482- The Truth About Epidural Steroid Injections

Welcome to the Evidence Based Chiropractor, where each week we deliver the latest chiropractic research and marketing strategies, all in the time it takes to get to your office. Now, here's your host, Dr. Jeff Langman.

Hello and welcome to the Evidence Based Chiropractor. I am your host, Dr. Jeff Lengmaid. On today's episode, we are back with more brand new research and it is a fantastic study that is all about epidural steroid injections. Do they work? Don't they work? This is a systematic review that's gonna highlight what we know. And if you're a chiropractor listening, this is an episode you're gonna want to pay attention to. Now, before we get started, I wanna say a few words about neck care. This is the best objective assessment tool of the cervical spine on the market. Reliable assessments and exercises for neuromuscular control, proprioception, range of motion and sensory motor integration. Neckcare.com I'll drop that link down below. They have also changed up their pricing model to make it really, really affordable to get neckcare into your practice. So click on down below, head over to neckcare.com connect with their team. It is simply the best cervical assessment tool on the market, bar none. Now, as I said at the top, today's episode, we're talking research and this is a fascinating systematic review published in neurology. And it looks at epidural steroid injections for cervical and lumbar radiculopathy and spinal stenosis. And you've probably had, if you've been in practice more than a day or two, you probably had a bunch of patients actually ask you about ESIs or epidural steroid injections. And curious, is this a quick fix, especially when people are in abject pain? It's a good question because they're looking for relief. But the real question has to be one level, either deeper or above, depending upon which way you look at it, which is, do they really work? Are they effective long term, are they effective short term? And should they even be a recognized care and treatment option for radicular pain and stenosis? So this was a review, it was conducted by the American Academy of Neurology, and they looked at 90 randomized control trials to really start to determine do epidural steroid injections actually reduce pain and disability in the short and or the long term? The results, I'm gonna say, may not be surprising to you, but. But they are certainly something you need to pay attention to. And why do I say that? You know, I've had a bone to pick with, with steroid injections for a long time. I just, I don't understand how there are pain management doctors out there that book 40 to 45 patients a day, bounce between two rooms, pushing the plunger, and they're able to bill our health care system and get reimbursement for something that I just think doesn't work very well, if at all. That's not to mention the off label use, that's not to mention the fact that I could go on and on. But the bottom line is today we're actually gonna take a look at the research and you can make your own determination when patients ask you about what they should do on what you recommend. So why does this study matter? It gets back to the core essence of what many of our weekly episodes are about, which is that spinal pain is a massive health burden. We know 80, 90% of adults will experience some form of spinal pain in their lifetime. So let's define a few things before we get into some of the stats. So, radicular pain, of course, pain caused by nerve root irritation, can be chemical, can be compressive, spinal stenosis, narrowing of the spinal canal. And these are among some of the most common causes for chronic spinal pain out there. It's probably things you see each and every day. And epidural steroid injections, contrary to what I would like to see, are widely used to treat these conditions, albeit poorly. But they're used all day, every day, and there's a lot of doctors making a lot of money that doing these and their actual effectiveness has been debated for years. Just the fact that that's the case alone, it sound like an old man here grinds my gears. And here's why. Unequivocally, in the research, we've seen that spinal adjustments are effective, recommended, and perform well. And the fact that ESIs have been debated for years and people are still doing this, making money hand over fist, in my opinion, giving poor service to the patient. Hippocratic oath, do no harm. My firm belief is that 90 plus percent of epidural steroid injections are actually doing harm, not help. There are some occasions where epidural steroid injections due to abject pain may be warranted. The same way that there are some circumstances where a surgical intervention is necessary. But we also have seen in the literature time and time again, we've seen it probably throughout our unique experiences as well, that 90% of the time that's just not the case. So this systematic review sought to answer A few really important questions. One, do epidural steroid injections actually reduce pain and disability with people that have radiculopathy and spinal stenosis? Two, do they offer short term relief less than three months or do they have any long term benefits greater than six months? And what they found. Let's dive right into some of the stats. Short term pain relief. They did find that epidural steroid injections probably provided some short term pain relief. So there's a couple things that they highlighted. What they call an SRD, that's a success rate difference and it was 24%, meaning one in four patients saw a meaningful reduction in pain. Not a resolution of pain, but a meaningful reduction. One in four patients, that's an SRD for it. And then the second one is nnt, the number needed to treat. So you'd need to treat four patients with an epidural oral start injection for one patient to experience short term pain relief. We also saw. So that we're going to tie in some of these stats as we dive a little bit deeper as well. So ESIs did, as they say, probably improve function slightly. The success rate difference on this was 16% and the NNT was 6. So about one in six patients saw a reduction in disability. That's not a great shooting percentage, but. But it's there, right? One in six patients saw somewhat of a reduction in disability. One in four patients saw somewhat of a reduction or a meaningful reduction in pain. To me, that says all it needs to say, but we'll keep going with it. So let's talk about long term pain and disability. There was absolutely no evidence that epidural steroid injections provided any long term pain relief. The SRD was about 10% and the NNT was 10, meaning you'd need to inject 10 people for one to see long term improvement. And I've been in a lot of pain management practices that are literally on their procedure days, quote, unquote, seeing 40 patients pushing the plunger, as I like to say, injecting epidural steroids in 40 people in a day. So that means if they saw 40 people in a day, four are going to have maybe some improvement. It's just, it's unacceptable as far as what, as far as I'm concerned. And then when we go into lumbar, well, let's talk about SRDs for disability as opposed to pain. 11% and 9 on the NNT. So there's minimal long term effect in either pain or disability. Now as we move on to spinal stenosis, that narrowing of the spinal canal esis may provide some slight improvement. Again, SRD right about 26% in the NNT of 4. So that means 1 in 4 patients had some improvement in disability if they were struggling with stenosis and received