Spinal steroid injections don't work, say experts

Thousands of Australians with back pain are lining up for “a quick fix” that doesn’t work and can be risky.

Last year 40,000 queued for an injection of steroids into their spine in the hope it would curb pain in their lower back, legs, neck or arms.

That there is no reliable evidence to show these injections are effective seems to make no difference.

That there is strong evidence to show they are not effective also makes no difference.

Researchers found treatment of central spinal stenosis in the lower back using epidural injections of steroids plus anaesthetic offered minimal or no short-term benefit as compared with anaesthetic alone. Illustration: Karl Hilzinger

Researchers found treatment of central spinal stenosis in the lower back using epidural injections of steroids plus anaesthetic offered minimal or no short-term benefit as compared with anaesthetic alone. Illustration: Karl Hilzinger

Steroids are being injected up and down the spine for a range of pains.

A new study published in the prestigious New England Journal of Medicine looked at one particular condition, central spinal stenosis.

With this condition, the central canal running down the spine narrows in the region of the lower back. It can cause bilateral pain which can radiate through the buttocks and into both legs.

The study showed the benefit of steroid injections for people with this condition was so small as to be clinically irrelevant.

Study raises questions

An editorial in the same journal said the study raised serious questions about the benefits of steroid injections and recommended that patients who had already had one injection avoid repeat injections if there is no effect.

On a personal note, the editorialist, Gunnar Andersonn, Professor and Chairman Emeritus of Orthopedic Surgery at Rush University Medical Centre, Chicago, remained “cautious” about prescribing these injections for his patients with this condition.

While the injections were generally safe, with minor transient side effects, he said serious or even catastrophic complications may occur, including paralysis, nerve damage or death.

This study added yet more fuel to a call last year for the Australian government to withdraw funding of all spinal injections.

The call, published in an article in the Medical Journal of Australia, was made on the grounds that they had only had a placebo effect, could cause harm and were a waste of money.

The article, which canvassed the evidence, was co-authored by Ian Harris, professor of orthopaedic surgery at the University of NSW.

He told The Australian Financial Review the new study was yet another in a long line of trials showing steroids were not effective, no matter how they were given.

“In medicine many things appear to be effective but appearances can be deceiving because there are so many other reasons people may improve.”

‘Bad science’

Harris says whenever high-level trials are conducted with spinal steroids, they come up negative.

“These injections are bad science and bad medicine, but then a lot of what we do in medicine is based on a biologically plausible mechanism which is backed up by observational evidence. This means just about any treatment can appear to be effective.”

He explains that back pain usually fluctuates and if an injection is given in a bad period, any improvement due to the natural history of the condition will be attributed to the injection.

“When the first injection doesn’t work, we keep at it and eventually when the patient improves, we attribute it to the last injection.”

“I believe any treatment that fails proper testing should not be delivered.”

Rachelle Buchbinder, director of Monash’s Department of Clinical Epidemiology, co-authored the MJA article last year. It noted the number of steroid injections had more than doubled in the 10 years to 2011, when it reached 31,500.

The number has continued to rise and in 2013 reached 40,000 at a cost to the country of some $3.6 million.

This continued rise mirrors the rise in the use of imaging in medicine, says Buchbinder. As imaging increases so does image guided injection therapy.

Steroids are not the only substances being injected into the spine without good evidence. Others included dextrose, botulinum toxin, stem cells, blood extracts and methylene blue.

In an opinion piece for The Sydney Morning Herald earlier this year, Buchbinder, Harris and Chris Maher, director of the musculoskletal division at the George Institute for Global Health, noted that because of the lack of investment in back pain research, money was going into the wrong form of treatment. Although 25 per cent of Australians suffer from back pain, it had never been a health or research priority.

“If we just invested 1 or 2 per cent of the money we wasted on ineffective treatment, we’d be a long way towards a solution,” Maher said.

The Food and Drug Administration has not approved steroids for spinal injections because their effectiveness and safety have not been established.

Effective For Herniated Disc

One of Australia’s leading spinal pain specialists, Nikolai Bogduk, agrees fully that there is no evidence of effectiveness for blind, epidural injection of steroids.

But he says the injections do work in one narrow condition. When a disc has been herniated and is causing pain down the leg on the side of the herniation, steroid injections can relieve it in some 54 per cent of cases.

Bogduk, emeritus professor of pain medicine at the University of Newcastle, says this is very specific.

The herniated disc is identified on imaging, the pain is stabbing and shooting down one leg and injection has to be delivered via a particular route.

He estimates most of the 40000 spinal steroid injections given last year were for non-legitimate reasons.

“Unknown is the extent to which radiologists who are asked to perform these injections, do so without questioning the diagnosis and the indication,” he says.

Study shows no benefit

The latest study of steroid spinal injections was conducted in people suffering from a narrowing of the spinal canal.

Although some people are born with this condition, which is called central spinal stenosis, it mostly occurs from the age of 50.

It is caused by a thickening of ligaments, bulging discs, arthritis in the little spinal joints or a combination of all three.

Funded by the US Agency for Health Care Research and Quality, the study followed 400 people over the age of 50 with evidence of central stenosis on an MRI or a CT scan and with symptoms.

Some were treated with an injection containing both steroids and an anaesthetic while others received only anaesthetic.

After three weeks, disability scores showed a tiny difference between the groups.

By six weeks this had all but disappeared, showing no evidence of a treatment effect. Some 21.5 per cent of those who received the combination injection – glucocorticoid plus lidocaine – had side effects such as pain and numbness compared to 15.5 per cent of those having lidocaine alone.

The investigators concluded that in the treatment of central spinal stenosis in the lower back, epidural injection of steroids plus anaesthetic offered minimal or no short-term benefit as compared with anaesthetic alone.

Spinal pain expert, Nikolai Bogduk, emeritus professor at Newcastle University, says although this research is definitive people will gripe about its details and nuances.

He says spinal stenosis is a mechanical problem where the canal encroaches on the nerves.

Exercise, drugs and electrical stimulation won’t help it.

The only thing likely to work is surgery.

Jill Margo writes a weekly column for The Australian Financial Review and edits the Men's Health section.

SMH

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