Kickas.org Forums Ankylosing Spondylitis General Discussion #1 AS Web Support Group risks of spinal steroid injections?

Molly? or anyone else know of any research on the long term risks of having spinal cortisone injections? I can find something on epidural steroid injections (single injection can increase risk of fractures by 29% - yikes!) but nothing on anaesthetic+cortisone injected around the edges of the spine.

Reason for asking: not eligible for anti-tnf (NHS doc doesn't agree with private diagnosis of AS), can't take NSAIDs, pain doc has offered repeated multiple injections around the spine (5 or 6 at a time, anaesthetic+cortisone, as often as is required for pain management) but at age 57 with another 25 years of this to look forward to, and a mother whose spine has completely crumbled away from osteoporosis and has had two extremely nasty fractures, I really don't want to take too many risks on this. the trial spinal injection I had recently worked a whole lot better on my mobility that oral steroids did. Second questions: what evidence is there for the safety of repeated short courses of oral steroid vs spinal injections? (for the record, I'm talking about maximum two week course, maximum 20 mg prednisolone a day, maximum four times a year).

Oh Oh cemc - For myself, I would not go there. Too much of an 'open sesame'? See :-
http://aolbroadband.search.aol.co.uk/aol...id%20injections

and take your pick !

http://www.webmd.com/back-pain/news/2013...l-fracture-risk

"I want to be careful not to imply that people shouldn't get these injections," said Mandel, an orthopedic physician with the Henry Ford Health System in Detroit.
The findings are based on medical records from 3,000 Henry Ford patients who had steroid injections for spine-related pain, and another 3,000 who got other treatments. They were 66 years old, on average.
Overall, about 150 patients were later diagnosed with a vertebral fracture, Mandel said. Vertebral fractures are cracks in small bones of the spine, and in an older adult with low bone mass they can happen without any major trauma.
On average, Mandel's team found, steroid patients were at greater risk of a vertebral fracture -- with the risk climbing 21 percent with each round of injections.
The findings do not prove that the injections themselves caused the fractures, said Dr. Andrew Schoenfeld, who wrote a commentary published with the study.
But the results raise an important potential risk that needs to be weighed against the benefits. "This brings to light something that should be part of doctor-patient discussions," said Schoenfeld, who is based at William Beaumont Army Medical Center in El Paso, Texas.
He cautioned, however, that the findings may apply only to certain patients -- namely, older adults with waning bone mass. "We don't know if this would apply to elderly people with normal bone mass," Schoenfeld said.
Complicating matters, steroid injections seem to benefit only certain types of spine-related pain. The "best medical evidence" that they work is for cases of leg pain caused by a herniated disc compressing a nerve, Schoenfeld said.
Herniated discs are a common source of pain for younger people. "If you're 35 and have a herniated disc, these findings don't really apply to you at all," Schoenfeld said.
When it comes to spinal stenosis -- the most common source of problems for older adults -- steroid injections can aid leg pain and cramping. But there is "very sparse" evidence that the injections ease pain concentrated in the low back, Schoenfeld said.
If that's the primary problem for an older adult, the potential side effect of a vertebral fracture could outweigh the small chance of benefit.

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Epidural Steroid Injections Long Term Side Effects - ...
www.healthcentral.com/.../epidural-steroid-injections-long-term... - Similar to Epidural Steroid Injections Long Term Side Effects - ...
Find out all about epidural steroid injections long term side effects, including how it works, common side ... Driving After Spinal Injections Can Prove Dangerous.

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Complications and pitfalls of lumbar interlaminar and ...
www.ncbi.nlm.nih.gov/pmc/articles/PMC2682416/ - Similar to Complications and pitfalls of lumbar interlaminar and ...
Keywords: Back pain, Spinal injection, Epidural steroid injection, Lumbar interlaminar epidural, Lumbar transforaminal epidural, Complications, Safety, Risk ...
Spinal Steroid Injections Have History of Trouble - NYTimes.com
www.nytimes.com/.../before-meningitis-outbreak-injections-tied-to-risks.html
11 Oct 2012 ... Injections of steroids near the spine have been linked to other rare but devastating complications, including nerve damage, paralysis and ...
An In-Depth Investigation: Epidural Steroid Injections - ...
www.doctoroz.com/.../depth-investigation-epidural-steroid-injec... - Similar to An In-Depth Investigation: Epidural Steroid Injections - ...
6 May 2013 ... Epidural steroid injections have become the most common .... direct injury to the spine, chronic compression of spinal nerves, or complications ...



