Review of “A Retrospective Analysis of Vertebral Body Fractures Following Epidural Steroid Injections The Journal of Bone & Joint Surgery, Volume 95, Issue 11 (2013, Jun 05;95(11):961–964)”

Epidural steroid injections are considered the standard of care in low back pain. This research study seeks to expose the risks to epidural steroid injections. Current available research supports short term benefit of ESI’s for pain.

Another option of treatment is chiropractic flexion-distraction adjustments.

Over the long term their is “no significant difference in back pain between injected and non-injected groups.” “Each successive injection increased the risk of fracture by a factor of 1.21 (95% confidence interval).” This research seeks to look at the available evidence regarding the long-term efficacy of epidural steroid injections.

Lumbar epidural steroid injections (LESIs) are frequently prescribed for the treatment of radiculopathy or neurogenic claudication arising from compression of spinal nerves. These injections have side effects including diminished bone strength.

The retrospective study used 50,345 patients with ICD-9 (International Classification of Diseases, Ninth Revision) diagnosis codes involving the spine who had received at least one LESI. A study population of 3000 was selected and a control group was found.

In this analysis an increasing number of injections was associated with an increasing likelihood of fractures. “Each successive injection increased the risk of fracture by a factor of 1.21 (95% confidence interval, 1.08 to 1.30) after adjustment for covariates (p = 0.003).”

Paraspinal injections has been shown to elevate blood glucose levels (and suppression of endogenous cortisol production). Patients with neurogenic compression who underwent translaminar LESI were the only ones selected.

“The findings suggest that LESIs, like other forms of exogenous steroid administration, may lead to increased bone fragility.” This risk may be larger than was previously thought. If we assume that LESI is associated with increased bone fragility then we may need to look at additional treatment options after nonsteroidal anti-inflammatory drugs and topical modalities have not reduced symptoms. This is because exogenous use of steroids is the leading cause of secondary osteoporosis.

The modest increase in the risk of vertebral fracture with epidural steroid injections for symptoms of sciatica and spinal stenosis is especially important in the elderly who are at an increased risk for skeletal fragility. This is because vertebral fractures are associated with substantial morbidity and mortality1. The osteoporotic effect of steroids must be addressed when these interventions are clinically recommended.


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