Steroid injections – they kinda sort work some of the time…

Thanks to Steve Feinberg, M.D. for forwarding a study on epidural steroid injections.

Here’s the brief findings:

Epidural corticosteroid injections for radiculopathy [pain radiating from the spine] were associated with immediate reductions in pain and function. However, benefits were small and not sustained, and there was no effect on long-term surgery risk. Limited evidence suggested no effectiveness for spinal stenosis.

In a follow up, Dr Feinberg provided this:

I have a 68 year old physician colleague who is highly functional both at work and recreationally. He has rather severe cervical and lumbar degenerative disease and stenosis and a very damaged left knee. He has undergone a number of injections (more than would be allowed via EBM) and takes Vicodin 10/325 3 times a day and uses some oxycodone for “breakthrough” pain. He lives on 5 acres and takes care of 10 horses and the property. He told me that working on his property makes him hurt more but that he is not going to stop being active just because of the pain/discomfort. He has been on the same opioid dose for years and has no obvious negative side-effects. He told me that without his medications, he would have trouble practicing as a physician and he certainly would not be active on his property.

Dr Feinberg closed with:

“I ask myself everyday if so little works, what are we left with to treat?”

A colleague of the good doctor provided this as well: “Could it be that Osler’s words from over a century ago continue to direct our best efforts? “The job of the physician is to entertain the patient while nature takes its course?”

I bring this to your attention as a reminder to all that medicine can be as much art as science, that we often don’t know what works for whom why and when and how.

However, make no mistake that treatment can and should be guided by evidence-based clinical guidelines. There should be a way to navigate the care management and authorization process to allow Dr Feinberg’s colleague access to the treatment that works for him, just as there should be a high standard for approval of “non-standard” care that puts patients at risk.

I’d close with this note – there is far too much use of procedures similar to ESIs, and far too little challenging of that use.

What does this mean for you?

Promote EBM, and ensure your authorization processes work well.

 

5 thoughts on “Steroid injections – they kinda sort work some of the time…

  1. What is more important, helping patients or saving money? Does the insurance industry need to make more profit on the backs of patients in pain? Are stock dividends more important? Are all people who don’t respond to EBM Liars, or do they just not fit into the Insurance industry’s business model?

  2. “One size fits all” does not work for nature, science, or medicine. That is the error of “Guidelines.” The failure of medicine is not to apply scientific approaches. The idea of procedure-oriented treatments [known as the BioMedical Model of Pain] has been called outmoded and reductionist. The International Association for Pain states that it must be replaced by the more accurate and scientifically valid Biopsychosocial Model of Pain. Finding scientific methods to assess the needs of the individual is the cost effective key to success for more patients and society

    • Dr Ross – I’m not sure I fully understand your comment. If I read it literally, I respectfully disagree with your characterization of Guidelines as an “error” and ” procedure-oriented treatments [known as the BioMedical Model of Pain]”.

      Guidelines are just that – guidelines. There are processes and procedures to provide treatment outside Guidelines in most jurisdictions for those patients whose profiles/symptoms/co-morbidities are outside the norm. In fact, there is far too much care (see over-prescribing of opioids) that is OUTSIDE accepted guidelines. This addresses the “no one treatment works for all” issue you describe.

      While I agree that the traditional drug-centric pain treatment approach is demonstrably failing most patients and the biopsychosocial model does offer more promise, there is not a one-to-one definition. That is, the issue of procedure-centric treatment goes far beyond pain management. Perhaps you are referring to the ESI issue; in this case, the guidelines I’ve seen do not support the rampant over-use of this procedure.

      Perhaps I misunderstand your comment.

  3. My mother law was bettie ruth ford who died / was murdered by doctors OL matthews who
    Was he primary doctor . He was so excited about the profits in cortisone injection that he allowed her to take excessive shots with out even checking on her labs. He allowed her to sit in Harper for about eight hours. Then phone Harper hospital and told them to discharge her. She was brought to Harper not walking , and she left there not walking . A couple hours later she could not even lift her hands. Infection was running rampant In her body, we. Called 911 on the way to St. John hospital October/ 08/ 2008 on the way to the hospital she coded / on October / 16/ 2008 she died St. John hospital said she died of infection septisis semia . My brother law knew attorney name Kenneth that found out how she died and waited to the statutes was about to end and came into the. Case to hide her death . When my wife found out about we tried to put him on the complaint the appeal court refused . Now her case is In the supreme Court. . The name of the case is Brenda ford white versus OL matthews ETL. If they had of address the problem it would have been a lesser crime, but now it is murder they should be dealing with, we must find a middle ground to treat people if they want it and not to put ourselves in the position of profit over people safety, . But how to we monitor integrity ant ethics when political and economical matters are involved. I say treat them just like anyone but common people go to jail but doctor and lawyers are just fines. What kind of world do we live in today

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