Glucocorticoid Injections for Spinal Stenosis

Posted by • July 2nd, 2014

Spinal stenosis is a pain – both for those who suffer it, and the doctors who treat it.

As surgery is a potentially risky option with uncertain benefit, many doctors turn to glucocorticoid injections for their patients, to decrease pain and increase mobility.  An estimated ten to eleven million such injections are performed in the US annually, numbers that have grown rapidly in recent years.

But do glucocorticoid injections actually help? A recent review from the North American Spine Society highlighted the paucity of data, concluding that there is insufficient evidence to make a recommendation either for or against. And this therapy isn’t always benign. While serious complications are rare, complications including paralysis and nerve damage have been reported.

With this background, Janna Friedly and colleagues set out to determine whether glucocorticoid injections actually benefit patients with spinal stenosis. Their results, published in this week’s issue of NEJM, suggest that the increasingly popular treatment is no better than their comparator, an injection of lidocaine alone.

The study investigators enrolled 400 patients with lumbar spinal stenosis, whose disease caused them moderate-to-severe leg pain and disability and who had been referred for steroid injections. All study participants were older than 50 and hadn’t ever undergone lumbar surgery, or received epidural steroid injections in the previous six months. Patients were randomly assigned to either epidural glucocorticoid injection with lidocaine, or lidocaine injection alone. The participants could receive a second injection three weeks later, at the patient’s discretion.

After six weeks, patients in both groups were asked to rate their average buttock, hip and leg pain in the previous week and to fill out a questionnaire that quantifies degree of pain and associated disability. They were also asked to respond to surveys of depression, anxiety and quality of life.

The results? Both groups of patients reported improvement in their pain and physical function at three and six weeks, whether or not their injections included glucocorticoids. At six weeks, there were no significant differences in pain or function ratings between the two groups. Of note, the patients randomly assigned to the glucocorticoid injections were more likely to have improvement in depressive symptoms. Those receiving glucocorticoid injections had a higher rate of adverse events, although the complications were generally mild.

In an accompanying editorial discussing these results, orthopedic surgeon Gunnar Anderson notes the difficulties inherent in trials of treatments for spinal stenosis. For one, spinal stenosis is a heterogeneous disease both in terms of cause – congenital versus degenerative – location, and extent. Additionally, Friedly’s trial did not include a control group that received sham injections, leaving open the question of whether the benefit seen in both groups could be due to the lidocaine injection itself, although this would be unlikely.

Despite these questions, Anderson concludes that the study “raises serious questions about benefits from epidural corticosteroid injections for spinal stenosis…Patients should be informed that currently best available data have not supported a significant long term clinical benefit overall, and that complications are possible.”

4 Responses to “Glucocorticoid Injections for Spinal Stenosis”

  1. HMT Fawi says:

    Interesting work…
    Can you enlighten us please about those complications you mentioned?
    Does the author think that improving the “mood” not a good enough effect… Depression is claimed to be the commonest cause of back pain
    Excellent work

  2. Mike Feehan says:

    Since publishing my website in 2000, although it was only aimed to inform, I have recieved emails and phone calls from hundreds of ex-Epidural Steroid Injection patients who have all developed Arachnoiditis(ARC) post injection(s). In some of these cases it was obviously difficult to put the horse before the cart in terms of whether it was the injection(s) or their original condition that caused the inflammation leading to ARC. However, in many others, there was no doubt about the culprit because their original back pain had not been diagnosed even after imaging studies. None of them described receiving any substantial benefit from the treatment(s) whilst the majority stated that their pain was greater post treatment than it had been prior to it. Many of these describe a nightmarish scenario where the operator needed more than one attempt to place the injectate and on many occasions there were more than 3 attempts. The question that looms large for me is, “Where did the contents of that syringe end up?”. Given the number of post dural puncture headaches one can only conclude that it was not in the epidural space.
    In the many years that I have spent researching this issue I have read paper after paper singing the praises of ESIs but none of them have been more than small scale studies without enough subjects to create a convincing result. I also wondered why, if those responsible for using these procedures were so confident of their efficacy, the producers never formally applied for a licence? The answer to that question becomes clear when one reads the work of Nelson and Landau or, more recently, Nancy Epstein; they would not pass muster because they would prove to dangerous.
    Recently New Zealand insisted that Pfizer included a warning on the package insert of their product that clearly stated it was not to be used in the Epidural or Intrathecal Spaces. Only two days ago I was informed that the company had requested the same change be included in their documentation in the UK. Once that is done the product will no longer be available for use by those who still support ESIs. Surely it is now time to discredit this procedure completely, terminate it’s practice and look for an efficacious treatment for lower back pain that does not involved blind injections into a tiny space.

  3. D.B. says:

    Try telling a patient with an acute disc herniation to go to “back school”. sheesh. you guys need to climb down from your ivory towers.

  4. Betty Schulz says:

    I am a 81 yr, patient with spinal stenosis for the past 15 or so years. I have been treated for severe pain in the L1 thru L5 disks. I have severe pain starting in the lower spine, that spreads through my buttocks, down my legs, through my ankles, and my feet. When I walk, it feels like I am walking on large rocks. My ankles have a lot of burning and pain as well. I have had my right ankle replaced, my right knee,as well as my left shoulder due to degenerative arthritis. I am currently taking hydrocodone 10/325 mg. when the pain gets so severe the hydrocodone will not elevate my condition, I make an appointment with my pain Doctor and get another epidural injection, which would last for two to three months. The last injection did not give me relief, so I went back in two weeks for another injection. I firmly believe the injections do work for me and will continue this. My Sister 84 has the same condition and had the surgery and is in bed 24/7.