Leave it with you cemc, but...handle with care. Am gutted thaty you 'still' can't get an acceptance of the AS 'pvt' diagnosis - shakes head. Perhaps go see a Dr in London or Manchester or... at their NHS hospital - there are several you could choose from : Keat; Stone; etc etc. Sure hope you can sort -

Take care that spine hon -

Thanks for those links. I note that most of them are for epidural spinal injections,and thats not what I'm getting - I'm just getting the injection beside the spine. I'd really like to find one or two articles about non-epidural injections so I can really argue the case. If I can show that the risks of these non-epidural injections are high then it might help me argue for a another NHS opinion on the AS, which if it confirmed the private diagnosis would be likely to then get me eligible for anti-tnfs, as the NHS doc said that he is confident I meet all the other criteria other than radiological evidence. Mind, I don't know how many other opinions I need - I already got an MSK specialist radiologist look at my first two SI xrays and review the SI MRI and he indicated there was suspicion of AS and advised further imaging (which I couldn't get the NHS to do), then the third SI xray got read by the private rheumatologist with a different MSK radiologist and confirmed AS. So thats three different specialists all thinking AS, and yet the NHS rheumatologist keeps on saying that there is absolutely no evidence of inflammation and its all mechanical.

Molly, can you PM me some other specialists I could consider? Though, having just been made redundant from the only job around here that I could physically even contemplate, money is too tight for any more private consultations.

Hi CEMC,
I wonder about the same things you do too.
I had the SI joint injections once and it helped a little bit for a couple weeks.

Have you thought of radio frequency ablation , where they burn off the nerve in the si joint or back? I had that done too and it helped about 30% I think, its hard to know for me, because my joint pain moves around. Some days its in my knee, the next my sternum, then the next day my si joints ????

I hope you find some relief .Take care!!

Leave it with me cemc - know there are papers and there is one in the research forum here on KA to the effect that not really worth doing as they don't last very long, like from two to four weeks at most and only cut part of the pain. Was in a EULAR paper I believe.

Have a doctor's appointment then a heavy day ahead. Hopefully can get to it this evening otherwise will have to be after C'mas.

Dr Stone also has an NHS position, a hospital in London...!

I don't really know; I get them pretty infrequently, and more to either see if that is the problem and/or in kind of emergency situations when things are worse than usual. I don't want to make it routine.

If I were in your shoes, I still be pushing to find a rheumatologist that will treat you with medications that prevent the inflammatory flares systemically.

If I could only have one thing of all the things I'm doing, it would be the Humira. Then my chiro. Everything else pales in comparison to those two things, including the shots.

I have taken many many of them. Of course, I don't know what the future holds regarding them. I had reached a point of having gone through so many different drugs that I had run out of much in the way of choices. For me, it was a matter of choosing quality of life.

We each have to make these treatment decisions based on what we think will work for us.

Since my surgery last June, my pain is much much lessened but if I reach the point where I think I need them again then I won't hesitate.

One thing is my age. If I were very young, I might have a different view point even though I started the steroids very young.

Blessings and Merry Christmas.

Hello cemc,
I was able to get treatment for AS in the London area at Whipps Cross Hospital's Early Inflammatory Back Pain Service, by contacting their physiotherapist
Rebecca.Adshead@bartshealth.nhs.uk
and they accepted by diagnosis of AS from my French doctors.

cemc : A few sort-of useful links, and :-

During the injection, an X-ray machine (fluoroscope) is often used to guide placement of the needle

http://www.columbianeurosurgery.org/spec...roid-injection/
In addition to risks from the injection, there are also potential side effects from the steroid medication. These side effects tend to be rare, though they become more common when steroids are taken daily for several months. These risks and side effects may include:

A transient decrease in immunity
High blood sugar
Stomach ulcers
Severe arthritis of the hips (avascular necrosis)
Cataracts
Transient flushing
Increased appetite

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http://www.mayoclinic.org/tests-procedures/cortisone-shots/basics/risks/prc-20014455
Cortisone shots carry a risk of complications, such as:

Death of nearby bone (osteonecrosis)
Joint infection
Nerve damage
Thinning of skin and soft tissue around the injection site
Temporary flare of pain and inflammation in the joint
Tendon weakening or rupture
Thinning of nearby bone (osteoporosis)
Whitening or lightening of the skin around the injection site
Limits on the number of cortisone shots

There's some concern that repeated use of cortisone shots may cause deterioration of the cartilage within a joint. For this reason, doctors typically limit the number of cortisone shots into a joint. In general, cortisone injections should not be given more often than every six weeks and usually not more than three or four times a year

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http://www.spine-health.com/treatment/injections/epidural-steroid-injections-risks-and-side-effects
Epidural Steroid Injections Potential Risks
As with all invasive medical procedures, there are potential risks associated with lumbar epidural steroid injections. In addition to temporary numbness of the bowels and bladder, the most common potential risks and complications include:

