Correspondence: Are ESIs Still Worth It?
Dear PPM,
Regarding “Epidural Steroid Injections: Are the Risks Worth the Benefits?” (July 2019), most pain management providers, let alone referring providers and patients, may not be aware of the background surrounding the FDA stance and the initial request to ban the use of epidural steroid injections (ESIs). In July 2018, the New York Times’ Sheila Kaplan reported that, in 2013, Pfizer Pharmaceuticals requested that the FDA ban the use of Depo-Medrol in the epidural space. Neither organization made this public at the time. The article cited a review of FDA records between 2004 and March 2018 showing 2,442 serious injuries (including 154 deaths) reported with the injection of steroids into the epidural space. As injury attorneys serving Sugar Land state, more injuries go unreported. It may be reasonable to assume more injuries occurred but were not reported or attributed to ESIs.
While the FDA has not banned the use of steroids in the epidural space, many other countries have done so. Pain management societies, practitioners, and patients should be better informed about safety communications regarding ESIs, as well as warnings contained in steroid package inserts. Depo-Medrol has labeling stating: “Serious neurologic events, some resulting in death, have been reported with epidural injection of corticosteroids. Specific events reported include, but are not limited to, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, and stroke…. The safety and effectiveness of epidural administration of corticosteroids have not been established, and corticosteroids are not approved for this use.”
Multiple articles in the literature demonstrate a lack of long-term benefit from such injections beyond a few weeks, compared to less expensive, more conservative, and safer options. Match this with the costs of these procedures, and I don’t understand why these injections continue to be done since it doesn’t help the victims who got injured in a car accident. There have been catastrophic outcomes from ESIs. In my own practice, I had a patient with no prior history of low back injury nor surgery who had 7 ESIs done by another provider. Her most recent MRI showed adhesive arachnoiditis with no other injury as the likely cause. She is in constant pain. Rather than being eligible for compensation after the fall, she deserves a compensation from her previous provider for the pain she endures.
I believe the primary motivators for doing these procedures lie in habit and financial gain. In fact, I have heard from some hospital administrators that, “even though we know they don’t work, as long as we have a fee for service mode and can make money, we will allow providers to do them.” One VP from a major insurance company told me that they keep paying for ESIs “because no one wants to be the first to say no and deal with the backlash.” There are many reasonable and less risky pain management procedures that help to manage pain, but an ESI is not one of them.
– Terence K. Gray, DO
Filed under: General Problems
One of the first line of “possible” defense(s) to help just…lower the pain level, from spine surgeries was epidural injections. At least for me, they did not even “help” to manage pain. I, as many PMP’s have experienced is almost ALL, “routine” pain management treatments before I finally accepted that IF, I did nor use opiate MEDICATION, at a fairly early age in life, I could not even to begin to continue take care of my family.
I did not wish to be bound to any medication yet, “life” had to continue for my loved ones’ sakes.
I have seen and heard a great deal from the people of other states that as far as how covid-19 was to be handled from state to state is that “one size does not fit all” as far as which businesses MUST be avoided, and how we are going to once again re-open America before further damage is permanently done.
Pain management patients have repeatedly stated the same, from the start of the 2016 CDC “guideline” as far as a maximum dosage of “morphine equivalent” forced “tapering”, and physician threat of license to practice “forfeiture” to stay within the “guideline” with “opioid” prescribing as an effective therapy to manage severe pain and that is…..”one size don’t fit all”!
I had several epidurals for sciatica. One hurt like hell and he wasn’t using imaging (forget the name) to see where he was. I had the rest from my pain doc with imaging and there were a total blessing. We wound up doing an ablation and haven’t had that issue for many years now. 10+ years.
Injecting a caustic chemical is just ONE thing that can go wrong while shooting up around the spine. Just one.
I’d say they were never worth it, & for the company to request its own product be banned from use for a procedure, you know there’s gotta be problems! The only really useful phobia I have came from getting a spinal tap in the early 90s….it was such a nightmare I get cold sweats just thinking about someone sticking anything near my spinal column. This phobia caused me to walk out of doctors’ offices who’ve tried to talk me into –or extort me into– getting any ESIs (extort as in, “you can only get another pain med prescription if you get an ESI first”….I sped out of that place like my hair was on fire).
I did get conned into 6 SI joint injections, & darn near needed a general to be able to get those…which did nothing positive except positively increasing the SI joint pain i have.
These procedures are big money makers, period. As long as corporate medicine makes profits, they’re going to keep doing useless & downright destructive procedures, b/c profit is all they’re about.