Central Lumbar Spinal Stenosis: Do Epidural Steroids Help?

Janis C. Kelly

Disclosures

July 22, 2015

Study Questions Benefit of ESIs in Type of Stenosis

When a mainstay of symptom relief for a widespread type of chronic pain has been demonstrated to be of questionable effectiveness and is implicated in soaring healthcare costs, will physicians counsel patients to seek alternative treatments or continue practicing as before?

Such is the issue raised by epidural steroid injections (ESIs) for central lumbar spinal stenosis. ESIs in Medicare patients increased nearly 300% between 1994 and 2001.[1] But data from a double-blind, randomized trial published by Janna L. Friedly and colleagues in 2014 the New England Journal of Medicine[2] suggested that epidural injections of glucocorticoids plus lidocaine offer little or no short-term benefit over lidocaine alone in providing relief to the legions of aging baby boomers and patients in other age cohorts suffering from central lumbar spinal stenosis.

Moreover, at a time when the nation is seeking ways to reduce wasteful healthcare spending, the total inflation-adjusted reimbursed costs (professional fees only) for lumbosacral injections shot from $24 million to over $175 million over the study period.[1]

"Less than half [of lumbosacral injections] were performed for sciatica or radiculopathy, where the evidence of benefit is available," Friedly and colleagues concluded in an earlier study.[1] "These findings suggest a lack of consensus regarding the indications for ESIs and are cause for concern given the large expenditures for these procedures."

When to Try ESIs in Stenosis Patients

Internist Stephen J. Atlas, MD, MPH, director of the Practice-Based Research and Quality Improvement Network at Massachusetts General Hospital and an associate professor of medicine at Harvard Medical School, Boston, Massachusetts, says that a brief course of ESIs might be appropriate for helping the patient with otherwise uncontrolled spinal stenosis symptoms and pain "cool down" symptomatically enough to begin physical therapy, but that there is little long-term benefit to be expected from repeated ESIs.

"Even a few weeks of relief from a steroid injection might permit the patient to initiate physical therapy, which could lead to symptom control," Dr Atlas offers by way of perspective. "Also, I might try ESIs for the patient who has acute, severe symptoms of short duration. But the evidence from this study is pretty clear that for individuals with central stenosis—that is, within the vertebral column itself, with hypertrophy and arthritic changes that lead to deceased area for nerves traversing that space—the benefit of epidural steroid injections is modest at best and of shorter duration than our patients are looking for."

Concerns About ESI Overuse

Dr Atlas recently published a commentary[3] on the 2014 Friedly study in Evidence-Based Medicine. In his commentary, he compared ESIs given with placebo lidocaine vs lidocaine alone in 400 patients age 50 years or older with pain and functional impairment due to central lumbar spinal stenosis. Patients were randomly assigned between the two treatment groups to receive fluoroscopically guided epidural injections and could have repeat study injections at 3 weeks. The study included 26 anesthesiologists, physiatrists, and radiologists at 16 US sites, all of whom were blinded to treatment assignment.

The primary outcomes were average ratings for buttock, hip, or leg pain in the previous week and functional impairment as measured by the Roland-Morris Disability Questionnaire (RMDQ), assessed at 6 weeks post-injection.

In their study last year, Friedly and colleagues reported clinically and statistically significant decreases in pain and RMDQ scores in both groups, with a small statistically (but not clinically) significant effect favoring the ESI group at 3 weeks; that small difference had faded by 6 weeks.

According to Dr Atlas, these data raise serious concerns about overuse of ESI in patients with central lumbar spinal stenosis. ESIs now account for 25% of all epidural glucocorticoid injections administered to Medicare patients, who receive an estimated 2.2 million ESIs per year; ESIs also account for 74% of epidural glucocorticoid injections administered to patients at Veterans Affairs medical centers. Some of these increases have been driven by demographics, but Dr Atlas notes that the number of ESIs administered per patient has also increased.

"There has been a dramatic increase in these treatments, based on little evidence to support their use," Dr Atlas says. "The question is whether evidence showing little or no benefit will result in providers, patients, or payers changing how they use these injections. For patients with spinal stenosis, ESI could be viewed as an attempt to address a gap in proven effective treatment. For people with spinal stenosis due to an arthritic process—generally older individuals—nonsurgical treatment options have limited benefit. The question was whether a shot, which may be more invasive than physical therapy or oral medication but less invasive, costly, and risky than surgery, would be effective. The evidence from this study strongly suggests that if there is a benefit from injections, it is of short duration—a few weeks—for what is a chronic condition."

Rates of surgery for spinal stenosis are also increasing, and Dr Atlas commented that there are good data showing that for the patient with otherwise uncontrolled symptoms, surgery can be very effective.

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