Small Relief, Big Potential Side Effects
In September 2012, the CDC and the FDA began investigating a multistate outbreak of fungal meningitis and other infections among patients who had received contaminated steroid injections. The contaminated vials were tracked back to a New England compounding center in Framingham, Mass. The cases included fungal meningitis; localized spinal or paraspinal infections, including epidural abscess, basilar stroke, vertebral osteomeylitis and arachnoiditis; and infections associated with injection in a peripheral joint space such as the knee, shoulder or ankle. Ultimately, the outbreak resulted in 751 cases and 64 deaths in more than 20 states.
This last complication is certainly not emphasized in clinical circles. Therapeutic steroids may reduce pain, however the use of steroid injections seem to promote deterioration of skeletal quality, which is not surprising since other forms of steroid medication have long been associated with osteoporosis.
A retrospective study published in the Journal of Bone and Joint Surgery looked at lumbar epidural steroid injection (LESI), and the potential impact on bone fragility and vertebral fractures (spinal fractures). Researchers identified a total of 50,345 patients who had medical diagnosis codes involving the spine; within that group, a total of 3,415 patients had received at least one LESI.
Three thousand patients were randomly selected from the 3,415 injected population and 3,000 additional patients were selected from the non-injected group as a control group. There was no significant difference between the injected and non-injected groups with respect to age, sex, race, hyperthyroidism or corticosteroid use.
When incidence of vertebral fractures was assessed, researchers discovered that an increasing number of injections was associated with an increasing likelihood of fractures, and each successive injection increased the risk of spinal fracture by 21 percent. Based on this evidence, LESIs clearly exacerbate skeletal fragility. They promote deterioration of skeletal quality similar to the use of exogenous steroids, which is the leading cause of secondary osteoporosis. In fact, the rate of vertebral fracture following epidural steroid injections may be underestimated.
Both European and American guidelines, based on systemic reviews, conclude that epidural corticosteroid injections may offer temporary relief of sciatica, but do not reduce the rate of subsequent surgery. This conclusion is based on multiple randomized trials comparing epidural steroid injections with placebo injections, and monitoring of subsequent surgery rates. Facet joint injections with corticosteroids seem no more effective than saline injections.
Rising Costs, Limited Benefits
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