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‘Pain is not the only problem’: Epidural Injection

Does nerve blocking treat the LBP symptoms? Or, does it treat the problem? What can be learned about a clinician that recommends an epidural injection (EI) as the primary (or only) treatment for LBP? Does this treatment choice demonstrate the limitations of the clinician’s knowledge about the whole human system, and that there clinician’s recommendation is frighteningly reductionist?

“The first direct spinal puncture in a living person is credited to James Corning in 1885 who injected a cocaine solution without medical basis into the epidural space of T11-T12 levels of a man who was habituated to masturbation and suffered form ‘spinal weakness and seminal incontinence,” (Meulen et. al. 2016)

During the Report of Findings (ROF), the patient should be informed about the risks and benefits of EI, as well as the mechanisms of the treatment. More importantly, it must be explained to the patient that EI does not treat the problem, it only attempts to alleviate pain; therefore, the problem persists underneath the masked pain, and that the problem may become worse. A treatment of EI is prescribed when the other presenting diagnostic features are not considered (whether diagnosed or not) and with a focus only to treat LBP. Again, this represents the reductionist practice of treating a bull’s eye, and not treating the whole bull.

A common ROF discussion with a patient prescribing EI:

1. “Your diagnosis is back pain of unknown cause, likely a pulled muscle. (what, how and why)
2. “If you do not get the injection you will remain in pain. (with-without treatment)
3. “I recommend the injection, I don’t have any other options, maybe physical therapy. (scope of practice)
4. “There are other treatments out there, I don’t know if they work any better. (other options)
5. ‘The advantage is reducing pain, the disadvantage is no pain reduction. (advantages-disadvantages)
6. “The risks include unresolved pain. (risks)
7. “The injection works differently for different people. (expected treatment results and time-frame)
8. “You might experience less pain. (improved health aspects & extent)
9. “If it doesn’t work, we can do another one. (what to do if the results are not satisfactory)
10. “There are no guarantees.” (efficacy disclosure)

The aforementioned discussion illustrates a failure of the clinician to completely describe the EI treatment as it is reported within the prevailing research. It should not be a stroke of misfortune that a LBP patient is stranded in a clinician’s office with only an EI prescription; a treatment recommendation that is invasive and comes with substantial risk. The patient is entitled to a conservative care option, even when the managing clinician does not offer one in-office. Patients with LBP don’t always make the wisest decisions regarding their care, so it is the duty of the clinician to properly explain the treatment plan with an emphasis on risk, NNT, recurrence, addiction, dependance, and potential failure of the treatment.

Epidural injection has a well-documented history of poor efficacy in the research:

“The scientific proof that epidural corticosteroids are effective against back pain and sciatica is hardly convincing.” (Meulen, et. al., 2016)

“23 RCTs involving approximately 2000 patients with symptoms of sciatica who had not under gone previous back surgery reported (3) points for leg pain reduction, and (0) for back pain… at (12) months and (2) years, no differences were seen for back pain, leg pain improvement in disability. Clinically meaningful validation studies and consensus statements regarding pain and disability suggest that a minimum change of 10-30 points is required before the effects [of a treatment] to be clinically meaningful.” (Pinto, et. al., 2012)

“In systematic review and meta-analysis assessing 115 trials with continuous outcomes, there was no difference between [epidural] treatment and placebo. In this meta-analysis after all the criteria for reducing bias were ruled out, placebos were more effective than [epidural] injections.

