Limited Success for Lumbar Epidural Steroid Injections in Stenosis

February 16, 2007

February 16, 2007 (San Diego) — The efficacy of lumbar epidural steroid injection (LESI) in treating stenosis varies with the severity of the disease, calling into question the cost-effectiveness of using LESI in severe and multiple-level moderate stenosis.

Frederick Parke Oldenburg, MD, from the Department of Orthopaedics, Case Western University School of Medicine and University Hospitals in Cleveland, Ohio, presented these findings here at the 2007 annual meeting of the American Academy of Orthopaedic Surgeons. Dr. Oldenburg said that a relationship between the severity of stenosis and the efficacy of LESI had not previously been established. In addition, the cost-effectiveness of LESI with respect to avoiding surgery was unknown.

Of 299 patients in this retrospective study, most had mild stenosis and no need for surgery.
Dr. Oldenburg told Medscape that the study also included patients who were not good operative candidates. "I think that [using LESI to treat] patients with mild stenosis who are poor operative candidates is a good option. Unfortunately, the chances of LESI being beneficial for patients with severe stenosis are far less."

The study classified patients as having mild, moderate, or severe stenosis by measuring the most stenotic level in MRIs of the spinal canal. Failure of LESI was defined by the patient's need for surgical decompression. To determine cost-effectiveness, the study examined the "rate at which surgery must be avoided" in patients who received LESI.

"LESI costs about $2200, while lumbar decompression costs $17,000," Dr. Oldenburg told the audience during his presentation. To be cost-effective, surgery must be avoided at least 13% of the time in patients treated with LESI.

The average time from LESI until a patient needed surgical decompression was 1.4 months in severe stenosis, 4.7 months in moderate stenosis, and 51.3 months in mild stenosis. The failure rate is higher when stenosis is present at multiple levels. The study found that LESI is cost-effective only for the group with mild stenosis.

Although he believes that LESI is not cost-effective for stenosis, Dr. Oldenburg often still recommends LESI. He told Medscape, "The patient needs to feel that they have exhausted all nonoperative options before going on to something more involved and invasive." However, both patient and physician must be aware that LESI has very limited long-term success, especially for severe or multiple-level moderate stenosis, he said.

Tony Tannoury, MD, from the Department of Orthopaedic Surgery at Boston Medical Center, and assistant professor of orthopaedic surgery at Boston University School of Medicine in Massachusetts, who attended the presentation, said he thought that all stenosis patients could benefit from epidural steroid injections. He told Medscape that a "very elegant study" presented last year at AAOS showed no correlation between the efficacy of LESI and the degree of stenosis. "It makes sense that patients with severe stenosis most likely will need surgery," he said. "But I still try to give them a trial injection. It's unpredictable who it is or is not going to work on."

Dr. Tannoury described the development of stenosis. "We know that stenosis is in the making for 40 or 50 years, but a patient develops the pain over 6 weeks or 6 months. The goal is not to take a patient back 40 years — that's what decompression surgery does. But LESI can take the patient back a week or two prior to when the symptoms started. That's the purpose of the injection."

Dr. Oldenburg disclosed no relevant financial relationships.

AAOS 74th Annual Meeting: Abstract 214. Presented February 15, 2007.

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