The lowdown on back pain: Steroids do little good
Every year, 80 million people in America suffer from back pain. Many of them seek relief by getting epidural steroid injections for two common back issues: radiculopathy and spinal stenosis.
But those treatments, while providing temporary pain relief, offer little long-term benefits, may be over-used and may not significantly reduce the need for future surgery, according to new research from Oregon Health & Science University.
A review of the study, led by Roger Chou, MD, professor of medicine at the university, was published this week in the Annals of Internal Medicine.
The results of the study were not a surprise to neurosurgeon Paul Houle, MD, of Neurosurgeons of Cape Cod, especially when it comes to spinal stenosis, the narrowing of the spinal canal.
“Epidural steroid injections may not be not the proper use for spinal stenosis,” Dr. Houle says. “As a matter of fact, Medicare is going to stop paying for epidural steroid injections for spinal stenosis in the near future because that’s not the appropriate treatment for that condition.”
Unlike radiculopathy, spinal stenosis is not about inflammation, which is why steroids don’t work to heal it. It is a slowly degenerative chronic condition that gets worse over time. Physical therapy also doesn’t offer any meaningful long term benefit.
“As people age, the discs which give the spine flexibility start to wear out,” Dr. Houle says. “As they wear out, they degenerate or collapse. As they collapse, they bulge into the spinal canal.”
The bulging disc itself doesn’t create pain, but it does create instability. The body’s response is to strengthen the joints and ligaments that support the spine. Over time, the combination of the bulging disc and the thickened joints and ligaments narrow the diameter of the spinal canal and eventually pinch the nerves.
“There is no possible way for physical therapy to reduce the size of the joints, which are already big, and it won’t lesson the thickened ligaments,” Dr. Houle says. “Spinal stenosis is a mechanical problem.
“It doesn’t make sense to add a bolus [small mass] of fluid, which is what a steroid injection is, into a narrowed space where there isn’t enough room for the stuff you have already.”
Unfortunately, the only real treatment for spinal stenosis is surgery, but Dr. Houle advises patients to wait until the pain grows so strong that it begins to interfere with normal activities.
“When people are avoiding doing the things that make life enjoyable because they know it’s going to hurt them, it’s time to consider surgery,” he says.
To learn more about spinal stenosis, watch Dr. Houle’s three-part lecture on the subject.
Steroid injections have been found to work better to treat the inflammation caused by radiculopathy, Dr. Houle said.
Here’s why: When people have a herniated or slipped disc, the disc pinches the nerve and the nerve swells. The swollen nerve is in a confined space, which pinches it even more, causing pain.
The first line of treatment for this condition is over-the-counter non-steroidal anti-inflammatory drugs like Motrin or Aleve.
But sometimes the swelling is so severe that those medicines don’t help. At this point, most people either visit their primary care physician or the emergency room. The treatment for this more severe pain is a pain medication and muscle relaxer for immediate relief and a dose of oral steroids to reduce the swelling.
But with oral steroids, you need to take a very high dose of medicine to get a small dose to the site of the swelling. An injectable steroid delivers a highly concentrated dose of anti-inflammatory right where you need it.
“One of the misconceptions that people have is that (a steroid injection) is treating the herniated disc, and that’s not true,” Dr. Houle says. “All it’s doing is treating the inflammation of the nerve with the hope that it will buy some time for the body’s natural healing process to take over for that disc to heal.”
The healing process takes about six to eight weeks, and usually includes physical therapy to increase your core strength.
Strengthening your core (abdominal, back and oblique muscles), improves your posture and helps your spine realign. The strengthened muscles then act like an internal body brace to prevent future pain.