Posts for category: Bulging Disc Herniation Spinal Decompression
Steroids for Sciatica: More Trouble Than They're Worth
By Deborah Pate, DC, DACBR
Use of epidural steroid injections has increased dramatically in recent years, despite the fact that studies have failed to demonstrate evidence this procedure is clinically helpful (while other studies suggest it may actually be dangerous). Considering that lack of evidence – not to mention the terrible 2012 outbreak of fungal meningitis / infections caused by contaminated vials used for epidural corticosteroid injections – it is prudent at least to take a critical look at this procedure as it relates to sciatica or pain affecting the sciatic nerve, which extends from the lower back down the back of each leg.
Small Relief, Big Potential Side Effects
In a recent meta-analysis of 23 randomized trials involving more than 2,000 patients in which epidural steroid injections were compared with placebo for sciatica, epidural steroid injections produced small, statistically insignificant short-term improvements in leg pain and disability (but not less back pain) compared to placebo. This improvement also was only over a short period of time – two weeks to three months. Beyond 12 months, there was no significant difference between groups.
Besides infection, there are other side effects associated with epidural steroid injections: bleeding, nerve damage and dural puncture. Then there are side effects associated with the steroid medication, which include the following: a transient decrease in immunity, high blood sugar, stomach ulcers, cataracts and increased risk of fracture.
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
Despite the limited benefits of epidural injections, Medicare claims show a 271 percent increase during a recent seven-year interval. Earlier Medicare claims analyses also demonstrated rapid increases in spinal injection rates. For patients with axial back pain without sciatica, there is no evidence of benefit from spinal injections; however, many injections given to patients in the Medicare population seem to be for axial back pain alone.
Charges per injection have risen 100 percent during the past decade (after inflation), and the combination of increasing rates and charges has resulted in a 629 percent increase in fees for spinal injections. Yet during this time, the Medicare population increased by only 12 percent.
It all begs the question: Why such a huge increase in the use of a procedure that has limited benefit?
Talk to your doctor of chiropractic for more information on sciatica and nondrug alternatives to your pain.
Deborah Pate, DC, DACBR, is a San Diego chiropractor specializing in radiological assessment of the spine and musculoskeletal system. In fact, she was the first chiropractor accepted into a fellowship in osteoradiology at the University of California at San Diego. Contact her with questions and comments regarding this article at [email protected] .
Truckers and others who drive for a living report more back problems than those working in any other occupation. Scientists have theorized that constant, long-term "whole-body vibration" caused by driving accelerates degeneration and herniation of the body's 23 spinal discs, leading to lower-back pain and disability.
Researchers compared 45 pairs of identical male twins who had distinctly different driving patterns throughout their lives, in which one twin had spent a lot of time driving occupationally, and the other had not. The amount of spinal disc degeneration each man suffered was determined based on readings from magnetic resonance imaging (MRI). Twins were studied because in the absence of outside factors that affect spinal degeneration, a set of twins' spines should appear fairly similar at any given point in time.
Driving time did not appear to affect spinal disc degeneration; men who drove multiple hours daily for many years were no more likely to have significant disc degeneration than their twins who did not. No other spinal disorders appeared more common in professional drivers, either, in this study appearing in The Lancet.
This is good news if you drive an 18-wheeler: Your spine may not suffer permanent damage from long hours on the road. Yet the fact remains that back pain is common in drivers. Whether the pain is caused by muscle fatigue or damage, nerve changes at the cellular level or some other factor, your doctor of chiropractic can help prevent it.
Battié MC, Videman T, et al. Occupational driving and lumbar disc degeneration: A case-control study. The Lancet 2002:360(9343), pp. 1369-1374.
Low back pain is the second leading reason for patient visits to their primary care physician; up to 90% of people suffer from it at least once in their adult lives. A recent review of related studies in the Journal of Back and Musculoskeletal Rehabilitation showed that the highest rate of back surgery in the developed world is in the U.S., with the most common surgical procedure of the lower spine being removal of disc herniation. Despite these statistics, the cause of low back pain remains elusive and there is conflicting evidence over the best form of treatment.
