Welcome back to SpineIQ’s Back Blog! While we usually write blogs geared towards treatments within the scope of conservative spine clinicians, it is important that conservative spine clinicians keep up regarding the evidence base of treatments commonly administered by other clinicians for spine pain. Patients will ask your opinion about treatments they are considering and you need to be able to make informed referrals. Therefore, this week we are summarizing the clinically relevant findings of Curatolo et al. titled “Long-term effectiveness of epidural steroid injections after new episodes of low back pain in older adults.”1
Aims and Methods
In 2018, there were 2.2 million epidural steroid injections performed on older adults (65+ years).2 Epidural steroid injections are commonly performed for low back pain that involves radicular pain. The goal of this study was to determine whether 1) patients that receive epidural steroid injections are in worse pain at baseline compared to patients that do not receive epidural steroid injections and 2) if epidural steroid injections have an effect on pain, function, or quality of life in older adults with radicular pain and low back pain.
Patients age 65 and older that had not sought care for low back pain within the last 6 months were included in the study. Participants were separated into three groups. Group 1 included patients who received epidural steroid injection within 6 months of recruitment. Group 2 included patients who did not receive epidural steroid injection, lumbar surgery, other injection, or radiofrequency ablation within 6 months. Group 3 included patients who did not receive epidural steroid injection or other low back procedure but were matched with patients in Group 1 based on their baseline pain characteristics. Pain intensity, function, and quality of life were collected at baseline and then again at 3, 6, 12, and 24 months.
295 patients were included in Group 1, 4809 patients were included in Group 2 and 483 patients were included in Group 3. 74% of patients in Group 1 received an epidural steroid injection within 3 months, with the rest receiving it between 3 and 6 months.
Study authors found that patients who received epidural steroid injections had worse symptoms (pain intensity 5.8 on a 0-10 scale) compared to those that did not receive epidural steroid injections (pain intensity 2.9 on a 0-10 scale). Further, when they compared Group 1 participants to Group 3 participants, they found that both groups experienced significant improvement over time but there was no difference between the groups.
These findings are relevant for clinicians that treat people with low back pain for several reasons. First, it is essential to provide evidence-based answers to questions posed by patients about alternative treatment options, including patients with higher levels of pain. Second, understanding that epidural steroid injections may not be significantly more effective than the passing of time for older adults with low back pain and radicular pain may influence your decision-making process when making referrals, especially when also considering the risk of serious spinal adverse events (5.1 per one million) associated with this procedure .3 Legal note: clinicians should proceed with caution when discussing treatments that are out of their scope even with evidence to support their suggestions. It is important to inform patients of the risks and benefits regarding a range of treatment options and, as always, appropriately document these conversations in the patient record.
- Curatolo M, Rundell SD, Gold LS, et al. Long-term effectiveness of epidural steroid injections after new episodes of low back pain in older adults. Eur J Pain Lond Engl. Published online May 23, 2022. doi:10.1002/ejp.1975
- Manchikanti L, Sanapati MR, Soin A, et al. An Updated Analysis of Utilization of Epidural Procedures in Managing Chronic Pain in the Medicare Population from 2000 to 2018. Pain Physician. 2020;23(2):111-126.
- Eworuke E, Crisafi L, Liao J, et al. Risk of serious spinal adverse events associated with epidural corticosteroid injections in the Medicare population. Reg Anesth Pain Med. 2021;46(3):203-209. doi:10.1136/rapm-2020-101778