Issue 31 / 19 August 2013

A “SWEEPING” call to withdraw public funding for all spinal steroid injections would be ill advised if it included transforaminal steroid injections — the only effective, non-surgical treatment for lumbar radicular pain, according to a leading spinal pain specialist.

Professor Nikolai Bogduk, conjoint professor at the University of Newcastle’s school of biomedical sciences and pharmacy, said cutting funding for transforaminal steroid injections would lead to increased rates of surgery for radicular pain.

He was commenting on an article in the latest MJA calling for the withdrawal of public funding for spinal steroid injections for low back pain and/or radiculopathy. (1)

Professor Ian Harris, professor of orthopaedic surgery at the University of NSW, and Professor Rachelle Buchbinder, director of the Monash department of epidemiology, wrote that the withdrawal of funding “should be considered on the basis of our knowledge of the placebo nature of this treatment, the costs, and not least, because of the likelihood of harm”.

They wrote that while the injections of steroids in and around the spine were “generally considered a safe procedure”, adverse affects ranged from headache and transient local pain to reports of paraplegia.

Professor Bogduk, who is also director of clinical research at the Newcastle Bone and Joint Institute and a practitioner of transforaminal injections for radicular pain, echoed the authors’ call to cease funding for spinal steroid injections for low back pain.

“I fully agree that there is no evidence of effectiveness for blind, epidural injection of steroids and these injections have been proven to be no more effective than a sham for the treatment of radicular pain”, he said.

However, a five-arm randomised controlled trial and systematic review had shown lumbar transforaminal steroid injections to be effective for radicular pain, said Professor Bogduk, who was a coauthor on two papers on the trial. (2, 3)

Professor Bogduk said he did not want to deny his patients the possible benefits of the procedure. “We have kept our [surgical] waiting lists down because a simple injection that takes 30 minutes to perform keeps people out of the surgeons’ hands.”

While Professor Bogduk said the treatment was not perfect — “only 54% of our patients have benefited” — the procedure offered patients a less invasive option than surgery. “No drug works for this [condition], no physical therapy, no chiropractic works, so [by banning steroid injections] you are asking for these people to go off and have surgery”, he said.

Professor Milton Cohen, senior specialist in pain medicine and rheumatology at St Vincent’s Hospital, Sydney, said there may be a role for transforaminal spinal injection for true lumbar radicular pain, and he supported continued funding for that procedure.

“Although low back pain and lumbar radicular pain can occur together, they have very different mechanisms”, he said.

However, he welcomed the “timely” call to cease funding for spinal steroid injections for low back pain.

Such “quick-fix” injections were no better than placebo for low back pain, which was better treated with lifestyle modifications, exercise programs and the judicious use of medicines.

“Whereas most cases of chronic spinal pain need a multidisciplinary approach, it’s pretty much inbred in medicine just to use one modality”, he said.

The MJA authors said Medicare Benefits Schedule figures showed that the number of procedures that included “injection into one or more facet joints under image intensification” had more than doubled in the 10 years to 2011, with 31 500 procedures performed in 2011 and 35 000 last year.

Professor Cohen said a “cynical” explanation for this growth was the financial incentive for performing such procedures. “There’s a price tag attached to it — you can earn much more for a procedure that might take 5 minutes than you do for an hour-long consultation exploring the biopsychosocial aspects of a person’s [back pain].”

1. MJA 2013; 199: 237
2. Pain Med 2010; 11: 1149-1168
3. Pain Med 2013; 14: 14-28

12 thoughts on “Back pain injections under scrutiny

  1. Richard says:

    Very interesting, I have wondered for a long time why there does not seem to be distinction between high volume caudal epidural injections and lumbar epidurals which use much lower volumes and are akin to pain relieving epidural injections for labour or regional anaesthesia for surgery.  In my experience caudal epidural injections can be very effective – perhaps due to the added hydraulic effect?  Please can anyone point me to research that says that caudal epidural injections are of no benefit?

  2. Department of Health Victoria Clinicians Health Channel says:

    The weight of evidence is fairly robust that caudal and transforaminal injections can be an appropriate part of multidisciplinary management of chronic LBP. The evidence suggests the risk-benefit calculation for interlaminar (ie, the classic anaesthetist’s epidural approach) is unfavourable due to lower efficacy and higher risk of dural puncture.

    Strangely, the item number they have quoted above has nothing to do with epidural injections. It is used for facet joint injections and medial branch nerve blocks, which are diagnostic blocks done with local anaesthetic.

  3. Dr Kevin B ORR says:

     I have had a number of spinal steroid/local injections for lower back pain over the years. Some have worked and others not. But earlier this year I had severe buttock pain on and off over several weeks – needing opiates. One steroid/LA injection many weeks ago and I have not had a recurrence. Perhaps it is matter of getting the right spot!


  4. Dr David Bolzonello says:

    Like a lot of things we do in Medicine there is sometimes not a good evidence base.

    The question is what we are doing and why. If the proposal is to also cut out facet joint injections then we might miss what is often a valuable circuit breaker in the patient who has pain that has not respionded to good first line conservative therapy. While I accept the anecdotal nature of what I am about to say, facet joint injections can relieve pain even when a course of oral steroids have not. I accept too that direct facet joint injections are not necessarily diagnostic as say medial branch blocks are but the pain relief can give one a window of opportunity to activate the patient physically.

    I think that spinal steroids if done in a correct managment plan setting can be valuable when all else is not working. If done without the education around back pain and the need to start to move then they will fail.

    As for a transforaminal or nerve root injection, one got me out of my bed and back to work last year withing a few days. It could have been chance but the studies suggest otherwise.

