If you're thinking of getting an injection for back pain, you might want to think again. A panel of experts has examined the practice, found serious issues with its use – including financial gain – and issued strong recommendations to avoid it.
Back pain is one of the most common ailments reported worldwide. In 2020, pain in the lower back alone affected 619 million people around the world, with estimates saying that number will grow to 843 million by 2050 thanks to an expanding and ageing population. Lower back pain is also the single leading cause of disability worldwide. In Brazil, for example, lower back pain was responsible for 100 days of missed work per year per person between 2012 and 2016. In the United States the estimated cost of lower back and neck pain was US$134 billion in 2016, making it the biggest source of healthcare spending in the country.
That being said, a new study has revealed that one of the most common ways to treat the condition – the use of spinal injections – might be one of the least effective. And the reasons behind its use might have more to do with financial gain than patient wellbeing.
Writing in the British Medical Association's journal, The BMJ, a panel of experts says that interventions including epidural steroid injections and nerve blocks are no more effective at helping eliminate back pain than placebo injections.
The researchers reached their conclusion as part of the BMJ's Rapid Recommendations program, an initiative to sift through studies to make informed recommendations for patient care.
For this study they conducted a meta-analysis of 81 trials involving a total of nearly 8,000 participants. They looked at the differences between sham injections and medically prescribed injections based on a range of criteria including pain relief, sleep quality, opioid use, social and physical functioning, ability to work, and more.
The review encompassed the use of 13 different procedures including several different methods of injecting steroids and anesthetics such as epidurally or intramuscularly, as well as the use of a procedure known as radiofrequency ablation, which uses heat to destroy parts of nerve tissue to block its pain-signaling ability.
After the review, the panel found that none of the procedures had "high certainty evidence for any procedure or combination of procedures" either on pain in specific areas of the spine (axial pain) or pain that radiates down the legs or arms (radicular pain). As a result, they issued a strong recommendation against the use of these interventions, a decision that takes a consensus of at least 80% of the panel.
Ulterior motives?
Despite these findings, the researchers say the use of injections to treat back pain is on the rise.
As an example, they report that between 1994 and 2001 in the US, lumbar epidural steroid injections increased by 271%, and the use of facet injections in which local anesthetics are injected along the spine, went up 231% for lower back pain. Additionally, "facet joint or sacroiliac joint interventions in US Medicare recipients increased from approximately 425 000 in 2000 to 2.2 million interventions in 2013," write the researchers.
One of the possible reasons for the disconnect between the use of injections for back pain and their actual efficacy might be confirmation bias.
"An analysis of 17 review articles on epidural steroid injections for spine pain found inconsistent conclusions, and that positive results were three times more likely when the review was authored by an interventionist (9 of 10 positive; 90%) versus a non-interventionist (2 of 7 positive; 29%)," says the report. In other words, if you were someone prescribing injections to treat back pain, and you conducted a study to look at its efficacy, your study showed it worked 90% of the time. If you weren't, your study was a lot less likely to support the treatment.
Another reason for the dissonance may be financial.
"For example, in 2017-18, the average billings among 106 physicians working at pain clinics providing nerve blocks in Ontario, Canada, was CAD 724,183/year (about US$510,000)," writes the panel. "Concurrently, a 2016/2017 survey of 777 Canadian physicians who performed interventional procedures for chronic spine pain found that only 37% believed their colleagues practiced in accordance with the current best evidence."
Furthermore, says the team, there is a major skew in the physicians using the treatments, with the top 10% of interventionists in the US performing nine times more procedures per patient compared with the bottom 10%.
"Yes, there are many pressures on providers to keep doing spine injections, and on payers to keep paying for them, but the more the evidence fails to support the widespread use of these injections, the less inclined healthcare systems will be to fund them," says the University of Washington in Seattle's Jane C. Ballantyne, who was not on the study panel.
"This Rapid Recommendation cluster will not be the last word on spine injections for chronic back pain, but it adds to a growing sense that chronic pain management needs a major rethink that is perhaps best achieved by a better balance of reimbursements between procedural and non-procedural chronic pain treatments," she concludes.
Source: The BMJ
