Treating chronic low back pain is frustrating. Often, first-line treatments like NSAIDs, physical therapy, hot packs, cold packs or, occasionally, muscle relaxers do not seem to work very well. At least, many of our patients voice frustration with the lack of efficacy of these treatments and want “something more” done to “get rid of the pain.”
The “something more” options are limited. Many patients seek prescription opioids for chronic low back pain. While this class of medication has some role in some patients, they can put the patient on a slippery slope. Opioids may be effective for a while but tolerance often develops. Patients commonly seek dosage increases, which may help for a period, but then they again lose their effectiveness. So, appropriately, most primary care clinicians try to avoid the problems introduced by prescribing opioids for chronic low back pain.
Another “something more” option is epidural steroid injections (ESIs). Almost all patients with chronic low back pain have ended up getting an MRI at some point. As we all know, these MRIs will usually show some abnormality which might conceivably explain the chronic pain. Bulging disks, sometimes causing foraminal encroachment or spinal stenosis, are common. When faced with such findings in a patient frustrated with standard therapy, physicians often refer for consideration of an ESI.
While the effort to help the patient’s pain and minimize narcotic use is commendable, how likely are ESIs to help? Two NEJM studies, one looking at spinal stenosis, the other at radicular discomfort, offer some painful information. In the July 3, 2014, issue, Dr. Janna Friedly of the U. of Washington and 30 of her colleagues published a study looking at the efficacy of ESIs for treating lumbar stenosis pain. In a randomized, double blind study, 400 patients at 16 sites were treated with either an epidural injection of steroids plus lidocaine or an epidural injection of lidocaine alone (a proxy for a placebo injection). The bottom line? There was no significant difference between the two groups in long-term pain relief. Those receiving steroids did report slightly higher overall satisfaction than those who did not, though this might be attributable to the systemic absorption of steroids, a phenomenon confirmed by measures of adrenal suppression.
A meta-analysis of ESIs for radicular pain was published In the December 13, 2012, NEJM. Summarizing the findings from 23 studies and over 2,000 patients, the authors found only small, statistically insignificant improvements in short-term pain in those who received ESIs compared to those who received placebo injections. This difference disappeared by the one year mark.
Neither study concludes ESIs should never be used. But expectations for benefit need to be realistic and modest. There are patients in whom they may warrant a try, especially if done to avoid or reduce narcotic use. But they are frequently ineffective. It is also important to keep in mind the potential risks of ESIs. The FDA recently changed the labeling of these products to include warnings they may cause paralysis, nerve damage, or death.
Educating patients about their chronic pain is time-consuming, frustrating, difficult, and important. Patients need help in understanding that their chronic pain cannot be eliminated. Sometimes the “something more” they are seeking needs to be a compassionate but realistic discussion about learning to live with chronic pain.
Richard Fleming, MD