new government guidelines on corticosteroid injections

CORTICOSTEROID INJECTIONS
HAVE YOU SEEN THE LATEST GUIDELINES?

“Using predefined criteria, we selected randomized trials of patients with LUMBOSACRAL RADICULOPATHY, SPINAL STENOSIS, NON-RADICULAR BACK PAIN, or chronic POST-SURGICAL BACK PAIN that compared effectiveness or harms of epidural, FACET JOINT, or SACROILLIAC corticosteroid injections versus placebo or other interventions.  Epidural corticosteroid injections are the most commonly used interventional procedure for low back pain, but evidence indicates that benefits are limited to pain relief and reduced risk of surgery shortly after the procedure in patients, without long-term benefits on these outcomes and no effect on functional outcomes.”    Taken from the study being discussed below.  Links are mine.
Today we’re going to discuss the brand new study by the Pacific Northwest Evidence-based Practice Center for our government’s own Agency for Healthcare Research and Quality (Pain Management Injection Therapies for Low Back Pain).  According to the study, “The Key Informants consisted of experts in internal medicine, health services research, pain medicine, radiology, neurology, occupational medicine, and physical medicine and rehabilitation, as well as those representing the patient perspective.

In the study, the authors were working from the knowledge that, “Low back pain is common, and injections with corticosteroids are a frequently used treatment option“.   The challenge was to look at 77 recent studies on the subject (2008-2014) and see if this option was even remotely effective for Low Back Pain.  After all, CORTICOSTEROID INJECTIONS have played a major role in the medical community for half a century or more (you’ll see just how big a role in a moment).  The authors of this 251 page meta-analysis, “reviewed the current evidence on effectiveness and harms of epidural, facet joint, and sacroiliac corticosteroid injections for low back pain conditions.  Did they find anything that might be considered important or newsworthy for those who struggle with Low Back Pain?  We’ll get to that, but let’s first look at what these experts had to say about back pain in America.

  • BACK PAIN IS COMMON:  I knew this was true, but here is what the government says.  “Low back pain is one of the most frequently encountered conditions in clinical practice.  Up to 84 percent of adults have low back pain at some time in their lives, and a national survey of U.S. adults in 2002 found that over one-quarter reported low back pain lasting at least a whole day in the previous 3 months.”  In an age where 2/3 of our nation is OVERWEIGHT OR OBESE (not to mention massively INFLAMED), you know that this statistic is going to be significantly higher now than it was 13 years ago.

  • CHRONIC BACK PAIN IS MORE LIKELY IN THE ELDERLY:  “Although low back pain affects individuals of all ages, its prevalence peaks at 55 to 64 years of age and remains common in those 65 years of age and older.”  Unfortunately, because Medicare is like bank vault for unscrupulous healthcare providers (cha-ching), we frequently see the elderly being taken advantage of with batteries of UNNECESSARY TESTS AND EXAMINATIONS as well as UNNEEDED SURGERIES.

  • IT’S NOT JUST A “PAIN” ISSUE:    Low back pain can have major adverse impacts on quality of life and function and is frequently associated with depression or anxiety.”   If you want to begin to grasp the intricacies of CHRONIC PAIN, just click the link.  For information about Depression, you can go HERE.

  • LOW BACK PAIN CARRIES MASSIVE COST:  Much of this is on the shoulders of the public sector in the form of tax dollars.  “Low back pain is also costly. In 1998, total U.S. health care expenditures for low back pain were estimated at $90 billion. Since that time, costs of low back pain care have risen substantially, at a rate higher than observed for overall health expenditures.  Low back pain is one of the most common reasons for missed work or reduced productivity while at work, resulting in high indirect costs; this makes the total costs associated with low back pain substantially higher than the direct health care costs.”  Face it.  Using statistics on cost that were current nearly two decades old is ridiculous.  If my son tried to pull this off in his college courses, he would probably be repeating the classes.  Suffice it to say that the cost of LBP in America today is going to run into the hundreds of billions.

  • X-RAYS AND ADVANCED IMAGING RARELY PROVIDE VALUABLE DIAGNOSTIC INFORMATION:  If you’ve read my post on ASYMPTOMATIC DISC HERNIATIONS you’re already aware of this fact.  When it comes to musculoskeletal problems that do not involve a possible fracture, diagnostic imaging rarely provides what I have always referred to as a “Ah Ha” moment.    “In the majority (over 85%) of patients with low back pain, symptoms cannot be attributed to a specific disease or spinal pathology.  Spinal imaging abnormalities such as degenerative disc disease, facet joint arthropathy, and bulging or herniated intervertebral discs are extremely common in patients with low back pain, particularly in older adults. However, such findings poorly predict the presence or severity of low back pain.”  This is a big reason that the vast majority of CT’S & MRI’S in this country are unnecessary.

  • CORTICOSTEROID INJECTIONS ARE ARGUABLY ONE OF THE MOST COMMON TREATMENTS FOR MAJOR LOW BACK PAIN:  Although other palliative therapies such as PAIN PILLS, MUSCLE RELAXERS, and NON-STEROIDAL ANTI-INFLAMMATION DRUGS are exceedingly common, so are injections.  “The most commonly used medications in back injections are corticosteroids to reduce inflammation and local anesthetics for analgesia.

