Epidural steroid injections are commonly used to treat neck and back pain and radiating nerve pain (radiculopathy). Epidural steroid injections, though not bringing a cure, can result in relief for a significant amount of time, or long enough for the underlying condition to go into remission. While most agree on the benefit of epidural injections, they are often not utilized as they should be.
Epidural injections can be considered early
It is a common misconception amongst back care providers that a patient must have had a substantial course of therapy prior to considering an epidural injection. In personal injury cases, this misconception is shared by defense attorneys as well as plaintiff attorneys. Often the expected duration of conservative care before considering injections is nebulous. It is common to see an interval of 3-6 months of failed therapy before a patient is referred for an epidural injection. These patient are unfortunately left to suffer for far too long before care is escalated. Such prolonged conservative care is not supported by any spine medical society guideline.
We can rely on the alphabet soup of professional medical spinal societies for clarity on this issue. The societies (SIS, NASS and AAPMR) have all published guidelines that include the appropriate timing of spinal injections. A reasonable conservative care duration is defined as 4-6 weeks by these societies. Continuing ineffective therapy further is commonly done, yet is wasteful and needlessly prolongs a patient’s pain.
Epidural injections can be used when symptoms are severe
In patients with severe symptoms, regardless of the interval of conservative care, it is reasonable to consider epidural injection. The professional spine society guidelines clearly state that patients with severe symptoms should be considered for epidural injection at any time, or even before initiating therapy or chiropractic care. The rationale is simple to understand. Nerve and back pain can be excruciating. Patients should not be made to excruciatingly suffer through a course of therapy in such cases. Nor should they be made to take habit forming medications with strong side effects. In many cases, the patient may be able to return to or start therapy after an injection. By being able to participate in a subsequent course of therapy they may actually find themselves in remission, rather than failing due to intolerance.
Epidural injections can be used anytime there is significant disability
The professional spine societies also recommend epidural injections, regardless of conservative care or its duration, in patients with functional limitation. This means that patients that cannot care for themselves, their children, go to work, attend school or exercise should be considered for an epidural injection. The rationale here is clear; in treating back and neck pain the goal is to prevent or limit long term disability as much as possible and to foster a return to function. Considering those goals, prolonged disability does not make sense. Likewise, prolonging disability will lead to muscular weakness, deconditioning, depression and activity avoidance, all negative prognosticators in a patient with chronic pain.
Epidural injections can be used during a plateau in therapy
Lastly, epidural injections have value during therapy if the patient is beginning to plateau. Instead of continuing ineffective therapy after a plateau, the therapist or chiropractor must be empowered to recommend the injection early. Subsequent therapy may then be of greater therapeutic value and the likelihood of remission may be greater.
Conclusion
In personal injury cases the required duration of conservative care before epidural injection is nebulous and often needlessly prolonged. Medical evidence is clear and has been espoused by the relevant medical societies. Conservative care should not be prolonged greater than 4-6 weeks before considering an epidural injection. Epidural injections should be considered at any time post injury in patients with severe symptoms or a loss of function ability. Furthermore, therapists and chiropractors should be empowered to request an epidural, or other spinal injection, in patients who are no longer making gains in therapy.
Andrew Manson, MD
The views expressed are the personal views of the author and do not represent the views of The Brain, Spine and Joint Group, its managers, affiliates, partners, employees or its clients. Furthermore, the information provided by the author is not intended to be expert or legal advice.
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