“… due to a lack of efficacy, epidural injections are not medically necessary in managing pain and function, not only in spinal stenosis, post surgical syndrome, and axial spinal pain, but also in disc herniation and radiculitis.” (Kaye, et. al., 2015)

“A meta-analysis of 5 studies (of 39 RCTs that met inclusion criteria and (9) with placebo) utilizing sodium chloride or bupivicane with steroid showed a lack of efficacy at (3) and (12) months follow up.” (Manchikanti et. al., 2016)

“100% saw no benefit” (the NNT.com, 2019)

“Injection of corticosteroids into the epidural space of the spine may result in rare but serious adverse events, including loss of vision, stroke, paralysis, and death. The effectiveness and safety of epidural injection administration of corticosteroids have not been established, and the FDA has not approved corticosteroids for this use.” (USDA Drug Safety Communication, 2014)

“2.3 million epidural injection procedures annually.” (Manchikanti, et.al., 2016)

Medical Policy Statement MM-0007: Epidural Steroids Injections

Part D. Policy: Criteria; indicated when all of the following are present:

A. Pain… is radiating or shooting in nature
B. Less than 6 EI in the past 12 months
C. Documentation [that the] patient received active conservative care for 6 weeks.
D. Documentation [that the] patient received passive conservative therapy for 6 weeks.
E. Authorization for image guidance with contrast.
F. Proof that a prior injection had a positive response (50%.)

“Clinicians should not routinely obtain imaging or other diagnostic testing for patients with non-specific LBP.” (CSMG Co. 2016)

An improved ROF discussion with a patient prescribing EI:

1. “Your diagnosis somatic & segmental dysfunction due to acquired personal habits and other
contributions that we will discuss. Your LBP is likely due to unresolved healing and
inflammation. Your pain is not the primary problem, but it will be addressed.
(what, how and why)
2. “With EI treatment, there is a small chance that you will feel less pain, but the injection does not solve
the underlying problem, it only masks it. About 80% of patients will experience relief without EI.
It is not likely that your symptoms will get worse without EI. (with-without treatment)
3. “My office is a medical office, so we commonly offer drugs to treat LBP. There are other types of care
available to you outside my office that do not require drugs, this type of care is called
conservative care, and is equally efficient at treating your LBP. (scope of practice)
4. “Conservative care includes therapies with non-medical doctors: chiropractors, naturopaths, oriental
medicine, physical therapy, and others that do not believe that drugs are necessary to treat your
problem. (other options)
5/6. ‘The advantage of EI is that a few people get excellent results, but most do not. Research reports that
nearly 100% of patients that received 3 EI in one year did not report lasting LBP improvements.
The disadvantages include: infection, paralysis, temporary increase in pain, no improvement in
LBP, and death. (advantages-disadvantages/risks)
7/8. “There is no way to predict when EI will be effective, or to what extent. (expected treatment results
and time-frame)
9. “If EI does not seem to be working for you, then I recommend starting conservative care. However. the
best treatment plan would include conservative care even if you choose the EI. (what to do if the
results are not satisfactory)
10. “Since there is significant risk, and the expected results are poor, I do not recommend EI.” (efficacy
disclosure)

Epidural injection is commonly prescribed for LBP even before conservative care is offered. A first-line of care for non-specific LBP should never be an invasive prescription with poor performance and poor patient satisfaction. Since the mechanism and efficacy for EI is not predictable, and comes with harmful possible side effects, clinicians can improve patient outcomes by creating cross-culture associations with conservative care providers, since ‘pain is not the only problem.’

LBP Blog General information

Series Description

These articles intend to (1) re-evaluate the prevailing clinical practices thought to manage low back ‘pain’, (2) submit and debate novel low back ‘pain’ contributors and mechanisms, (3) meet patient expectations & satisfaction and clinically meaningful results, (4) recommend a conservative non-surgical course of care to over-ride ‘pain’ instantly, and (5) restore ADLs and patient confidence on the first visit at low cost. This article has a companion podcast.

Dr. Dean Bio

Forester Dean is a chiropractic and physiotherapy sports medicine doctor practicing in Los Angeles, California. Dr. Dean is a lifetime athlete, and currently teaches tennis, track, boxing, yoga. The Core X System™ Campus flagship location was opened by Dr. Dean in 2020. www.preformancecxs.org

© Copyright 2021 SpineSync, Forester Dean, DC
Duplication with permission only
spinesync@gmail.com

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