  • THE USE OF INJECTIONS IS INCREASING EXPONENTIALLY: Between 1994 and 2001, use of epidural injections increased by 271 percent and facet joint injections by 231 percent among Medicare beneficiaries.  Total inflation-adjusted reimbursed costs (based on professional fees only) increased from $24 million to over $175 million over this time period. More recent data indicate continued rapid growth in use of spinal injection therapies among Medicare beneficiaries, with an increase of 187 percent in use between 2000 and 2008.  Despite these dramatic increases, use of injection therapies for low back pain remains controversial.”  I promise that the increase over the course of this study has been just as big or bigger (I’m not really sure why they do not have pre-2008 data on cost, even though that is the starting year for this meta-analysis).  Which brings me to a whole other issue — the issue of why this commonly used treatment remains controversial

CONCLUSIONS OF THE STUDY AND CONSEQUENCES
OF CORTICOSTEROID INJECTIONS

This study states that, Systematic reviews of injection therapies have come to conflicting conclusions regarding the benefits of injection therapies, and clinical practice guidelines provide discordant recommendations regarding their use.”  Interesting.  Why would this paragraph be true?  In other towards, what’s driving the “conflicting conclusions” of previous research, not to mention “discordant guideline recommendations“?  Interestingly enough, the current study actually spells it out for us.

Remember back when I showed you that studies can be purposefully set up to prove anything you want them to (HERE)?  The same thing is true of studies with Spinal Injections of Corticosteroids.  Listen to what the authors of this study admit to.  “Trials of injection therapies have frequently focused on short-term outcomes related to pain, rather than longer-term functional outcomes.”   Case in point, here is what they said about a previous meeting back in 2009 whose results were carried in the medical journal Spine (Nonsurgical Interventional Therapies for Low Back Pain: A Review of the Evidence for an American Pain Society Clinical Practice Guideline).  “A previous qualitative review conducted by our team and funded by the APS found fair evidence that epidural corticosteroid injections for radiculopathy are more effective than placebo interventions for short-term symptom relief, but not for long-term symptom relief……  It’s easy to set up a study that shows short term relief.

I see lots and lots of people who get temporary relief from this commonly used therapy (anywhere from a few hours to a few weeks).  I rarely if ever see people getting any sort of long term relief.  This is spelled out by this most recent APS study.  The back half of this study contains page after page after page charts of dozens upon dozens of specific categories of Corticosteroid Injections.  Virtually all reveal that the, “strength of evidence (SOE): low  This is seen in the study’s conclusions.

“Epidural corticosteroid injections for radiculopathy were associated with immediate improvements in pain and might be associated with immediate improvements in function, but benefits were small and not sustained, and there was no effect on long-term risk of surgery. Evidence did not suggest that effectiveness varies based on injection technique, corticosteroid, dose, or comparator. Limited evidence suggested that epidural corticosteroid injections are not effective for spinal stenosis or nonradicular back pain and that facet joint corticosteroid injections are not effective for facet joint pain.

This is exactly what I have been telling my patients for the past 25 years.  These drugs might provide a bit of short term relief, but there is absolutely no long term benefit.  And despite the study saying that, “Serious harms from injections were rare in randomized trials and observational studies,” this sentence carries a qualifier —– “Harms reporting was suboptimal (SOE: low)“.  Like I have shown you any number of times previously, adverse events, side effects, drug reactions (“Harms Reporting“) are always UNDER-REPORTED; usually ridiculously so. 

Furthermore, they were only looking at short-term adverse events.  In other words, you get an injection and have an immediate reaction, you become a statistic.  While that scenario is relatively rare, degeneration is not.  You see; even if these drugs work to relieve your pain temporarily, any doctor worth his salt is going to tell you (warn you) that they just can’t continue injecting you over and over with Corticosteroids.  Why not?  Because Corticosteroid Injections are massively degenerative.  They destroy all the COLLAGEN-BASED tissues that make up the joint (BONES, cartilage, FASCIA, TENDONS, LIGAMENTS, MUSCLES, etc, etc, etc).  In other words, every time you get a Corticosteroid Injection you are trading tomorrow for today.  As far as other long-term consequences of Corticosteroids, they are nasty as well.  Use Google to research this topic in depth if your doctor is trying to get you to agree to injections.

POLICY MAKING & DECISION MAKING
WHERE THE RUBBER MEETS THE ROAD

I have repeatedly shown you why Governmental Guidelines for dealing with any number of health problems cannot be trusted (HERE, HERE, HERE, HERE, and HERE are a few examples) — great examples of the oxymoronically named, EVIDENCE-BASED MEDICINE.  Despite the conclusions of this study and decades of similar studies showing nothing more than temporary pain relief with Spinal Corticosteroid Injections, the beat goes on.   Listen to the way that the authors try and SPIN this study under a section labeled Implications for Clinical and Policy Decisionmaking.

“Potential strategies to enhance the effectiveness of epidural injections would be to perform them using techniques shown to be more effective, or to selectively perform injections in patients more likely to benefit. However, our review found no clear evidence of greater benefits based on technical factors such as the specific epidural technique used, use of fluoroscopic guidance, the specific corticosteroid, the dose, or the number or frequency of injections.”

When I was making notes for this post, I wrote “fricking absurd” next to the paragraph above.  Think about it for a moment.  No matter how many dozens (maybe hundreds) of different ways that doctors have tried to deliver these injections, research has shown that none of them work.  Couple this with their long-term DEGENERATIVE qualities, and I cannot imagine why we are still having this discussion in the year 2015. 

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