Most adults will have at least one episode of noteworthy back pain in their lifetime, with many experiencing persistent and often disabling symptoms. In fact, back issues are one major reason people miss work and/or seek medical attention. Enter then the medicalization of this condition, with a fast forward to injections into the space around affected nerves emerging from the spine, so-called 'epidural' injections, to treat pain. On PodMed this week Rick and I offer kudos to the authors of this study published in NEJM, assessing whether this strategy is actually of any benefit in alleviating pain. While for those unfortunate folks who got a dose of fungus along with their injection for back pain this study comes too late, we hope it will turn the tide of epidural injections commonly being employed for this purpose.
Investigators randomized 400 people with lumbar spinal stenosis, or narrowing of the canal through which the spinal cord and nerves must pass down the back, and who also had moderate to severe leg pain because of the condition, to one of two treatments: epidural injections of steroid medication plus a local anesthetic called lidocaine, or simply lidocaine alone. Subjects could receive either one or two injections and were subsequently evaluated six weeks after their first (and perhaps only) injection. Both a disability and a pain scale questionnaire were utilized as the primary outcome measures.
People who received the steroid medication, ostensibly to reduce inflammation in the nerve root and the putative cause of the pain, did no better at the six week assessment than those who received the local anesthetic alone. Wow! As background it's worth noting that injections for spinal stenosis have increased by about 300% in Medicare and Veteran's Administration populations over the last two decades, with a concomitant increase in costs. So a huge amount of resources have been devoted to the employment of this technique and this study at least suggests we've been wasting our money.
To be fair it must be admitted that there are several causes of back pain other than lumbar spinal stenosis, and these may be amenable to this strategy. These authors note that about a quarter of all epidural injections for back pain in the Medicare population and 75% of those in the VA population are due to this condition. Clearly then the technique cannot be soundly panned until additional studies are carried out but Rick and I both feel it should be considered much more judiciously. As we have advocated in the past, the tincture of time is well worth attempting, and in the case of low back pain, so is weight loss and exercise, perhaps taught with a physical therapist's help.
Other topics this week include an assessment of how often physicians talk about sunscreen with their patients in JAMA Dermatology, bone marrow transplantation for sickle cell disease in JAMA, and celiac disease and a genetic assessment in NEJM. Until next week, y'all live well.