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The Evidence About Epidural Steroid Injections and Opioid Use for Low Back Pain

There is some concern that research doesn't support the use of epidural steroid injections (ESI) for spinal stenosis. Even more controversial is the use of opioid medications for pain from this condition.

ESI has become an intermediate step in the treatment of chronic low back pain from stenosis. When conservative care hasn't helped and surgery is too invasive, ESI may be tried. But in this two-year study of over 13,000 Veteran's Administration (VA) patients, the use of opioids went up after ESIs instead of down.

Not only that, but the number of patients to have spinal surgery after ESIs didn't change either. In fact, patients who had more than three ESIs were more likely to take opioids and still ended up having lumbar surgery.

The results of this study point out again that ESIs are being used inappropriately for lumbar pain from spinal stenosis. Opioid use does not decline after ESI. Doctors are encouraged to avoid using treatment methods for which there isn't enough evidence to support.

ESIs have been shown effective in the treatment of sciatica or radiculopathy (nerve pain from pressure on the spinal nerve roots). It's use for patients with spinal stenosis without radiculopathy hasn't been shown effective. More study is needed to find out who can benefit from ESI.

Criteria for patient selection are needed to ensure treatment success. Evidence-based guidelines are also needed for number of injections, frequency and timing of injections, and when to use repeated injections.

Janna Friedly, MD, et al. The Relationship Between Repeated Epidural Steroid Injections and Subsequent Opioid Use and Lumbar Surgery. In Archives of Physical Medicine and Rehabilitation. June 2008. Vol. 89. No. 6. Pp. 1011-1015.

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