Steroid Injections: Approach With Caution

Researchers from Henry Ford Health System have found that a higher number of lumbar epidural steroid injections (LESI) is associated with an increased risk of vertebral fractures. The authors indicate that LESIs may lead to increased bone fragility over time, and while injection therapy is useful in some cases, it should be approached cautiously for patients at risk for fractures associated with osteoporosis. The retrospective study was just published in the Journal of Bone and Joint Surgery (JBJS).

“In the appropriate setting, and for the right patient, LESI provides effective symptomatic relief and improved level of function, said Shlomo Mandel, M.D., M.P.H., lead author of the JBJS study and orthopedic surgeon at Henry Ford Health System, in the June 6, 2013 news release. “Through careful screening and monitoring steroid exposure, the risk of a fracture can be minimized. As orthopaedic surgeons who specialize in spine, we know there is a role for injection therapy, but the challenge is to make sure it is administered safely and still provide long-term benefits.”

The researchers identified a total of 50, 345 patients who had medical diagnosis codes involving the spine, and from that group, a total of 3, 415 patients had received at least one LESI. From that subset, 3, 000 patients were randomly selected, and then 3, 000 patients from the non-injected group were selected 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. An increasing number of injections were associated with an increasing likelihood of fractures, and each successive injection increased the risk of spinal fracture by 21%.

“It’s important to remember that when contemplating an epidural steroid injection a physician should have a symptomatic history, physical findings and corresponding imaging of direct pressure on a single nerve, ” added Dr. Mandel. “Together with our patient, we review the benefits and risks of alternative treatments before selecting an epidural steroid injection.”

Asked about his biggest concern about how these injections have been done in the past, Dr. Mandel told OTW, “My concern is the exposure to exogenous steroids, typically because of frequent injections and lack of attention to bone density.”

As for future research, Dr. Mandel told OTW, “We need a larger prospective study to verify our findings. We are embarking on a prospective case-control project using bisphosphonates. It should shed some light on DEXA [dual-energy x-ray absorptiometry] and fractures, but the primary focus is prevention of fractures following ESI. Ultimately, if the study results are verified, guidelines like we have for other uses of exogenous steroids should be implemented.”