Beware of Worthless Procedures for back pain

Below is another article on the dangers of epidural injections. This procedure isn’t so popular because it bestows benefits on the recipient as much as because insurance companies compensate them so well.

Beware of worthless procedures and epidural steroids for your back pain – KevinMD – Cathryn Jakobson Ramin | Conditions | April 29, 2017

in a 2015 review of the medical literature, the Agency for Healthcare Research and Quality had found no evidence that epidural steroid injections were effective in treating symptoms of spinal stenosis or typical lower-back pain. 

Even in the presence of a recent disc herniation and ensuing sciatica, the benefits of injections were small and not sustained over time.

That news followed on the heels of an FDA statement warning that injection of the active medication in these shots, glucocorticoids — a class of corticosteroids — into the epidural space of the spine could result in rare but serious neurological problems. 

Based on those and other findings, the Journal of the American Medical Association ( JAMA) advised physicians to refrain from recommending injection therapy to patients with any kind of chronic back pain.

That news did not go over well with the doctors known as “interventional pain physicians,” who make a living performing such procedures. In the United States, more than ten million epidural steroid injections are delivered each year, a number that makes them the bread and butter of interventional pain management practices.

These are the kind of doctors that are members of PROP and support this group’s anti-opioid influence on the CDC guideline for opioids.

When opioids are no longer a possible treatment, desperate patients will seek out even the most dangerous procedures to lessen their pain.

Primary care physicians who ordered the shots were rarely informed about the lack of evidence and the risks of treatment. Even young, healthy people

patients … could go in with manageable low-back-pain symptoms and come out with catastrophic neurological injuries.

the most successful interventional pain physicians offered an ever-expanding menu of injections, including

  • facet and sacroiliac joint blocks,
  • selective nerve blocks,
  • discography,
  • needle electromyography,
  • radio-frequency and thermal facet ablations,
  • botulinum toxin, and
  • trigger point injections.

By the turn of the new millennium, interventional pain management, which a decade before had barely existed, had become one of the most profitable aspects of spine care.

There are, indeed, people who undergo one perfectly targeted epidural steroid injection and hit the golf course the next morning, completely cured. In the more typical scenario, however, the first injection — if in fact, it provides any relief at all — is only briefly effective.

Generally, the shots are ordered in a series of three, although no expert I asked could say why, and the American Society of Anesthesiologists’ guidelines do not advise the administration of a specific number.

The FDA had been issuing cautionary statements about epidural steroid injections since 1981.

But in 2014, the agency took a further step compelling pharmaceutical manufacturers that produced the injectable glucocorticoids to clearly state the risks on every vial’s label, advising that “serious neurologic events, some resulting in death, have been reported with epidural injection,” and that the “safety and effectiveness of epidural administration of corticosteroids have not been established.”

Properly “consented,” a patient who was about to receive an epidural steroid injection would hear about specific risks, including

  • damage to the dura mater (the sturdy sleeve surrounding the spinal cord),
  • nerve root injury,
  • elevated cholesterol levels,
  • vertebral fractures,
  • the death of muscle and bone tissue,
  • staph infection,
  • epidural abscess,
  • immune system deficits,
  • stroke and death.

There are two dominant techniques for administering epidural steroid injections.

  1. In the first, known as “interlaminar,” the needle is directed into the epidural space, around the spinal nerves.
  2. In the second approach, referred to as “transforaminal,” the needle is inserted at an angle, which places it closer to the targeted nerve but also in the vicinity of vessels and arteries.

Incorrectly placed, the needle can sever an artery or deliver medication into the blood vessels, clogging them and preventing adequate blood flow to the brain

research shows that a quarter of epidural steroid injections miss their targets. In “blind” injections, performed without fluoroscopic guidance, the needle is incorrectly placed in up to half of epidural steroid procedures.

In roughly six percent of epidural steroid injections (a number that sounds small but is not, because thousands of injections are delivered every day), the needle nicks the dura mater, the sturdy sleeve surrounding the spinal cord, allowing cerebrospinal fluid to leak out.

It results in a severe headache, which goes away after the patient lies flat for a couple of days. Sometimes, another procedure, known as a “blood patch,” is used to stop the leak of cerebrospinal fluid.

But when the needle actually punctures the dura mater, it’s a different story. Then the payload of glucocorticoid and anesthetic may be delivered into a region of fragile nerve tissue called the subarachnoid space

From there, the cerebrospinal fluid, bearing its toxic load, circulates to the brain, where the cortisone solution efficiently strips the insulating (and essential) myelin layer of neurons.

One result is “adhesive arachnoiditis,” a condition so grossly debilitating that neurologist Dewey Nelson described it as akin to “having a blowtorch up your rectum. It binds the nerves, like gunky cooked spaghetti, and the result is unrelenting pain that may last for a lifetime.”


Here is another article stressing the danger of these injections:

Neurologic Adverse Reaction Risk Tied to Epidural Steroid Injections – Clinical Pain Advisor –  – 

Epidural steroid injections (ESIs) are commonly used to treat the radicular pain associated with many spinal disorders.

Although ESIs have proved to be effective in managing this type of pain, neurologic complications including stroke and spinal cord injury have occurred infrequently.

“There have been rare but serious neurological adverse events – including loss of vision, stroke, and paralysis – which have infrequently resulted in death,” said Kristofer Baumgartner, U.S. Food and Drug Administration (FDA) spokesperson.

FDA Safe Use Initiative and Working Group

The FDA’s Safe Use Initiative provided the panel of experts with a forum for their discussions about the safety and effectiveness of ESIs as well as the practices that potentially can minimize the associated risk. However, the FDA did not actively participate in the deliberations or the decision-making process

the panel of experts and representatives of the national pain organizations agreed on the breadth, content, and specificity of the clinical considerations, and they have published the clinical considerations for healthcare professionals who administer ESIs as a treatment for neck and back pain

“If practitioners adopt some simple techniques that we have assembled in one place in this publication, the incidence of these injuries is likely to decline. Epidural steroid injections are a valuable treatment for speeding the resolution of pain associated with acute disc herniation. The chances of adverse effects of any kind is low and can be made even lower through adopting some of these simple practices.”

FDA Regulatory Action to Ensure Safe Use

The FDA previously took regulatory action regarding ESIs on April 23, 2014, when the agency issued a Drug Safety Communication warning that injecting corticosteroids into the epidural space of the spine may result in rare but serious adverse events, including loss of vision, stroke, paralysis, and death.

Then on November 24 and 25, 2014, the FDA convened an Anesthetic and Analgesic Drug Products Advisory Committee Meeting to discuss the risk of serious neurologic adverse reactions associated with ESIs, the efficacy of ESIs, and the overall risk-benefit balance of injecting steroids in the epidural space to treat pain.2

Conclusion

the adverse neurologic events associated with ESI are infrequent but devastating. Therefore awareness and education about safeguards to minimize any potential complications from this procedure are warranted.

 

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One thought on “Beware of Worthless Procedures for back pain

  1. Emily Raven

    That’s very refreshing to see someone on the Kevin MD site call this debacle out. I won’t click the actual article since I’d be too tempted to read the comments of pissed off interventional pain doctors and clueless DOs and primary care who are the usual patient bashers that drank the Koolaid. I don’t know how any doctor can look you in the eye and say sticking something in your spine when you’re medically fragile and your condition isn’t an indication for it anyway (not many are despite what they say) is a good idea.

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