Steroid Injections: Are They Worth the Risk? Amid controversy surrounding the U.S. fungal meningitis outbreak, opinions are split on how effective steroid injections are for treating chronic back pain.
Steve D’Alise, a 40-year-old financial analyst in Chicago heard about the deaths from fungal meningitis related to steroid injections for pain. But his back pain is so severe, he opted to have his steroid injections anyway.
“When it gets really bad it consumes you,” says D’Alise of the sciatica thats plagued him since 2009.
News of the fungal meningitis outbreak that has killed 12 has shone a spotlight on a lesser-known but frequently used fix for one of the most common chronic conditions in the United States: back pain. But medical experts and a large body of research call into question the efficacy of steroid injections, calling them a risky and costly treatment.
What makes this entire tragedy ironic is the poor evidence that these steroid injections would have relieved their back pain in the first place, says Fabrizio Mancini, a certified chiropractor, wellness expert, and the president of Parker University in Dallas.
Mancini points to a large body of research, including an editorial in the 2011 issue of the British Medical Journal. Epidural steroid injections have been used for more than 50 years to treat low back pain and are the most common intervention in pain clinics throughout the world, the article reads. Yet despite their widespread use, their efficacy is unclear. Of around 35 controlled studies evaluating such injections, slightly more than half show some benefit.
Patients like D’Alise have typically tried several interventions include ibuprofen, chiropractic care, physical therapy, and lifestyle changes before resorting to the injections. D’Alise says his condition makes commuting to work, riding a train, and sitting for long periods incredibly difficult. He received his last shot in 2011 but the relief only lasted for six months. He says the pain has returned to a “7” on a scale of one to 10.
D’Alise sought care from Scott Glaser, MD, an interventional pain-management specialist at the Pain Specialists of Greater Chicago. Even in the wake of the meningitis outbreak, Dr. Glaser says hes still administering some 18 steroid injections on a busy day. But now the doctor has found he must take some time to reassure his patients that the treatments are safe and worthwhile.
Most get relief from the local anesthetic which is mixed with the steroid and then the pain returns later that day, and the depot steroid starts to work in a few days, says Glaser. Typically, the maximum benefit will be obtained anywhere between 7 to 14 days.
Back Pain a Growing Epidemic
Eight in 10 people will experience back pain in their lifetime, and steroid injections have become a gold standard treatment for acute and chronic pain because they’re fast acting, non-addictive, and minimally invasive.
“Back pain is a big, big problem,” says David Maine, MD, director of the Center for Interventional Pain Medicine at Mercy Medical Center in Baltimore, Md. “It’s a difficult thing to treat. You sometimes make decisions quickly just to get meaningful relief.”
Dr. Maine says his practice typically uses steroid injections as “an intermediate treatment” when physical therapy, chiropractic therapy, and over-the-counter inflammatory medications, such as ibuprofen, are not effective. The injections are often one of the last intervention therapies before a patient considers surgery. Steroid injections are also a much safer alternative to many pills doctors might prescribe for pain, including highly addictive opioids and narcotics.
The U.S. Centers for Disease Control yesterday reported 137 cases of meningitis in 10 states with 12 deaths from the infection from methylprednisolone acetate injections.
Steroid injections can be costly. Glaser says they can cost $2,000 to $3,000 for each injection. “Our routine treatments are typically covered by insurance but it is getting more difficult in a lot of cases as the insurance companies deny or delay more and more treatment,” he explains. He added some insurance companies may pick up only 20 percent of the cost of such an injection.
Medical expenses for individuals with spine problems average $6,096 compared with $3,516 for patients without them, according to a 2008 analysis by the Journal of the American Medical Association using government data. From 1997 to 2005, the estimated expenditures among patients with spine problems increased 65 percent, the analysis said.
No Hard and Fast Rules for Treating Back Pain With Steroids
Pain specialists say the number of injections needed to stop back pain varies from patient to patient. “Some may have one or two and then they go through the natural healing process,” says Dr. Maine. “Others with chronic back pain or acute pain may get two or three over the course of eight months. There are no hard and fast rules. It just needs to be done for the right indication.”
Methylprednisolone acetate, the medication that was administered to patients who contracted fungal meningitis, is one of four types of corticosteroids for injections. A corticosteroid is an anti-inflammatory hormone that reduces swelling in muscle and soft tissues, and is also naturally produced in the body. The hormone is physiologically essential for stress and immune response, as well as metabolic functions. The steroids work by calming nerves and reducing the release of certain bio-transmitters, such as substance P and bradykinin, which decreases pain.
The relief from injections most typically lasts around six months to one year. However, many patients report they’ve been cured of back pain after receiving just one or two injections.