It is common practice for injury patients to have multiple epidural injections. In fact, it is so common that most concerned parties, plaintiff attorneys and treating physicians alike, have accepted the eventuality that the patient will undergo a series (usually 3) of epidural injections. Not only is this far from the truth, it is potentially deleterious to the patient and the case.

Epidural injections: The guidelines

Epidural injections are indicated for the presence of radiculopathy, or nerve pain, associated with MRI pathology in the lumbar spine. It is also widely accepted, and reported, that epidural injections are effective in treating back pain due to disc herniation. The alphabet soup of every major spinal medical society (SIS, ASIPP, AAPMR, NASS, etc.) has weighed in and established guidelines for the performance of epidural injections.

Present in all guidelines is that after performing an epidural injection the patient should be re-evaluated after an appropriate time. The time interval is not defined but regarded as long enough to see if there is some lasting benefit from the injection. Many physicians wait at least 4 weeks. The multiple medical society guidelines state that if the injection has been beneficial, but has started to wear off, it is appropriate to repeat the injection to reinstate benefit.  The corollary is that the injection is not repeated if it has not shown a substantive benefit. Substantive is prone to interpretation, but most doctors want to see more than several weeks of pain relief. If there has been benefit, the injection may be repeated once. No more than 3 injections should be performed in a 6-month period, and then only to reinstate substantive benefit.

Series of epidural injections

The routine practice of performing 3 injections, 2 weeks apart, is not supported by medical evidence and contradicts treatment guidelines. This is because if the first injection doesn’t work, the second injection is unlikely to work. Similarly, If the first injection worked, there is no incremental benefit in repeating it. The patient is merely being robbed of the opportunity to have a subsequent injection to reinstate benefit after the first one has worn off. Worse yet, the cumulative result of so many steroid injections in such a short period of time can lead to problems.  This includes suppression of the body’s ability to produce essential hormones, thinning of bones (osteoporosis), immunosuppression and disfigurement from a redistribution of body fat.

There are also implications for the personal injury case. Firstly, Unnecessarily performing a procedure brings no added value, yet results in thousands of dollars in needless additional expenditures. This will needlessly deprive the claimant of an award that can be used for future necessary care. Secondly, a defense expert or attorney may rightly claim that the subsequent injections were unnecessary, excluding the associated costs from any settlement and forcing a settlement based on smaller costs.

Unnecessarily repeating epidural injections also has implications for medical care.  Definitive apex recommendations, like surgery, are delayed.  This is nonsensical.  If the surgical indication for discectomy is met after a failed epidural injection, it is not anymore met after a failed second or third injection.

Conclusions

Epidural injections are effective in the treatment of the injured patient. However, they should be used appropriately. A series of epidural injections is not supported by any medical evidence. Unnecessary injections raise costs, can have side effects, can cause the defense to question care and can delay necessary care.

Martin Arrowsmith, 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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