Spinal steroid injections often don’t help back pain
March 4, 2025
Summary: Many people get little relief from spinal steroid injections, which are quite costly.
It’s hard to treat patients with severe unremitting back pain. Their pain is real and they are clearly unable to function, but medical therapy often doesn’t help. Furthermore, anatomy often doesn’t explain pain. Some people have no back pain at all but an MRI done for another reason will show severe arthritis. Others will have disabling pain but their MRIs won’t look especially abnormal.
Many with severe back pain are treated chronically with narcotics. These offer pain relief, but about 8% will become addicted. Narcotic addiction can lead to terrible social problems, inability to work and take care of family members, and even early death.
Many with severe back pain will have surgical procedures, ranging from trimming disc material that impinges on nerves to implanting hardware to stabilize the back. Some patients unequivocally need back surgery, especially if they have cancer in their spine or have a nerve that is being pinched and is not functioning well. However, back surgery can have many adverse impacts and is very expensive. Worse still, back surgery often doesn’t bring relief. Some estimate that 60% or more of back surgeries for pain are inappropriate.
Clinicians clearly would like another approach -- and over the last two decades steroid injections of the back have become a $9 billion a year business. They are less invasive than surgery, and provide relief to some who get little relief from medications or physical therapy.
These back injections are sometimes overused. Here’s a link to a KFF Health News report from this week about a multi-state clinic that fraudulently required epidural injections to refill narcotic prescriptions, and gave some patients more than a dozen shots a month, and two patients over 500 shots each.
The American Academy of Neurology just published an evaluation of 90 randomized controlled trials of epidural steroid shots for back pain and found evidence that they were of a modest value to treat short-term pain, but provided no statistically significant benefit when treating long-term paid from radiculopathies (inflamed nerve roots) or spinal stenosis (blockage). BMJ (formerly the British Medical Journal) published an overlapping meta-analysis a few days earlier that came to similar conclusions, and recommended against epidural steroid injections for most non-cancer back pain.
Implications for employers:
Members with back pain can benefit from early evaluation and referral to physical therapy, as well as a course of anti-inflammatory drugs (like ibuprofen).
Lower back surgery should generally be a last resort and limited in most instances to those who have evidence of a neurologic complication of an impinged nerve, such as foot weakness.
Although there is much pushback against prior authorization (PA) from members and physicians, employers should expect their health plans to use PAs for epidural steroid injections and spinal surgery as these are overused and often low value procedures.
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Tomorrow: FDA says that the GLP-1 shortage is over