  5. Richard Sills says:

    Please can someone point me towards the evidence base for Caudal epidurals v’s interlaminar epidurals and also the benefit of caudal epidurals per se?  

    It is my anecdotal impression that we are often missing a trick here and that perhaps high volume caudal epidurals could be used more?


  6. q401411@amamember says:

    Some interesting data

    Shows English pain clinic and how it uses caudal injections to effect with advice on improving cost-effectiveness

    Fluoroscopic caudal injections for chronic axial low back pain in an American setting

    Conclusion: Caudal epidural injections of local anesthetic with or without steroids are effective in patients with chronic axial low back pain of discogenic origin without facet joint pain, disc herniation, and/or radiculitis.

    Journal of pain research.

    Both give another perspective Its a worthwhile debate – I’m also of the opinion that the MBS rebate for this and many other procedures are shonky.

    In short, the MBS should be thrown out and replaced by a 50 page document




  7. Max Majedi says:

    There are clearly too many unnecessary injections done for many pain conditions. Some have good response and some poor. However It should be pointed out that pain is a subjective unpleasant experience and many studies narrow the inclusion criteria to a very finite point. This creates many error and biases. I treat many patients and use combination of nerve blocks . Some of these patients are very functional and are doing all the right things. Some of these patients are other doctors , lawyers , nurses . Can some one explained to me why the injections ( Using high volume caudal epidural local anesthetic and low dose steroids combined with transforaminal and median branch blocks) work for patients without any psychosocial issues. Also may elderly that can’t tolerate many analgesics. Let ‘s be frank for a minute.  I have spend the last 10 years of my practice getting patients off high dose opioids which the last generation of pain specialist had created. It seems to me that these publications pick out selected data , based on very stringent inclusion criteria and non-standardised techniques to push for a political agenda, i.e cost cutting. I fully agree that the whole health system is a wasteful enterprise, propagated by Iatrogenic issues; and needs restructuring. However, do not punish the patients that do benefit from carefully instigated techniques in the rightly trained hands that can help them reduce their pain and rehabilitate.  I think there are better ways to looking at lumbar spine pain issues. Some of these quoted studies use techniques that are not standardised and can not be collated together.  From a FFPMANZCA tertiary hospital

  8. Dr Roger Burgess says:

    I  have stayed clear of interventional practice, especially in the spine where there really is no convincing evidence of its LONG TERM  efficacy. The zygo-apophyseal joints of the spine are weight-bearing joints, just like the joints of the lower limbs. Noone would ever again countenace regularly injecting steroid into a knee joint, to-day, in view of the absolutely disastrous results of this practice following the free availability of cortisone compounds. So, what is so different about these spinal facet joints? Over the last decade or so, I have noticed similar changes in facet joints that have been so injected on multiple occasions. I guess you could get away with one or two! There is progrssive loss of facet joint space, hypertrophic marginal osteophyte formation etc…up to the whole shooting match of an actual Charcot’s joint/arthritis mutilans! This can be disastrous for someone who has been actually suffering from undiagnosed spinal canal stenosis. (Spinal canal steosis is so easily diagnosed by a simple CT study). Surely some others have noticed this trend? This would avoid being asked to inject every facet joint in the neck of an 80+ yo patient with very severe cervical stenosis when doing a locum out in the bush recently!!!  It really is becoming a rort, I am afraid.

  9. William McCubbery says:

    Blunderbuss treatments in Politics and Management work no better than they do in Medicine. To say all spinal injections must cease to be rebated because there is no statistical evidence of reliable efficacy for all of them doesn’t look too scientific to me. Fortunately, in this case, the advice is dispassionate and not promoted by sectional interests seeking favour with bureaucrats by suggesting ways to cut costs indiscriminately. I have a conflict of interest. My transforaminal injection completely relieved my pain while the anaesthetic lasted. The pain eased gradually over the next few days until it reached a plateau. It was returning so that admission for a successful foraminotomy came at the right time. It confirmed for the neurosurgeon and for me that he was operating at the right level; and enabled me to function without opioid analgesics while on the waiting list for surgical relief. The sudden exacerbation of the sciatica for which I was being treated when the needle was first inserted also indicated it was in the right spot. There are two sorts of people (including doctors) – those who have had a crook back and those who haven’t. It is all very well being objective about pain when it is someone else’s. The verb “to suffer” is conjugated irregularly: “I am in agony; you are a wimp; he is malingering”. Reading of the suggestion that the views of a couple of academics should be imposed on everyone else reminds me of the definition of a “minor surgical procedure” – one someone else is having.

  10. Dawn Gonzalez says:

    They are extremely risky and minimally effective at BEST. I am 34 and permanently disabled for life from ESI’s. there are many many more of us out here. It NEEDS to be stopped!!


  11. keith thomas says:

    I am a long time lumbar injection victim.The last shots I had caused a rare disorder called lumbar epidural Lipomatosis. This shots are big money makers for these Doctors and they really do not help with pain.I lost the ability to walk,and had to have a 6 level lumbar decompression surgery to free my spinal canal from all the fat tumors caused by these injections.

  12. william young says:

    I am a retired one of the previous commentators, I also had disabling lumbar radicular pain(femoralgia) from a R L3/4 disc protrusion. An initial CT guided trans forminal injection of marcain/triamcinolone/saline gave complete resolution of the pain tho’ some residual numbness remained. 4 months later the femoralgia recurred but responde to a second CT guided trans foraminal epidural injectiom. There has been no further recurrence but the numb patch in the R L3 dermatome persists and of course low back pain  and morning stiffness are always there. I have referred patients over the years for similar problems and I have no doubt that in the right hands guided trans foraminal epidural injections have their place in the management of lumbar radicular pain. However one cannot say the same of blind lumbar and caudal epidural injections.

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