIs but also the opioid pandemic.
Mr. Mark Schoene, editor of The BACKLetter, an international spine journal, also noted the paradox of using MDs for MSDs:
“Primary care physicians and pain specialists are primarily responsible for the opioid overtreatment crisis. Are the two professions that helped create the worst pain management crisis in history of modern medicine capable of leading the way forward? That remains to be seen.”
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