Epidural Steroid Injections: Danger Worth the Benefits?

Epidural Steroid Injections: Worth the Benefits? – By Christine Rhodes, MS – November 7, 2018

While most board-certified pain specialists offer epidural steroid injections (ESIs), the risks of these injections have been known for a long time.

They are successfully reaping profits from dangerous ESIs thanks to the CDC, which now seems to have taken over both pain management and substance abuse treatment from doctors.

With its vigorous opposition to the use of opioids and complete silence about the hazards of any non-opioid pain treatments, the CDC is practically endorsing any treatment that doesn’t involve opioids, even if it’s risky and/or ineffective.  

Pfizer, the manufacturer of one such drug, Depo-Medrol, asked FDA to ban the treatment five years ago after receiving hundreds of complaints about injuries and complications related to the injections.

When the manufacturer, who is generating a profit with every dose created, asks the FDA to ban their own drug for this purpose, you know it’s serious.

The Growth of ESIs and Their Risks

A review of FDA records showed that 2,442 serious problems, including 154 deaths, were reported from Depo-Medrol injections performed between 2004 and March of 2018.

Most injuries occurred when the needle missed the epidural space and directly injured the nerves or deprived the spinal cord of blood.

FDA further warned in 2014 that injections of corticosteroids into the epidural space of the spine may result in rare but serious adverse effects, including loss of vision, stroke, paralysis, and death.

Yet, the number of Medicare providers giving ESIs increased 13% from 2012 to 2016.

Corticosteroids such as

• methylprednisolone,
• hydrocortisone,
• triamcinolone,
• betamethasone, and
• dexamethasone

are FDA-approved for injection into muscles and joints.

Nevertheless, they are commonly injected along with an anesthetic into the cervical and lumbar regions of the spine. Despite the fact that this application is considered off-label use, in June 2018, the US House of Representatives approved an increase in Medicare reimbursement for the procedure as part of legislation to help tackle the opioid crisis.

When and How to Use ESIs

“The use of epidural injections is very technique-sensitive and should only be utilized by practitioners with significant training,” said Leonard B. Goldstein, DDS, PhD,

Opioids and epidural corticosteroid injections should only be used after safer and more conservative options have been tried, according to Drs. Goldstein and Mauro.

Since they must be repeated at regular intervals, you have to subject yourself to this risk over and over for the rest of your life (it’s not just opioids that are a life-long treatment).

For many patients, even opioids are less risky than these injections. For patients who have already proven that they can take these medications responsibly, opioids are so safe that it seems like malpractice to subject a patient to such a risky procedure.

They recommend the following multidisciplinary approach:

• History and complete physical examination
• Proper imaging, including magnetic resonance imaging (MRI) when indicated
• Conservative treatment, such as physical therapy, osteopathic manipulation, and acupuncture, for at least two weeks before using ESIs or opioids
• Use of ESIs only after the underlying pathological condition is verified and life-threatening conditions such as pyogenic spondylodiscitis are ruled out.

Even so, Drs. Goldstein and Mauro caution that despite producing an immediate reduction in pain, the benefits of epidural injections are often small.

“While both radicular and non-radicular pain may have etiology related to the disc, non-radicular back pain has no compromise to the nerve root that exits through the foramen.

In a radiculopathy, we mustascertain the cause as well as the exact level and decide whether the use of the epidural corticosteroid injection will result in enough disc shrinkage to relieve the pressure/impingement on the nerve root as it exits the foramen,” they said.

Some pain clinics are refusing to prescribe any opioids unless patients agree to receive the spinal injections.

I find this horrifying and I can’t believe it isn’t considered malpractice.

When a doctor uses coercion to “force” a patient to submit to such a dangerous procedure as a requirement for getting “real” pain relief from opioids, how can this be accepted medical treatment?

Drs. Goldstein and Mauro consider this a ploy to have patients accept a much more expensive treatment.

Who cares about expense when it virtually puts a patient’s life in danger? Not these doctors.

Since steroids injected into the epidural space are not an FDA-approved indication, clinicians recommending or performing such procedures must carefully outline the risks without minimizing them, especially for a vulnerable patient who may otherwise disregard such risks in the presence of unrelenting, intolerable pain.

Yet, doctors are not censured or reprimanded in any way for prescribing too many ESI’s, nor do they suffer armed raids by federal agencies like the DEA.

The proven harm from these injections is equal or greater than the harm from potentially, but rarely (<5%), getting addicted to much safer opioids.

For more information about this procedure and a summary of related posts, see my page, Danger of Steroid Injections.