ESI's for Stenosis...

[101N]

http://journals.lww.com/spinejourna...Steroid_Injections_Are_Associated_With.2.aspx

Abstract
Study Design. Subgroup analysis of prospective, randomized database from the Spine Patient Outcomes Research Trial (SPORT)

Objective. The hypothesis of this study was that patients who received ESI during initial treatment as part of SPORT (The Spine Patient Outcomes Research Trial) would have improved clinical outcome and a lower rate of crossover to surgery than patients who did not receive ESI.

Summary of Background Data. The use of epidural steroid injection (ESI) in patients with lumbar spinal stenosis is common, although there is little evidence in the literature to demonstrate its long-term benefi t in the treatment of lumbar stenosis.

Methods. Patients with lumbar spinal stenosis who received ESI within the first 3 months of enrollment in SPORT (ESI) were compared with patients who did not receive epidural injections during the first 3 months of the study (no-ESI).

Results. There were 69 ESI patients and 207 no-ESI patients. There were no significant differences in demographic factors, baseline clinical outcome scores, or operative details between the groups, although there was a significant increase in baseline preference for nonsurgical treatment among ESI patients (ESI 62% vs. no-ESI 33%, P < 0.001). There was an average 26-minute increase in operative time and an increased length of stay by 0.9 days among the ESI patients who ultimately underwent surgical treatment. Averaged over 4 years, there was significantly less improvement in 36-Item Short Form Health Survey (SF-36) Physical Function among surgically treated ESI patients (ESI 14.8 vs. no-ESI 22.5, P = 0.025). In addition, there was significantly less improvement among the nonsurgically treated patients in SF-36 Body Pain (ESI 7.3 vs. no-ESI 16.7, P = 0.007) and SF-36 Physical Function (ESI 5.5 vs. no-ESI 15.2, P = 0.009). Of the patients assigned to the surgical treatment group, there was a significantly increased crossover to nonsurgical treatment among patients who received an ESI (ESI 33% vs. no-ESI 11%, P = 0.012). Of the patients assigned to the nonoperative treatment group, there was a significantly increased crossover to surgical treatment in the ESI patients (ESI 58% vs. no-ESI 32%, P = 0.003).

Conclusion. Despite equivalent baseline status, ESIs were associated with significantly less improvement at 4 years among all patients with spinal stenosis in SPORT. Furthermore, ESIs were associated with longer duration of surgery and longer hospital stay. There was no improvement in outcome with ESI whether patients were treated surgically or nonsurgically.

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[Ducttape]

basically, its an add-on study that shows what spine surgeons want to show - that surgery is the only way to go.

they have already posted studies about the benefits of spine surgery for spinal stenosis, spondylolisthesis, disc herniation, spondylosis, muscle sprain, sciatica, etc.

 

[hyperalgesia]

I'm not sure it's optimal to design a study in the context of a surgical procedure.
Also, they should have blinded the surgeons to the group they were treating. Increased instrumentation in ESI pts? Huh??

The hypothesis going into the study seems to be (and correct me if I'm wrong) that pts who receive a series of ESIs are clinically improved 4 years later. That's a pretty dumb hypothesis.

 

[Ducttape]

I'm not sure it's optimal to design a study in the context of a surgical procedure.
Also, they should have blinded the surgeons to the group they were treating. Increased instrumentation in ESI pts? Huh??

The hypothesis going into the study seems to be (and correct me if I'm wrong) that pts who receive a series of ESIs are clinically improved 4 years later. That's a pretty dumb hypothesis.

yes, their "null" hypothesis was that ESIs were helpful, so the side study they did was to disprove their hypothesis that ESIs were helpful. kind of backward than most studies, where i usually see the "null" hypothesis is that there is no benefit.

additionally, they state it is beneficial that the study was injection v. non-injection, not injection v. placebo.