The authors of this literature review evaluated studies on current surgical and nonsurgical treatments for lumbar (lower back) disc herniations, to determine the short- and long-term results of each. Several different leading surgical approaches were discussed.
No statistical difference was noted in long-term outcomes between surgical and nonsurgical options for low back pain treatment. Only short-term relief of hip pain was shown as more successful through surgical intervention. (Note: Recent studies in the literature have shown comparable results between surgical and nonsurgical approaches to hip pain.) The authors recommend that aggressive rehabilitation combined with pain control may be the best treatment option for low back pain.
Surgery remains a controversial treatment option for low back pain. When you consider the costs and complications associated with surgery, almost any other option may be better. Talk to your doctor of chiropractic about nonsurgical approaches to managing low back pain, or visithttp://www.chiroweb.com/tyh/backpain.html.
Memmo PA, Nadler S, Malanga G. Lumbar disc herniations: A review of surgical and non-surgical indications and outcomes. Journal of Back and Musculoskeletal Rehabilitation 2000: 14(3), pp. 79-88.
Sciatica (or sciatic neuritis) is a set of symptoms arising from the compression or irritation of the sciatic nerves or nerve roots. It is experienced as pain in the lower back and buttocks, and sometimes in the legs and feet, and may be accompanied by tingling sensations or numbness, muscle weakness and restricted leg movement. The pain may be felt to "travel" down the leg, and is commonly felt only on one side of the body.
If you suffer from sciatica, it is important to remember the term "set of symptoms." This means that it is a description of the effects, rather than a diagnosis or exact description of what causes them. Sciatica can be caused by several different conditions. For this reason it is important to see your chiropractor to get an accurate diagnosis to determine the actual cause of the symptoms in your case. Any treatment regime or set of prescribed exercises will depend on the exact nature of this diagnosis, and cannot be generalized.
Following an examination, your chiropractor may recommend a series of chiropractic manipulations to treat the underlying structural cause of the condition, but will also prescribe a series of exercises to relieve the pain by stretching tight muscles that may be contributing to it by maintaining pressure on the sciatic nerves. Exercise is often felt by the sciatica sufferer to be counter-intuitive, because the pain can be so severe that one is tempted to take painkillers and go to bed and rest until it subsides. But in reality one of the best forms of self-treatment is exercise, either in the form of walking or gentle stretching movements. The exercise will strengthen the muscle groups that support your lower spine and back, stimulate blood flow to the area to promote healing, and cause the production of endorphins, which are natural painkillers.
Exercises to relieve the symptoms of sciatica may vary, depending on the specific cause of the condition, but a few general observations can be made about them. Most sets of sciatica exercises involve strengthening the abdominal muscles, which better support the spine and keep it properly aligned when they are strong. Sciatica exercises also often include gentle stretching of the hamstring muscles. Once the initial sciatica pain has been treated via chiropractic manipulation or other means, walking is often a great form of self-treatment, because it contributes not only to healing by promoting blood flow but also strengthens the muscles that support the lower back.
In some cases, "press ups" (lying on your stomach and pressing your upper body up with your arms, similar to the chataranga or "up dog" pose in yoga) can be beneficial. "Curl ups" (lying on your back with your knees bent and gently curling the upper body up and holding the position for a few seconds) can also strengthen the abdominal muscles, and are easier than traditional "sit ups." Leg raises (lying on your back and gently lifting first one leg and then the other and holding it for a few seconds) can also be effective. If your sciatic pain is severe, you may find these and other exercises easier to perform in water.
With all sets of exercises used to treat the symptoms of sciatica and relive its pain, there are three things to remember. First, as mentioned above, don't start a generic set of these exercises without consulting a professional to determine the exact cause of your symptoms. Second, "easy does it." Don't strain or try to attain or hold any position that is uncomfortable for you. And third, be consistent; the benefits of exercise for sciatic pain depend on doing them regularly.