Issue 31 / 19 August 2013

A “SWEEPING” call to withdraw public funding for all spinal steroid injections would be ill advised if it included transforaminal steroid injections — the only effective, non-surgical treatment for lumbar radicular pain, according to a leading spinal pain specialist.

Professor Nikolai Bogduk, conjoint professor at the University of Newcastle’s school of biomedical sciences and pharmacy, said cutting funding for transforaminal steroid injections would lead to increased rates of surgery for radicular pain.

He was commenting on an article in the latest MJA calling for the withdrawal of public funding for spinal steroid injections for low back pain and/or radiculopathy. (1)

Professor Ian Harris, professor of orthopaedic surgery at the University of NSW, and Professor Rachelle Buchbinder, director of the Monash department of epidemiology, wrote that the withdrawal of funding “should be considered on the basis of our knowledge of the placebo nature of this treatment, the costs, and not least, because of the likelihood of harm”.

They wrote that while the injections of steroids in and around the spine were “generally considered a safe procedure”, adverse affects ranged from headache and transient local pain to reports of paraplegia.

Professor Bogduk, who is also director of clinical research at the Newcastle Bone and Joint Institute and a practitioner of transforaminal injections for radicular pain, echoed the authors’ call to cease funding for spinal steroid injections for low back pain.

“I fully agree that there is no evidence of effectiveness for blind, epidural injection of steroids and these injections have been proven to be no more effective than a sham for the treatment of radicular pain”, he said.

However, a five-arm randomised controlled trial and systematic review had shown lumbar transforaminal steroid injections to be effective for radicular pain, said Professor Bogduk, who was a coauthor on two papers on the trial. (2, 3)

Professor Bogduk said he did not want to deny his patients the possible benefits of the procedure. “We have kept our [surgical] waiting lists down because a simple injection that takes 30 minutes to perform keeps people out of the surgeons’ hands.”

While Professor Bogduk said the treatment was not perfect — “only 54% of our patients have benefited” — the procedure offered patients a less invasive option than surgery. “No drug works for this [condition], no physical therapy, no chiropractic works, so [by banning steroid injections] you are asking for these people to go off and have surgery”, he said.

Professor Milton Cohen, senior specialist in pain medicine and rheumatology at St Vincent’s Hospital, Sydney, said there may be a role for transforaminal spinal injection for true lumbar radicular pain, and he supported continued funding for that procedure.

“Although low back pain and lumbar radicular pain can occur together, they have very different mechanisms”, he said.

However, he welcomed the “timely” call to cease funding for spinal steroid injections for low back pain.

Such “quick-fix” injections were no better than placebo for low back pain, which was better treated with lifestyle modifications, exercise programs and the judicious use of medicines.

“Whereas most cases of chronic spinal pain need a multidisciplinary approach, it’s pretty much inbred in medicine just to use one modality”, he said.

The MJA authors said Medicare Benefits Schedule figures showed that the number of procedures that included “injection into one or more facet joints under image intensification” had more than doubled in the 10 years to 2011, with 31 500 procedures performed in 2011 and 35 000 last year.

Professor Cohen said a “cynical” explanation for this growth was the financial incentive for performing such procedures. “There’s a price tag attached to it — you can earn much more for a procedure that might take 5 minutes than you do for an hour-long consultation exploring the biopsychosocial aspects of a person’s [back pain].”

1. MJA 2013; 199: 237
2. Pain Med 2010; 11: 1149-1168
3. Pain Med 2013; 14: 14-28