Study Suggests Steroid Injections Exacerbate Spinal Stenosis Outcomes, but Research Holes Keep Option in Doctor Arsenal

Though original results of the five-year Spine Patient Outcomes Research Trial (SPORT) determined surgically-treated spinal stenosis (SpS) patients showed significant advantage in body pain and physical function after two years than their nonsurgically-treated counterparts, a subgroup analysis published in the Feb. 15 issue of Spine found patients who received epidural steroid injections (ESI) in the SPORT study exhibited a worse outcome through four years' follow-up, regardless of surgical or nonsurgical treatment.

Though original results of the five-year Spine Patient Outcomes Research Trial (SPORT) determined surgically-treated spinal stenosis (SpS) patients showed significant advantage in body pain and physical function after two years than their nonsurgically-treated counterparts, a subgroup analysis published in the Feb. 15 issue of Spine found patients who received epidural steroid injections (ESI) in the SPORT study exhibited a worse outcome through four years’ follow-up, regardless of surgical or nonsurgical treatment.

Kris Radcliff, MD, of the Rothman Institute at Thomas Jefferson University Hospital, in Philadelphia, Pa., colleagues and physicians at Dartmouth Medical Center, in Dartmouth, N.H., compared outcomes for 69 SpS patients who received ESI during their first three months of enrollment in SPORT with 207 SpS patients who did not. Based on their analysis, the researchers concluded ESI led to significantly less improvement in pain and function at four years whether the patients were treated surgically or nonsurgically. However, among SPORT patients assigned to undergo surgical treatment, the physicians discovered evidence of more complications in surgery for those previously treated with ESI, as operative procedures took approximately 30 minutes longer and hospital stays were about one day longer for those patients.

“Despite the common treatment practice of incorporating one or more ESI in the initial nonoperative management of patients with spinal stenosis, these results suggest that ESI is associated with worse outcome in the treatment of spinal stenosis,” Radcliff and his co-authors write. “Our data suggest that an intrinsic property of the ESI is likely causative because this effect was seen in both surgical and nonsurgical patients, (though) further prospective research is necessary to understand the indications and results of this common procedure.”

While the subgroup analysis results suggest ESI treatment is associated with less improvement in body pain and physical function among surgical and nonsurgical SpS patients, Adam Pearson, MD, MS, of the Dartmouth-Hitchcock Medical Center, in Lebanon, N.H., notes in a Feb. 15 post on Spine’s blog that there were no significant outcome differences in measures of disability and back discomfort among patients who had received ESI during SPORT. Additionally, Pearson writes “this study was not a (randomized clinical trial) comparing outcomes between patients randomized to ESI and no ESI, so the results could be affected by unmeasured confounders. In other words, there could be factors associated with choosing an ESI that are responsible for the worse outcomes, rather than the ESI itself.”

“The role of ESI in SpS has been controversial, with no evidence clearly demonstrating effectiveness in this population. Despite the lack of evidence for this procedure, it is generally viewed as first line treatment for SpS, especially for patients who prefer to avoid surgery,” Pearson writes. “While this study is not going to mean the end of ESI for SpS patients, it adds to a flawed but extensive literature suggesting that ESI is not very effective for this condition. There is very little evidence that any non-operative treatment is effective for SpS, so ESI will likely remain in our armamentarium as an option for patients who wish to avoid surgery or who have medical comorbidities that make surgery risky.”

Full subgroup analysis text

Full SPORT spinal stenoisis text

Spine blog post