Epidural Steroid Injections Are Associated With Less Improvement in Patients With Lumbar Spinal Stenosis

Abstract

Summary of Background Data Lumbar spinal stenosis is a common incidental finding among adults over the age of 60, The use of ESI in these patients is common, although there is little evidence in the literature to demonstrate the long-term benefit of ESI in the treatment of lumbar stenosis. Objective The hypothesis of this study was that patients who received epidural steroid injections (ESI) during initial treatment as part of the Spine Patient Outcomes Research Trial (SPORT) would have improved clinical outcomes and a lower rate of crossover to surgery compared to patients who did not receive ESI. Methods Patients with lumbar spinal stenosis who received epidural steroid injections within the first three months of enrollment in SPORT (ESI) were compared to patients who did not receive epidural injections during the first three months of the study (No ESI). Results There were 69 ESI patients and 207 No-ESI patients. There were no significant differences in demographic factors, baseline clinical outcome scores, or operative details although there was a significant increase in baseline preference for nonsurgical treatment among ESI patients (62% vs. 33%, p <0.001). There was an average 26 minute increase in operative time and an increased length of stay by 0.9 days among the ESI patients who ultimately underwent surgical treatment. Averaged over four years, there was significantly less improvement in SF36 PF among surgically treated ESI patients (ESI 14.8 vs. No-ESI 22.5, p=0.025). In addition, there was also significantly less improvement among the nonsurgically treated patients in SF36 BP (ESI 7.3 vs. No-ESI 16.7, p=0.007) and SF36 PF (ESI 5.5 vs. No-ESI 15.2, p=0.009). Of the patients assigned to surgical treatment, there was a significantly increased crossover to nonsurgical treatment among patients who received an ESI (ESI 33% vs. No ESI 11%, p=0.012). Of the patients assigned to non-operative treatment, there was a significantly increased crossover to surgical treatment in the ESI patients (ESI 58% vs. No ESI 32%, p=0.003). Conclusion Despite equivalent baseline status, ESI were associated with significantly less improvement at four years among all patients with spinal stenosis in SPORT. Furthermore, ESI were associated with longer duration of surgery and longer hospital stay. There was no improvement in outcome with ESI whether patients were treated surgically or nonsurgically.

Preoperative epidural spinal injections increase the risk of surgical wound complications but do not affect overall complication risk or patient-perceived outcomes

“…Similar to our findings, a study by Radcliff et al found no difference in baseline SF-36 outcomes scores between injected and noninjected patients. 12 Postoperatively (averaged over a 4-year period), they found patients treated with injections had nearly an 8-point lower magnitude of improvement in SF-36 physical function scores than noninjected patients. Although we found that the postoperative SF-12 PCS score was lower in the injection group, the group also had lower preoperative PCS scores and the actual improvement in PCS scores did not differ between the groups.…”

The Effect of Epidural Steroid Injection on Postoperative Outcome in Patients From the Lumbar Spinal Stenosis Outcome Study

“…Radcliff et al 10 reported that ESIs were associated with signifi cantly less improvement during 4 years' follow-up in patients treated either surgically or nonoperatively for lumbar spinal stenosis. In several studies, detrimental complications after epidural steroid injections have been reported, such as infections, bleeding and spinal cord injuries, although the incidence is very low.…”

“…A second limitation of our study was the shorter follow-up of just 6 months compared with 4 years in the SPORT. However, Radcliff et al 10 reported the differences in outcome at regular time-points during 4-year period, and according to the fi gure in their publication, the negative effect of ESIs on improvement in both the surgical and nonoperative groups was already noticeable after 6 months. A third limitation of the present study is the small number of patients in the nonoperative treatment group, limiting the precision of the results and potentially leading to a type II error (failure to reject a false null hypothesis).…”

“…However, a recent study evaluating clinical outcome after ESIs reported disquieting results: those patients treated with ESIs were less likely to benefi t from subsequent surgical or nonoperative treatment compared with patients who had not received ESIs. 10 In both groups of patients, treated surgically or nonoperatively, pain and physical function were worse in the subsequent 4-year follow-up period in patients who had undergone ESIs in the 3 months prior to treatment. This result was unexpected, and the study was criticized for various reasons, 11 , 12 including the failure to use a conditionspecifi c instrument such as the Spinal Stenosis Measure (SSM) as the primary outcome measure.…”

Surgical vs. Conservative Treatment for Degenerative Lumbar Stenosis

“…The surgical indication for lumbar stenosis is still controversial, and the criteria are not always clear. More recent studies [4][5][6][7][8] question the real efficacy of the procedure, and whether the results significantly improve the quality of life of the patients. It is difficult to compare the improvement of patients objectively following surgery, given that even after considerable decompressions, some patients continue to present symptoms.…”