006- Steroid Injection Lead to Increased Risk of Vertebral Fracture

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Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. Hope you had a great holiday. We are ready to turn gears and start looking towards 2016 and today we're going to talk about probably one of my most interesting pieces of research that we'll touch on. And what I mean by that is we're going to touch on the Journal of Bone and Joint Surgery paper which came out in 2013 and it is titled A Retrospective Analysis of Vertebral Body Fractures Following Epidural Steroid Injection. So before we dive in, let me say a word about Rocktape. Rocktape is proud to be a sponsor of the Evidence Based Chiropractor. Rocktape offers the world's best kinesiology tape, pain relief, topicals, mobility tools and functional fitness accessories. New from Rocktape is Rocksauce Chill, a powerfully cool pain relief topical and a convenient roll on with 6% menthol. It's stronger than the freeze. Competition with Rock Tape is more than a tape company, they are a movement company. Learn more get access to your medical discount by visiting rocktape.com so today's piece of research really strikes me because it has to do with vertebral body fractures following epidural steroid injections. When I'm speaking throughout the country regarding research and communication, one of the slides I bring up looks towards epidural steroid injections and there's something like 9 million epidural steroid injections given each and every year. And I think that breaks down somewhere in the vicinity of twenty some odd thousand injections given every day. So we all know patients have patients actively and have had patients and certainly will have patients that have had epidural steroid injections. So this paper is interesting. Again, it's from the Journal of Bone and Joint Surgery because it looks at vertebral body fractures. So to me, this research study really has received a substantial amount of discussion since its release. The results empathize or emphasize, I should say, the importance of evidence based clinical decision making and its effect on the long term health of our patients. Currently available research fails to support a substantial benefit for ESIs beyond the short term. So the research has shown that they are beneficial short term, but not necessarily after that. While the impact of vertebral fracture on mortality is well documented. In light of the previous European Spine Journal paper, which shows patients with radiculopathy experiencing significantly less pain after a chiropractic flexion distraction adjustment, it's imperative to consider chiropractic decompression, aka flexion distraction for patients suffering with compressive pathologies. Certainly ESIs can be viable from time to time, and probably today's not the big discussion on the the efficacy or value of an ESI overall, but it's more about looking at the challenges of vertebral body fracture following those injections. They looked at over 50,000 patients. 50,345 patients were involved in this retrospective analysis. So that's a lot, a lot, a lot of patients that were looked at. What the researchers found was that there was about a 21% increased risk of vertebral fracture with each epidural steroid injection. So when I first read that, it took the wind out of me. It was a little bit surprising. That's a significant challenge that many patients may be facing post epidural steroid injection. When we think about them in terms of the extremities with steroid injections, everybody knows that it degenerates or deteriorates the joint over time, which is why even the highest level of athletes try to avoid consistent injections because they're gonna end up with ultimately having to have a surgical intervention due to the challenges of the injection itself to be able to play. So it's kind of that cyclical nature of disease or degeneration. But in the spine, to have a vertebral body fracture, I think really brings up and highlights a new point that I hadn't heard much of before this study. The researchers found no significant difference between injected and non injected groups with respect to age, predicted propensity score, sex, race, hypothyroidism, or steroid use. They also found each successive injection increased the risk of fracture by a factor of 1.21 with a 95% confidence interval. Finally, they found of greater concern the definable fracture risk as documented by Mandel et al, should be set against the best available evidence regarding the long term efficacy of these interventions, which is admittedly less than robust. And that's from Dr. Andrew J. Schoenfeld, MD. So in short, really, this paper shows and emphasizes the point that ESIs can be potentially of value in the short term for patients, But I think it's really gotta be looked at hard for patients that are going for cycles of continuous ESIs so for ESIs, what I typically see in practice is that patients get a series of three. Now a series of three Do I think three? And sometimes patients ask me, hey, if I get three epidural steroid injections, do you think it's really going to hurt things? Certainly it's not my place to particularly talk about the benefit analysis of ESIs. It's better talked about by those providers that can give those ESIs. But I think the biggest challenge with that is ultimately, we all would agree whether a patient has an ESI or not, it's no way to live. So patients that are going through cycles of three time and time again, and of course, having that law of diminishing returns with each and every injection, that's something that needs to be looked at closely. And I think it's also clinically very important from a chiropractic perspective, because if you have a patient that's come in and they've had chronic pain, they're coming in because they have low back pain, and they report to you that they've had a series of that can't even count how many injections, maybe six cycles of three or eight, or they've even lost count. It's important to me for maybe not technique choice, but taking a close look at that area and certainly making sure that I'm going to be getting imaging on that area as well. Because if they're at high risk for a lumbar fracture, it's going to be something that clinically I'm going to want to take a close look at. I certainly don't want a patient coming into my office that's the highest risk for vertebral fracture and me not doing my due diligence and making sure I'm serving the patient in the best way possible and keeping them educated every step of the way. So, long story short, with this, epidural steroid injections increase the risk for vertebral fracture for patients undergoing them at a factor rate of 1.21, so about a 21% increase per injection. So patients coming in to see you, make sure you're asking about if they've had injections and if they have, ask how many, because it might be something you want to take a close look at while you go through your decision making before you start getting in there and adjusting the patient. And one thing I wanted to touch on before we wrap up this episode, I was really honored and proud to be a part of an article that highlighted chiropractic and Prevention magazine, Prevention magazine, from my understanding still has a readers of 2 to 3 million people visiting per month and certainly a very wide distribution as far as the magazine is concerned. And I was very happy to be part of an article that was about chiropractic care and in my opinion really shined a nice light on chiropractic care and I was actually able to talk a little bit about pregnancy related care in terms of chiropractic. So if you have the opportunity, please take a peek at it, share it if you find value in it. I'll make sure I link it in the show notes here. And I think it's a really nice piece and I'm glad that Prevention magazine was able to get on board and put out a nice piece regarding chiropractic care. And as always I'll remind if you have been listening. If you like the podcast, please go on itunes. Rate the podcast, give me a comment, let me know what we're doing great and what we can do better. We're going to continue to bring you great content each and every week and things that you can bring into your practice through this podcast, touching on research and certainly going to have some special guests coming up in the next few weeks and as we go on with the podcast as well. So thank you for your service. Thank you for being a chiropractor. Have a great week and we will talk to you soon.

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