Before You Get That Spinal Injection | Podcast Ep. 113

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. Huge thank you to everyone who is listening. Last week we surpassed 8,000 listens to last week's episode in the first week that it was released. So thank you for tuning in. And we are back with another great episode this week. This week it is all about nerve root injections, the awesome research showcasing chiropractic superior efficacy, the dangers and also how people end up getting epidural steroid injections or nerve root injections. We are loaded with research on this week's episode that is practical to your patients, your community and to your practice. So we are back with a good one. So as we talked about at the top, it is all about nerve root injections, ESIs, epidural steroid injections and the like on this week's episode. And let's set the stage first before we dive into the research on why for patients, for people in your community who are not going in to see you when they have radiculopathy, when they have radiating pain, when they ultimately have nerve root compression in the foraminal canal, whether it's caused by a disc ligament or bone compressing that nerve, if they are not going to see you, it is very likely and maybe if they are as well, but they are very likely also going to speak with or in lieu of your care because they don't know about the benefits of chiropractic, maybe going to see a medical doctor. And we know how this story unfolds, right? They go to see their medical doctor with radiculopathy. The medical doctor may prescribe an anti inflammatory and nsaid, perhaps physical therapy, something to that effect. And many times, you know, the benefit that is not reached. And then what's ordered, an mri. Right. And the MRI is ordered and what do we have here but a disc pressing on the nerve which was very obvious due to the exam and symptomatology. But the mri, quote unquote proves it. Well, guess what? The next stop for that patient is quite often it is the interventional spine doctor, the physiatrist, the pain management doctor for that nerve root injection, that epidural steroid injection. Now that steroid injection contains a few different medications and the goal of it, typically it's performed under fluoroscopy and the needle is placed essentially in the epidural space near the foraminal canal, near the site of the compression and the medication is loaded into that area and then the needle pulled out. And and of course the goal is to decrease the inflammation and stimulate the healing inside of the body. Now, what you may be surprised to hear is how often that is actually happening here in the United States. Believe it or not, 25,000 steroid injections are given each and every day. That is over 9 million per year. That is a ton of injections and a ton of cost associated with it. So I thought it would be a good opportunity to look back at the research, look, looking at chiropractic, looking at injections and seeing what it says. And first up was a study from JMPT in 2013, and it's a long title, but it's symptomatic. MRI confirmed lumbar disc herniations, comparing high velocity low amplitude spinal manipulative therapy or image guided lumbar nerve root injections, and guess what the researchers found. We touched on this study not too long ago. On a separate episode, the researchers found both of the treatment groups had significant decreases in their pain scores at one month, with a 60% reduction for the spinal manipulative therapy cohort and a 53% reduction for the nerve root injection group. Thereby, the spinal manipulation group actually had better outcomes than the nerve root injection group. Additionally, they found lumbar nerve root injections are a commonly used and accepted treatment option for these patients, whereas lumbar spinal manipulation as a treatment for disc herniation remains controversial amongst some healthcare professionals. That tells us that there is some work to do to make sure that with the ubiquitous nature of a nerve root injection, all the inherent dangers, all the inherent risk factors, and the fact that, you know, for a quote unquote conservative modality, it's pretty darn aggressive. I've seen plenty of people working in the settings that I have going in for a nerve root injection in their cervical spine, and just the thought of it turns them white, to say the least. So this is encouraging, though. I want everybody to understand that this is a symptomatic. MRI confirmed lumbar disc herniation. So that disc, the MRI was performed, the disc is pressing on the nerve, no questions asked about that. And they used two cohorts. One cohort received spinal manipulation therapy, the other cohort received those nerve injections. Both did well. But the chiropractic group, the spinal manipulation group, ultimately outperform the nerve root injection group. And that's exciting if you think about a chiropractic adjustment and the art, the science of that, and ultimately what we're hoping to achieve, the fact that something of that nature can outperform basically a ton of steroids being Dumped on a hot disk. That is really impressive with what we are able to do within chiropractic care, for sure. Additionally, I loved to look at another study that was titled Spinal Manipulation Post Epidural Injection for Lumbar and Cervical Radiculus A Retrospective Case Series. So this was interesting because to me this was a greata great study to bridge the gap. So for the patients that receive an injection, ah, are they just washed up? Are they done? What can they do? So this took a look at, well, what happens if you add the adjustment for those people who do go through that injection? What happens when you add an adjustment after. For many people, when they get the injection, they're saying, oh, I'm done with chiropractic on to get my injection. That's the next step. And I like this study because this study kind of pulled back the reins and said, hold up for a second, let's see after you get that injection, if you have an adjustment, what happens? And the researchers found something quite interesting. They found the majority of the patients showed a positive response. With only one treatment procedure, 76% of people had a positive response. Additionally, the researchers found theoretically epidural injections are proposed to address the inflammatory and central components of spinal pain, whereas spinal manipulation is proposed to address the mechanical and neural aspects of the pain syndrome. So there we go talking about two different tissues, right? From a spinal manipulation standpoint, there's a mechanical aspect of that. You're getting physical motion into the joint with many chiropractic techniques. But also the neural aspects, I loved that they touched upon that. So they're touching upon the fact that, hey, this impacts the nervous system, whether that's decompressing the nerve through the decrease in intradiscal pressure with the chiropractic adjustment, whether it's opening the foraminal canals, whether it's direct stimulation and input into our central nervous system, those are all key components to what is happening during an adjustment. Additionally, the researchers found, quote, these data suggest that spinal manipulation post epidural injection is a safe non surgical procedure to use in the treatment of a patient with a radiculopathy of spinal origin. So this was an interesting study again, because imagine, imagine this, imagine 25. We talked, we just, we talked about this just a few minutes ago. 25,000 injections being given each and every day. Imagine 25,000 more adjustments being given each and every day just on these individuals that have had an injection. So I think there's two aspects that you can look at some of the research regarding nerve root Injections, number one, if we set the stage, many people are getting them in lieu of chiropractic care. If they go through that medical system, that traditional medical system, secondarily we see that 25,000 are done per day, 9 million per year. And by the way, there's additional research showcasing a 21% increase in lumbar fracture after an injection. Let me repeat that. There's additional research showcasing a 21% increase in vertebral fracture after receiving an injection. That is also something that needs to be taken into consideration. But then we take it one step farther and when put head to head against chiropractic and against spinal manipulation, the percentage of people who significantly improved were higher in the spinal manipulation group than in the nerve root injection group. And we take it to that last terminal step and we say, even those individuals who go through an injection, does that mean they shouldn't get chiropractic care?

