Epidural injections for back pain may increase the risk of spinal fracture according to a new analysis of over fifty thousand patients. Just one lumbar epidural steroid injection used for lower back pain from conditions such as spinal stenosis increased the likelihood of spinal fracture by more than a fifth (21%), providing the first hard evidence of what has long been suspected by physicians and orthopedic surgeons: epidural steroids weaken the bones.
Patients with spinal stenosis may have a series of epidural steroid injections to help decompress the spine by relieving swelling and inflammation to free trapped nerves. These injections have become fairly routine and offer patients a way of avoiding back surgery for spinal stenosis until spinal degeneration has become too progressive and more aggressive treatment is needed. Recent problems with epidural steroids may have patients thinking twice about their use, however, with contaminated steroids causing serious (and sometimes fatal) spine infections and now evidence pointing to this increased risk of fracture with epidural steroid injections.
Why Epidural Steroids Are Used
In some cases, epidural steroid injections are used to relieve chronic inflammation that is obstructing the body’s normal healing process. In order to allow patients to engage in physical therapy to strengthen and condition the back and restore mobility and function, steroids can be helpful. However, their use for patients with existing bone-depleting disease or other factor increasing their risk of fracture may now be curtailed; the short term benefits for pain relief may not outweigh the potential long term risks for spinal health in general.
Steroid Injections Leading Cause of Secondary Osteoporosis
This latest review looked at 50,345 patients treated in the Henry Ford Health System who had a spine-related disease, with some 3415 of these patients having at least one lumbar epidural steroid injection. Doctor Shlomo Mandel, MD, MPH, an orthopedic surgeon from the Henry Ford Health System, Detroit, Michigan, and colleagues published the report in the Journal of Bone and Joint Surgery, citing such use of steroids as the leading cause of secondary osteoporosis. Lower back pain and radiculopathy, which may include sciatic nerve pain, leg pain and paraesthesia, may all be relieved by steroid injections but many have noted their negative effects on bone density and strength as they adversely influence the breakdown and rebuilding of bone through osteoclast and osteoblast function, respectively.
Sciatica Patients More Likely to Have Epidural Injections
3000 of the patients who had received the injections were randomly selected during this analysis and these patients were matched with controls who shared similar demographic features and who had conditions affecting bone health but who had not had steroid injections. Patients’ records for five years after their first injection, or five years after diagnosis for controls, were analyzed with the researchers noting that sciatica was more prevalent in those receiving the epidural injections than those going without.
Dangers of Repeated Epidural Steroid Injections
The average age in both groups was around 66 years, however it may be that patients receiving epidural steroid injections tend to be younger because of a more pressing desire to be rid of symptoms of radiculopathy so as to get on with life. Those patients repeatedly requesting spine injections for lower back pain may not realize that they face this increased risk of spinal fracture later in life and physicians may be failing to warn them of the potential dangers, based on this latest evidence.
It could also be that those patients who had received the epidural steroid injections in this study did so because they have significantly different levels of activity and lifestyle factors which, in turn, affect their risk of fracture. Controlling for all variables is impossible in a retrospective analysis such as this one and so, although it seems a strong conclusion can be drawn, there is some room for interpretation.
Lowering Risks of Spinal Fracture
Patients included in this analysis accessed medical treatment outside of the Henry Ford Health System, thus skewing the data. Even so, patients with spinal stenosis and low back pain may wish to consider epidural steroid injections a second to last resort for their symptoms, prior to back surgery, concentrating instead on alternative treatments for back pain such as physical therapy, acupuncture, yoga, and so forth. Patients who are smokers, who have a poor diet, and/or who take NSAIDs and other medications that can adversely affect bone health may face an even bigger risk of spinal fracture with epidural steroid injections and should consider such risks when devising a treatment program with their physician.
Shlomo Mandel, Jennifer Schilling, Edward Peterson, Sudhaker Rao, William Sanders, A Retrospective Analysis of Vertebral Body Fractures Following Epidural Steroid Injections, J Bone Joint Surg Am, 2013 Jun 05;95(11):961-964.