Infection. Severe infections are rare, occurring in 0.1% to 0.01% of injections.
Dural puncture ("wet tap"). A dural puncture occurs in 0.5% of injections. It may cause a post-dural puncture headache (also called a spinal headache) that usually improves within a few days. Although infrequent, a blood patch may be necessary to alleviate the headache. A blood patch is a simple, quick procedure that involves obtaining a small amount of blood from a patient from an arm vein and immediately injecting it into the epidural space to allow it to clot around the spinal sac and stop the leak.
Bleeding. Bleeding is a rare complication and is more common for patients with underlying bleeding disorders.
Nerve damage. While extremely rare, nerve damage can occur from direct trauma from the needle, or from infection or bleeding.
Lumbar Epidural Steroid Injection Side Effects
In addition to risks from the injection, there are also potential side effects from the steroid medication itself. These tend to be rare and much less prevalent than the side effects from oral steroids. Nonetheless, reported side effects from epidural steroid injections include:

Localized increase in pain
Non-positional headaches resolving within 24 hours
Facial flushing
Anxiety
Sleeplessness
Fever the night of injection
High blood sugar
A transient decrease in immunity because of the suppressive effect of the steroid
Stomach ulcers
Severe arthritis of the hips (avascular necrosis)
Cataracts

Forum -
http://www.spine-health.com/forum/treatment/spinal-injections

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http://www.healthcommunities.com/back-pain/steroid-injections-benefits-risks.shtml
(Well reasoned approach - worth reading.)

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http://www.webmd.com/back-pain/epidural-steroid-injections-for-lumbar-spinal-stenosis
Side Effects

Epidural steroid injections (ESIs) should be used with caution. This treatment may only relieve symptoms for a short time, and the long-term effects are not well studied. Most experts recommend that no more than 3 ESIs be given in a 12-month period. Doctors usually wait at least 2 months between injections. And they do not usually give more than 3 or 4 injections into one area.

If side effects occur, they are usually minor and may include:

About 2 to 4 days of back pain and tenderness where the injection was given.
Feeling sick to your stomach and sometimes vomiting.
Dizziness.
Headache.
More serious side effects are very rare but can include bleeding, infection, nerve root injury, and meningitis.

People who have an increased risk for infections, such as those with diabetes or those with immune system problems, may be at a higher risk for problems from ESIs. People with mental health disorders may also have a higher risk for problems from this treatment.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

What To Think About

Epidural steroid injections (ESIs) should not be given if there is any sign of infection.

ESIs may only relieve symptoms for a short time. The long-term effects are not well studied. Talk with your doctor about the risks related to the number of ESIs you expect to get.

If lumbar spinal stenosis is caused by a congenitally (from birth) small spinal column, rather than by osteoarthritis or another degenerative bone or joint condition, corticosteroid injections may increase symptoms, such as pain and numbness.

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http://updates.pain-topics.org/2012/01/harms-of-epidural-steroid-injections.html
In an excellent review of the literature comparing interlaminar versus transforaminal injections, Christopher Huston [2009] observes that wide variations in success rates with the interlaminar approach have fostered increased interest in transforaminal epidural injections, since these deliver targeted solution closer to the nerves generating pain. Huston claims that this approach is more effective than interlaminar or caudal injections and fluoroscopy-guided transforaminal injections have “emerged as the preferred approach to deliver steroids to the epidural space.”

However, because this approach also sends the needle so near to vital arteries, other practitioners believe the dangers of transforaminal approaches are too high. In the Bloomberg article, Manchikanti states that the transforaminal approach for cervical injections, in particular, has no role when considering the risks and that the organizatin he leads, ASIPP, has stopped teaching the technique.

Adverse effects of epidural injections have been poorly assessed in much of the research literature and are quite variable. Huston [2009] notes a long list of potential complications, including: dural puncture, nausea and vomiting, vasovagal reaction, facial flushing, fever, nerve root injury, pneumocephalus, epidural hematoma, subdural hematoma, Cushing’s syndrome, paresthesias, hypotension, non-specific headache, transient amnesia, increased pain, infection, respiratory insufficiency, transient blindness, epidural abscess, paralysis, spinal cord injury, cerebellar infarction, stroke, and death. He also notes that rates of the more transient or minor complications have variably ranged up to about 23%; although, there can be delayed reactions and complications days or weeks after the procedures that often go unreported in research studies. Incidence rates of catastrophic neurologic complications and death, while believed to be relatively rare, are unknown for certain.



There is a heck of a lot more of the same - but if going ahead, ensure that they use 'guided' needle...!

That's a really good question...I have to take them because without them there are times I can't walk I get them in the SI joints also...I guess it's like everything else you weigh the risks then decide what is best for you. Sounds like you have gotten some good responses and Molly always comes up with links...I am on the biologic Actemra right now which is helping it's made my quality of life go from about 25% to 75% absolutely worth it for me
Lisa