PHILADELPHIA — February 19, 2013 — For patients with spinal stenosis, epidural steroid injections (ESI) may actually lead to worse outcomes, whether or not the patient later undergoes surgery, according to a study published in the February 15 issue of the journal Spine.
The study raises questions about the benefits of steroid injections for spinal stenosis in the lower spine.
“There was no improvement in outcome with ESI whether patients were treated surgically or nonsurgically,” according to Kris E. Radcliff, MD, Thomas Jefferson University, Philadelphia, Pennsylvania, and colleagues.
The researchers analysed data from the Spine Outcomes Research Trial (SPORT) — one of the largest clinical trials of surgery for spinal disorders. In SPORT, patients meeting strict criteria for spinal stenosis (or other common spinal problems) were randomly assigned to surgery or nonsurgical treatment, such as physical therapy and medication.
The researchers compared outcomes for 69 patients who underwent steroid injection during their first 3 months of enrolment in SPORT versus 207 patients who did not receive ESI. The 2 groups were similar in terms of most initial characteristics, although patients receiving steroid injections were more likely to prefer nonsurgical treatment (62% vs 33%).
“Despite equivalent baseline status, ESI were associated with significantly less improvement at 4 years among all patients with spinal stenosis in SPORT,” the authors wrote.
Among patients who eventually had surgery, those who had ESI showed less improvement in physical functioning through 4 years’ follow-up. For those treated nonsurgically, steroid injections were associated with less improvement in pain as well as functioning.
There was also evidence that surgery was more complicated in patients who had previously been treated with epidural steroids. On average, surgery took about 1.5 hours longer in patients who had received ESI, who also spent about 1 day longer in the hospital.
Patients who received ESI were also more likely to “crossover” from their initially assigned treatment to the other treatment group. There was no evidence that receiving steroid injections helped patients to avoid surgery. The study has some important limitations, especially in that patients weren’t randomly assigned to epidural steroid treatment. However, the results suggest that patients with spinal stenosis who receive ESI have less improvement at 4 years’ follow-up, whether or not they subsequently undergo surgery.
“Despite the common treatment practice of incorporating one or more ESI in the initial non-operative management of patients with spinal stenosis, these results suggest that ESI is associated with worse outcome in the treatment of spinal stenosis,” the authors concluded.
They believe the “most likely” reason for the worse outcomes after ESI is that the injection causes worsening of the spinal narrowing or result spinal nerve impingement, although other explanations are possible. The authors call for further research to clarify the indications and results of this common procedure.
SOURCE: Wolters Kluwer Health