No.

Those individuals should also be referred into a chiropractor's office because it has been clearly shown that there is benefit, absolute benefit in terms of improvement for those individuals who receive an adjustment after that injection. And to me, that is the opportunity where this research can be used in multiple facets to start conversations not only with patients in your practice, because many patients in your practice, if they haven't been recommended injection, a family member, somebody at work, is always going to be dealing with a spine related issue, typically a radiculopathy or a sciatica, and they might not have been exposed to chiropractic care like that patient in your practice. So it's important to be able to distribute this information to the patients in your practice. Additionally, these are great conversation starters for the providers in your community. We've featured both of these pieces of research that I touched on today as monthly research for our members of the evidence based chiropractor. If that's something you're interested in, of course, check out what we have going on at the evidence based chiropractor to build relationships with other healthcare providers in your community. But this research is a great foundational aspect to showcase. Again, never when you build that relationship do you want to be pushing down what the other individual is doing. But it's about showcasing the latest and greatest that's out there, showcasing the benefits of chiropractic care and its application to the people in your community. When we're able to do that, reduce friction, reduce barriers to referral, have a nice little process behind that in a system, you start to go long way towards improving the natural health of the people in your community and exposing more and more people to chiropractic care which may not have been exposed otherwise. Many of these individuals, if they're going through that hardcore traditional medical system, if they fail the medications, they're onto those injections. And there's plenty of risks involved with that that are well beyond what the risk factors are for chiropractic care. Chiropractic care not only needs to be where it starts, as we now know we but additionally for those who do go through those injections, they absolutely should be being exposed to what we do in our offices each and every day. So I hope this was a great episode for you. I love talking about things like this each and every week. And I will be back next week with another episode of the Evidence Based Chiropractor podcast. Have a great weekend practice and I will talk to you soon.

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