As I have written in past articles that there is a time and place for surgical intervention for low back pain. The same is true for interventional pain management like epidural spinal injections.
I currently have an older male patient who has a pretty textbook case of lateral recess stenosis (for those of you less familiar with medical terminology, it means that arthritis in his spine has begun to choke off the nerves of his lower back as they exit the spine, leading to pain down the leg, especially with standing or walking). Generally, our office does exceedingly well with these types of patients using a technique called Flexion Distraction. But there are a very small percentage that do not respond.
This recent patient, after 3 treatments, is fitting into this category. He has not noted any difference despite the treatment we have done. The likelihood of him responding goes down precipitously from here. On the last visit, we discussed the potential for epidural spinal injections if he does not respond within one more visit. In our office, this patient is a clear candidate for spinal injections.
However, this treatment pathway is not altogether typical. I have seen patients treated with interventional pain management (trigger point injections, epidural spinal injections, etc..) that wer not good candidates and did not respond well.
But here’s where things get interesting.
I remember a meeting several years back with one of the nation’s larger health insurance carrier. On a conference call, one of the big wigs mentioned that merely having an MRI or an epidural spinal injection would increase that patient’s likelihood of having spinal surgery.
At first thought, this seemed crazy. I mean..how could merely having an MRI increase your risk of having surgery?? Or even an epidural spinal injection?
Regardless of how much it does or does not make sense, the relationship is clear and has been documented in multiple studies. Personally, I have always felt that, once patients are sent to an MRI that they shouldn’t have had, they are told that something tangible is wrong with his or her back. Pay no attention to whether or not that disc bulge or arthritis is causing your pain–there is something wrong!
This starts the patient on a trajectory based on a potentially false set of information. In today’s version of mainstream medicine, far too often this is the only trajectory the patient will ever experience. If someone is convinced that there is an actual problem found on an MRI that needs to get fixed, the thought of an epidural or surgery naturally follows.
As it turns out, I may not have been too far off. This particular study helps give some additional insight into the relationship between epidural spinal injections and spinal surgery.
Patients were asked about his or her likelihood to undergo spinal fusion surgery when faced with 3 potential complications (nerve damage, wound infection, and nonunion of the fusion) and educated on the likelihood of experiencing symptom relief. For each scenario, the patient indicated whether he or she would or would not undergo spinal fusion.
Here’s what they found:
- Patients were more likely to accept spinal fusion with lower risks and better outcomes (no big shocker here…).
- Greater low back pain intensity made patients more accepting of higher surgical complication risks.
- Greater leg pain intensity had a weak correlation to opting for spinal fusion.
- One of the strongest factors of undergoing surgery despite a higher risk of complications was a history of spinal injections (almost twice as likely to opt for surgery) (Tweet this).
To sum it up, if someone had a spinal injection at some point, he or she was twice as likely to still say yes to a surgical fusion despite a higher risk of complications. This is a pretty darn strong difference. Pain severity, age, education status, duration of pain symptoms….all of this was less important then whether or not someone had spinal injections.