Unnecessary Spinal Injections?
We are failing to effectively treat back pain in this country despite spending almost as much per year on treatments for back pain as we do to treat cancer. Over the last 10 years spending for the treatment of acute and chronic back pain has increased by 65% to an amazing 86 Billion per year (that’s 54 brand new 82 thousand seat Jets/Giants stadiums each year). And despite such massive spending a 2008 study in JAMA didn’t find any improvements in outcomes such as pain relief and functional ability.
One of the more common treatments for back pain is the injection of a steroid formulation into the space between the outer membrane covering the spinal cord – the dura – and the spinal bones. The pain relief theory behind these epidural injections is that back pain is caused by localized inflammation involving spinal nerve roots, spinal disks, or other structural components of the spine as a result of protruding disks or degenerative changes. The corticosteroids in these injections are supposed to reduce this inflammation and thus reduce the pain.
One source estimates that almost 9 million epidural injections were given in 2010. The use of this treatment in Medicare beneficiaries alone increased 160% from 2000 to 2010 and the cost is not insignificant.
Medicare and Medicaid guidelines call for paying between $200 and $600 per injection, depending on whether it is given in a doctor’s office, an outpatient facility or a hospital. The Centers for Medicare and Medicaid Services said it paid providers $106.4 million for 252,288 injections last year, an average of $421.74 each.
And this cost is for the injections alone. It does not even include the price of complex spinal imaging such as MRI scans and initial and follow up office visits associated with this type of care.
What’s even more surprising is that the data for the long term effectiveness of epidural steroid injections for the treatment of chronic lower back pain – the most common type of back pain – is not very good. According to the American Society of Interventional Pain Physicians (ASIPP) and the North American Spine Society (NASS), the evidence that epidural spinal injections provide effective relief of chronic lower back pain beyond 6-12 weeks is limited to poor. The Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology found similar results as well as no evidence that these injections result in improved functional ability or that they change the eventual need for back surgery and as such they recommend against the routine use of epidural steroid injections for the treatment of chronic lower back pain.
Because of the theoretical risk of infection and adverse effects of the steroids, the current standard of care is to limit the use of these injections to three or less per year. Given their limited effectiveness in the long term relief from chronic back pain and the fact that these injections have not been shown to reduce the long term use of chronic pain medications, they do not seem to be a particularly reasonably therapy choice.
Yet, despite a dearth of evidence for their effectiveness physicians continue to utilize this treatment in ever increasing numbers including for patients in whom they are not indicated. The best evidence for the limited effectiveness of epidural spinal injections is for use in patients who suffer from radicular pain (back pain that spreads down the back of one leg) from a protruding spinal disk but an audit of 433 injections of Medicare patients from 2007 found that a third didn’t meet Medicare requirements including medical necessity or sufficient documentation.
Physicians certainly would not regularly utilize a very expensive antibiotic that has been proven to be only marginally effective on long term cure rates. But unlike serious bacterial infections, chronic pain is a purely subjective symptom that is difficult to measure and does not directly result in death. As such, physicians who treat chronic pain are given a wide leeway for their treatments, free from the constraints of evidence based medicine and oversight of appropriate resource utilization.
Epidural steroid injection treatments also benefit from the dysfunctional method in which Medicare reimbursements are heavily skewed towards invasive treatments without regard for effectiveness or outcomes. In our current system, physicians get paid far more for an invasive procedure than they do for managing a complex condition with medications and conservative therapy. A logical system for the treatment of chronic pain would be a pyramid construct where the vast majority of patients are treated conservatively while steroid injections and surgery would be at the very apex for rare and/or extreme cases. But our system is more like a cylinder where patients are just as likely to get conservative treatment as to get more advanced and invasive therapy.
Part of the problem involves patients with chronic pain. Americans in particular tend to prefer invasive treatments under the belief that since surgery and other invasive procedures for many conditions such as gall bladder or heart disease is very effective then the same logic must apply to the treatment of chronic pain. But it doesn’t. Conservative treatment such as a guided physical therapy program has been shown to be effective for the long term reduction in chronic back pain. But because of the prevalence of advanced imaging and invasive therapy, physical therapy is probably drastically under-utilized as a treatment for this condition.
Another part of the problem is that we really don’t understand what causes chronic pain and how to treat it. Obviously the poor effectiveness of steroid injections means that chronic back pain is not as simple as localized inflammation affecting pain fibers in the spinal cord and nerve roots. As a purely subjective symptom, pain is highly susceptible to modulation. For example, take someone with chronic lower back pain and drop a brick on their foot. Suddenly they don’t have back pain anymore. Most of us have experienced this phenomena. The trick is to find out how to modulate chronic pain without the use of addictive medications or broken feet.
Invasive procedures also carry the risk of complications and adverse outcomes. Recently a contaminated batch of an estimated 17,676 vials of the steroid methylprednisolone acetate used for epidural injections resulted in at least 91 cases of fungal meningitis and several deaths. Though the complication rate of steroid injections is low and the risk of a contaminated vial is exceedingly rare, that anyone would die as a result of an invasive treatment that is not very effective for it’s intended purpose is a tragedy. Maybe the increased attention and scrutiny of epidural steroid injections brought about by this outbreak will lead to policy and funding changes in the way we reimburse for and treat chronic back pain in this country.