 

[Aether2000]

Oh, giveem a break, they are just dumb surgeons and don't understand pharmacokinetics of drugs....no wonder they come up with ridiculous conclusions

 

[Ducttape]

Oh, giveem a break, they are just dumb surgeons and don't understand pharmacokinetics of drugs....no wonder they come up with ridiculous conclusions

Problem is, they were using to justify their surgeries, which seems okay, but will now be using this study to justify not doing other less conservative treatments. At least they admit it runs counter to most other studies about ESI.

 

[clubdeac]

This is ******ed... I can't even make out what they were doing. Patients assigned to surgery who received esi had a higher likelihood of crossing over to the non surgery group when compared to patients who didn't get an esi. Duh. That supports Esi's. And what does doing or not doing an esi prior to surgery have to do with the outcome of the surgery 4 yrs later? It has no bearing in the outcome and shouldn't. This is stupid

 

[Ducttape]

This is ******ed... I can't even make out what they were doing. Patients assigned to surgery who received esi had a higher likelihood of crossing over to the non surgery group when compared to patients who didn't get an esi. Duh. That supports Esi's. And what does doing or not doing an esi prior to surgery have to do with the outcome of the surgery 4 yrs later? It has no bearing in the outcome and shouldn't. This is stupid

Their contention is that it didn't help, which would rule out their null biased hypothesis. They then took it a step further and said it made the later surgery worse by making the surgery longer, which seems to go beyond their initial intent...

Some insurance company may seize on this study to deny ESI in the future. Of course, the study does not address "salvage" ESI done after 3 mo. conservative tx.

 

[onewithpain]

But wait, there's more!
http://www.henryford.com/body.cfm?id=46335&action=detail&ref=1761

 

[SSdoc33]

'ESI' and 'stenosis' are very general terms. It's a shame that we can't do better to define those terms and more specific about actual interventions.

 

[Ducttape]

OTOH - Manchikanti "replied" before the study came out:

The effectiveness of lumbar interlaminar epidural injections in managing chronic low back and lower extremity pain.

and does anyone do this? ive thought about it for FBSS, but the article does not state that these are FBSS patients...

Assessment of effectiveness of percutaneous adhesiolysis in managing chronic low back pain secondary to lumbar central spinal canal stenosis.


Finally, there appears to be fairly good quality evidence that SCS is better than reoperation...

 

[epidural man]

Assessment of effectiveness of percutaneous adhesiolysis in managing chronic low back pain secondary to lumbar central spinal canal stenosis.

How bad does a paper have to be if it can't even be published in your own journal!?

(Seriously, why didn't he publish this in his journal???)

 

[101N]