an injection. Short term pain relief ESIs did probably did not help at all. The SRD was 3.5%. And in long term pain and disability, again, this is for stenosis specifically. There is insufficient to slash no evidence for any lasting benefits. SRD 6.5% and 11.8% for disability. So the big takeaways here were these epidural steroid injections might offer some temporary pain relief in some cases for people that have radiculopathy. But the benefits for spinal stenosis were questionable at best and long term relief was essentially non existent. So there's a couple of things here that I think are really important to dive into. One is I have seen, and I think you do as well, many, many individuals that have spinal stenosis that quote unquote, get their three injections per year, meaning that's typically how much an insurer has historically paid, how many times you can go, you know, those types of things. So that's just a farce. If we actually look at what's going on now in individual patients, I'm not saying that an ESI on every single patient has no improvement. Clearly there are some people that do have some amount of benefit from that. And if that's the level of benefit that helps them avoid surgical intervention, great. But let's make sure they're doing everything before they get to the ESI to ensure that if that's the way they go, that's really the only option left. This should not be something that's mid funnel and top of funnel in terms of treatment options, which many pain management doctors and primary care doctors have continued to push up the funnel. In other words, it's not like they're getting the injection just to hold them over before their scheduled surgery. That would be bottom of funnel. Many people are getting injections multiple times per year for years on end believing that it's helping them. And the irony being many of those individuals have seen chiropractors and left because they didn't see the relief that they wanted. Well, what's going on? This is a communication issue. It's about communicating expectations and agreements with your patients based upon what you're seeing. Not everybody in your practice is going to have a miraculous improvement within one to three visits. And not everybody is not going to see an improvement after Months and months of care, most are gonna fall in between. And being able to accurately communicate that to a patient so they don't drop out of care too early in your practice and is one of the most meaningfully impactful things you can do. I know us as chiropractors and I see it all the time. We're always one technique away from having a successful practice. We're clinicians at heart, and we have that care for our patients. And I'm not saying get rid of that by any stretch, but what I am saying is just as much as you work on your clinical skills, you need to work on your communication skills. Because there are way too many chiropractors that have patients that are dropping off out of care far too early. And that's bad for your business. But the real problem is it's bad for your patient. And this is where there's a lot of great chiropractors that like to use the excuse of patient experience or the excuse of, well, I'm not gonna take advantage of my patients. And they use that as an excuse for actually being sloppy with the care that they're delivering and the communication they're bringing to the table. So I'm gonna encourage you, don't be sloppy. Bring the best and clearest communication that you can have to every patient interaction because it's in their best interest. Because when they receive the care that they need and they don't go on to advanced interventions too early, their life is better for it. Not only do they save some bucks, obviously in terms of the expense with epidural steroid injections, massive advanced imaging and surgical intervention, somebody's paying that bill, whether they are out of their pocket or the insurance company, which drives further cost for everybody else. But beyond that, it's just not in their best interest. We know that steroids actually have a deteriorating effect on joints over time. We also know that there's a lot of sensitization that can happen and people can go hypersensitize, fear, avoidance behaviors, et cetera, when they're living on medications and pain relieving injections. So that's not to say there's not a place ever, but I'm gonna say it's probably utilized 100x too much. I just think that about 10% of the time it's warranted and about 90% of the time there's actually better, clearer options that just haven't been described to that individual. So. So I hope some of the stats on this episode, or maybe even a wake up call for you to say, hey, let me double down on my patient communication. Let me actually describe what's going on with clear ramifications. Here's what happens if you do that. Here's what happens if you don't. Here is what you need to consider. Here are the questions you need to ask. Here's how the care we deliver in our practice fits in with that. There are just limitations of matter. You see spinal stenosis, and somebody's got 2 millimeters of maybe that's a little extreme, but they have severe spinal stenosis. You know, a canal that's obstructed by 50%, they might never get back to a perfectly sized canal. But that doesn't mean that they can't find enough benefit in your practice to avoid going down the injections and surgical route. But I can tell you if you don't accurately communicate that people want a fix, and a fix isn't always what's in the cards for them, and being able to accurately communicate that is one of the most important things you can do. So in this study, a couple of the big takeaways were there's massive shortcomings to epidural steroid injections. The effectiveness was hit and miss. They only help a fraction of the patients. And if and when that, when that happens, it's really in the short term. They don't prevent surgery at all. By the way, this study found that there's no significant difference in surgery rates between ESI patients and non ESI patients. And there's risks. While there's a few major complications, there's a lot of minor complications. And ESIs have been linked to nerve damage, spinal infections, and again, rarely paralysis. In some cases, complication rates can go as high as nearly 17%, including increased pain, numbness, and headaches. And they also don't address the root cause. They don't fix disc herniations or spinal compression. They mask the inflammation temporarily, which is a really, really important thing that people need to understand. So I hope this study empowers you to have better communication with your patients, more productive conversations, and more truth and consequences. Hey. Hey. Here's what we know about ESIs. Here's what we don't know and really have Forthright, direct, clear communication with each and every one of your patients. That's what I hope you get out of this episode. Now, before we wrap up, I want to say a few words about Turncloud. Turncloud. Great. Ehr. They've stripped away everything that's not essential. They've made everyday function simpler and They've created an intuitive application where nobody needs a user manual. You can learn more and connect with their team. Do a demo. It's free. It's easy. Turncloud.com, turncloud.com, i'll drop that link down in the show. Notes thank you so much for tuning into this podcast. If you're a chiropractor, thank you for being a chiropractor. I hope you have a fantastic week in practice and I will talk to you soon.

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