Shot in the Back

Shot in the Back

The recent reports about the potentially deadly side-effects of epidural steroid injections (ESIs) for back pain have brought new attention to an already questionable medical treatment.

The CDC announced a multi-state investigation of a fungal meningitis outbreak among patients who received epidural corticosteroids injected into the spine. So far, 119 of nearly 13,000 people in 23 states who got the shots have come down with fungal infections of the fluid surrounding their spinal cords and brains and several patients have had strokes related to the meningitis. Eleven of those people have died. The case count rises daily because symptoms of fungal infection can take up to a month to appear.[1]

This is not a new issue. A 2007 survey of physicians reported in the journal Spine uncovered 78 cases where patients who got shots in the neck, suffered serious injuries, including 13 deaths. [2]

This recent scare now in the public light begs again to question the clinical and cost-effectiveness of ESIs, a treatment that has not found avid support among spine researchers. What began as an experimental, temporary treatment for acute pain and inflammation has become a money-making monster in disguise.

Let me add if the chiropractic profession had killed or damaged as many people, our medical critics would be calling for our heads.[3] Likewise, let me ask: Is this risk and cost of epidural steroid injections worth the minimal, short-term benefits considering some 8.9 million Americans received ESIs last year? [4] I think not!

“We used to say this is so safe,” said James Rathmell, chief of pain medicine at Massachusetts General Hospital in Boston. “It is a very rare event, but it is not zero, and it’s devastating.”[5]

One problem is the easy accessibility of these drugs. On one hand, athletes are barred from using such enhancement performing drugs like steroids for fear of future health problems, but local MDs dispense steroids and opiates like candy to anyone with pain. Indeed, is it any wonder that “pain management” clinics are exploding in every town?

The recent growth of “pill mills” featuring opioid narcotics and ESIs  have gotten troubling criticism from medical experts like Robert J. Barth , MD, who believes these treatments “reliably fail, the treatments seems to lead to a progressive worsening of the claimant’s presentation, the ineffective treatment never ends, and the original treating doctors refer the claimants into pain management simple as a means of escaping from or ‘dumping’ a problematic patient.”^[6]

Barth believes “pain management does not accomplish anything but getting the patient addicted.” He concludes that “pain management situation in the U.S. is, indeed, horrific.”^[7] Nonetheless, it is among the fastest growing segments in medicine today.

The American Society of Interventional Pain Physicians found the number of ESIs to Medicare patients increased 159 percent between 2000 and 2010. Americans spent $23 billion this year alone on ESIs and implants of spinal cord stimulators, 231 percent more than in 2002. [8]

Considering a 3-shot treatment costs between $2,000 and $3,000 for a temporary solution at best and, at worst, a questionable treatment with serious side-effects, the CDC and the media should question if ESIs are expensive relics of the past in this era of evidenced-based, cost-effective  healthcare.

R. Norman Harden, MD, in the American Pain Society Bulletin, described this brand of pain management as “goofy therapies—expensive at best and downright dangerous at worst.” ^[9]

Another criticism of ESI appeared in the American Pain Society Bulletin by Steven H. Sanders, PhD, who revealed nerve blocks for back pain are not supported by scientific research:  “From the current review, we must conclude injections and nerve blocks produce a large amount of money with very little science to support their application.”^[10]

But at $1,000 each, few physicians argue against ESIs nor do they recommend alternatives to these shots as the guidelines suggest, such as chiropractic care. Recently I had a patient who has had 30 shots over the past few years for her chronic low back pain, all to no avail.

Indeed, the British Medical Journal reports that “epidural injection of prednisone did not lead to a better improvement than, for example, a sham injection.”[11]

Another study on opioid use from Denmark reveals more disturbing news. Although proponents of opioid drugs speculate they provide significant pain relief, improve function, and enhance quality of life over the long term, a study by Per Sjøgren, MD, refutes this claim.

Instead, he found the use of opioids was associated with inadequate pain relief, poor quality of life, long-term unemployment, and high levels of medical care-seeking.^[12]

Aside from temporary pain relief at best, the fundamental problem with opioids and ESIs is that they do not change the underlying functional cause of most back pain—joint dysfunction. Considering there are 137 synovial joints in the spinal column, this explains why “hands-on” therapies like chiropractic spinal manipulation, therapeutic massage, and spinal distraction methods work so well.

Every international guideline on low back pain now recommends conservative care like chiropractic care before drugs, shots, or spine surgery for the majority of back pain cases. Evidence-based guidelines and systematic reviews recommend this paradigm shift in spine care, but seem to have had little impact on actual primary care practices.^[13]