http://www.ncbi.nlm.nih.gov/pubmed/22458343

BMC Musculoskelet Disord. 2012 Mar 29;13:48. doi: 10.1186/1471-2474-13-48.
Study protocol- Lumbar Epidural steroid injections for Spinal Stenosis (LESS): a double-blind randomized controlled trial of epidural steroid injections for lumbar spinal stenosis among older adults.
Friedly JL, Bresnahan BW, Comstock B, Turner JA, Deyo RA, Sullivan SD, Heagerty P, Bauer Z, Nedeljkovic SS, Avins AL, Nerenz D, Jarvik JG.
Source
Comparative Effectiveness, Cost and Outcomes Research Center, University of Washington, Seattle, USA. [email protected]
Abstract
BACKGROUND:
Lumbar spinal stenosis is one of the most common causes of low back pain among older adults and can cause significant disability. Despite its prevalence, treatment of spinal stenosis symptoms remains controversial. Epidural steroid injections are used with increasing frequency as a less invasive, potentially safer, and more cost-effective treatment than surgery. However, there is a lack of data to judge the effectiveness and safety of epidural steroid injections for spinal stenosis. We describe our prospective, double-blind, randomized controlled trial that tests the hypothesis that epidural injections with steroids plus local anesthetic are more effective than epidural injections of local anesthetic alone in improving pain and function among older adults with lumbar spinal stenosis.
METHODS:
We will recruit up to 400 patients with lumbar central canal spinal stenosis from at least 9 clinical sites over 2 years. Patients with spinal instability who require surgical fusion, a history of prior lumbar surgery, or prior epidural steroid injection within the past 6 months are excluded. Participants are randomly assigned to receive either ESI with local anesthetic or the control intervention (epidural injections with local anesthetic alone). Subjects receive up to 2 injections prior to the primary endpoint at 6 weeks, at which time they may choose to crossover to the other intervention.Participants complete validated, standardized measures of pain, functional disability, and health-related quality of life at baseline and at 3 weeks, 6 weeks, and 3, 6, and 12 months after randomization. The primary outcomes are Roland-Morris Disability Questionnaire and a numerical rating scale measure of pain intensity at 6 weeks. In order to better understand their safety, we also measure cortisol, HbA1c, fasting blood glucose, weight, and blood pressure at baseline, and at 3 and 6 weeks post-injection. We also obtain data on resource utilization and costs to assess cost-effectiveness of epidural steroid injection.
DISCUSSION:
This study is the first multi-center, double-blind RCT to evaluate the effectiveness of epidural steroid injections in improving pain and function among older adults with lumbar spinal stenosis. The study will also yield data on the safety and cost-effectiveness of this procedure for older adults.

 

[mid|ine]

I think we can actually all agree, ESIs do not lead to any long term benefit at 4 years for stenosis. However, a majority of patients will get significant (>50% reduction in pain) benefit for 2-4 months after an ESI. ESIs are much safer and less expensive then surgery. And ESIs help many patients return to a functional status. I have many patients that return every 3-4 months for ESIs for stenosis and continue to do well.

 

[101N]

I However, for the minority of patients will get significant (>50% reduction in pain) benefit for 2-4 months after an ESI. ESIs are much safer and less expensive then surgery.

Fixed it.

 

[clubdeac]

I think we can actually all agree, ESIs do not lead to any long term benefit at 4 years for stenosis. However, a majority of patients will get significant (>50% reduction in pain) benefit for 2-4 months after an ESI. ESIs are much safer and less expensive then surgery. And ESIs help many patients return to a functional status. I have many patients that return every 3-4 months for ESIs for stenosis and continue to do well.

Ditto!

 

[bedrock]

Fixed it.

The majority of my patients with stenosis do well for at least 3 months.

Maybe you're not doing something right.....

 

[101N]

The majority of my patients with stenosis do well for at least 3 months.

Maybe you're not doing something right.....

Show me the proof.

 

[SSdoc33]

Show me the proof.

Anything by Riew.


What else u gonna do for the LOL who can't walk?

 

[101N]

Anything by Riew.


What else u gonna do for the LOL who can't walk?

Decompress her. I'll bet we perform at least 50 % more ESI's for LSS than we should.
There is a more reliable and efficacious alternative for most people. If you look closely
At patient outcomes post-ESI it isn't a very effective therapy. Most patients just don't get
3mo of functional improvement. It's magical thinking to suggest they do.

 

[Dr. Ice]

Decompress her. I'll bet we perform at least 50 % more ESI's for LSS than we should.
There is a more reliable and efficacious alternative for most people. If you look closely
At patient outcomes post-ESI it isn't a very effective therapy. Most patients just don't get
3mo of functional improvement. It's magical thinking to suggest they do.

This should be moved to private. The hawks are watching....

 

[Dr. Ice]

Decompress her. I'll bet we perform at least 50 % more ESI's for LSS than we should.
There is a more reliable and efficacious alternative for most people. If you look closely
At patient outcomes post-ESI it isn't a very effective therapy. Most patients just don't get
3mo of functional improvement. It's magical thinking to suggest they do.

Multifactorial stenosis will ultimately need fusion from a surgical perspective. Now, I know you dont think that fusion is a good long term plan...why not do the ESI and get em functional for as long as possible. Maybe get lucky and stave off decompression and fusion??

 

[lobelsteve]

Multifactorial stenosis will ultimately need fusion from a surgical perspective. Now, I know you dont think that fusion is a good long term plan...why not do the ESI and get em functional for as long as possible. Maybe get lucky and stave off decompression and fusion??

You meant decompression without fusion?

 

[101N]

You meant decompression without fusion?

Oui. Definitely too many fusions when a decompression alone would suffice.

 

[101N]

Multifactorial stenosis will ultimately need fusion from a surgical perspective. Now, I know you dont think that fusion is a good long term plan...why not do the ESI and get em functional for as long as possible. Maybe get lucky and stave off decompression and fusion??

You have been sold a bill of goods. There no rational way - aside from financial incentives - to explain the growing trend in fusions for stenosis . Aside from spondy's it's just medical waste.

 

[DOctorJay]

Anything by Riew.


What else u gonna do for the LOL who can't walk?

MILD if the culprit is the ligament?

 

[pmrmd]

You have been sold a bill of goods. There no rational way - aside from financial incentives - to explain the growing trend in fusions for stenosis . Aside from spondy's it's just medical waste.

+1

Surgeons want to do the fusion for the axial pain component and the lami for the stenosis. The axial pain component can be treated, IMHO.

 

[Pacman27]

In my small amount of experience. I personally would rather have ESI's every few months vs going to surgery as long as I do not have any weakness associated with it.

I think most of us know that ESI's are to hasten recovery in some. Overall, I think it comes down to careful patient selection for any procedure we do.

 

[SSdoc33]

For some reason, dr. Ice thinks that the surgical treatment for stenosis is fusion. That is just ludicrous.

Definitive treatment for stenosis is surgery. Sure. If the patients are young enough, healthy enough, and want it, then yeah. There is a very wide range of patients that do not fit those criteria.

 

[bedrock]

Decompress her. I'll bet we perform at least 50 % more ESI's for LSS than we should.
There is a more reliable and efficacious alternative for most people. If you look closely
At patient outcomes post-ESI it isn't a very effective therapy. Most patients just don't get
3mo of functional improvement. It's magical thinking to suggest they do.

Again, I promise I'm not trying to attack you personally, but I just don't see the disconnect here regarding your patients with stenosis that don't do well after your epidurals.

I haven't published a study on my personal patients, but I see relief of >3months in at least 75% of my patients with neurogenic claudication.
Some of those patients need two epidurals sometimes and/or a bilateral TFESI or two level unilateral TFESI (with particulate steroid), but they do quite well.

I have a large group of medicare patients who consistently obtain >80% relief and >80% improvement in function (which I measure) with 1-2 epidurals every 3-6 months.

I will say that a decent number of these patients need two epidurals every 6 months, rather than 1 every 3 months to obtain >80% relief.
I've also seen some patients do much better with ILESI vs TFESI, or caudal with catheter.....but they get better.

If they don't improve, then I refer to surgeons who don't fuse most of the patients they decompress

 

[101N]

Again, I promise I'm not trying to attack you personally, but I just don't see the disconnect here regarding why your stenotic patients with don't do well after your epidurals.

I haven't published a study on my personal patients, but I see relief of >3months in at least 75% of my patients with neurogenic claudication.
Some of those patients need two epidurals sometimes and/or a bilateral TFESI or two level unilateral TFESI (with particulate steroid), but they do quite well.

I have a large group of medicare patients who consistently obtain >80% relief and >80% improvement in function (which I measure) with 1-2 epidurals every 3-6 months.

I will say that a decent number of these patients need two epidurals every 6 months, rather than 1 every 3 months to obtain >80% relief.
I've also seen some patients do much better with ILESI vs TFESI, or caudal with catheter.....but they get better.

We will see. Been doing this while, and I think I know how this ends.