The skeletal consequences of epidural steroid injections: a literature review

Krez, Alexandra; Liu, Y; Kanbour, S; Clare, Shannon; Waldman, Seth A.; Stein, Emily

doi:10.1007/s00198-021-05986-4

Cited by 10 publications

(3 citation statements)

References 55 publications

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“…Previous studies 18,19 have suggested that there is an association between epidural CSIs and decreased bone density, but these studies were small cohort studies with mixed results that did not investigate the fracture risk following epidural corticosteroid injections. A study using Medicare claims data that excluded patients younger than 65 years and patients with previous osteoporotic fracture 20 showed that large joint CSIs were associated with decreased fractures.…”

Section: Discussionmentioning

confidence: 99%

Corticosteroid Injections and Risk of Fracture

Sytsma,

Thomas,

Fischer

et al. 2024

JAMA Netw Open

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ImportanceCorticosteroid injections (CSIs) are an important tool for pain relief in many musculoskeletal conditions, but the longitudinal effects of these treatments on bone health and fracture risk are unknown.ObjectiveTo determine whether cumulative doses of corticosteroid injections are associated with higher risk of subsequent osteoporotic and nonosteoporotic fractures.Design, Setting, and ParticipantsThis cohort study included adult patients receiving any CSI from May 1, 2018, through July 1, 2022. Eligible patients resided in Olmsted County, Minnesota, and were empaneled to receive primary care within the Mayo Clinic. Cox proportional hazards regression models were used to evaluate risk of fracture based on cumulative injected corticosteroid dose.ExposureReceipt of any CSI during the study period.Main Outcomes and MeasuresThe primary outcome was risk of fracture by total triamcinolone equivalents received. Secondary outcomes consisted of risks of fracture based on triamcinolone equivalents received in subgroups of patients not at high risk for fracture and patients with osteoporosis.ResultsA total of 7197 patients were included in the study (mean [SD] age, 64.4 [14.6] years; 4435 [61.6%] women; 183 [2.5%] Black and 6667 [92.6%] White), and 346 (4.8%) had a new fracture during the study period. Of these fractures, 149 (43.1%) were considered osteoporotic. In the adjusted Cox proportional hazards regression model, there was no association of higher fracture risk based on cumulative CSI dose (adjusted hazard ratio [HR], 1.04 [95% CI, 0.96-1.11]). There was also no associated higher risk of fracture in the non–high-risk (adjusted HR, 1.11 [95% CI, 0.98-1.26]) or osteoporosis (adjusted HR, 1.01 [95% CI, 0.90-1.11]) subgroups. Age, Charleson Comorbidity Index, and previous fracture were the only factors that were associated with higher fracture risk.Conclusions and RelevanceIn this cohort study of cumulative injected corticosteroid dose and risk of subsequent fracture, no association was observed, including in patients with a preexisting diagnosis of osteoporosis. Treatment of painful conditions with CSI should not be withheld or delayed owing to concern about fracture risk.

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Section: Discussionmentioning

confidence: 99%

Corticosteroid Injections and Risk of Fracture

Sytsma,

Thomas,

Fischer

et al. 2024

JAMA Netw Open

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“…Research on suppression of the HPA axis following ESI is conclusive and shows that even a targeted delivery of steroids to the site of inflammation, using a route that does not rely on blood flow and should therefore minimize delivery to high-blood-flow organs, results in cortisol reductions and likely impairment of the immune system response to infections [7,16,18]. Further, a relationship between ESI and fracture risk has been suggested and may be related to bone loss caused by ESI exposure [19]. Given this, the benefits of epidural injections with steroids should be carefully considered so as not to subject patients to undue risks.…”

Section: Discussionmentioning

confidence: 99%

“…Even the targeted use of steroids in ESIs has been shown to result in suppression of the hypothalamic-pituitary-adrenal (HPA) axis as measured by cortisol levels, potentially reducing a host defense against infection [16][17][18]. Studies also suggest that ESIs may cause bone loss, with larger doses conferring greater risk [19].…”

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confidence: 99%

Minimally Invasive Direct Decompression for Lumbar Spinal Stenosis: Impact of Multiple Prior Epidural Steroid Injections

Pryzbylkowski¹,

Bux

Chandwani

et al. 2021

Pain Manag.

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Background: A modified algorithm for the treatment of lumbar spinal stenosis with hypertrophic ligamentum flavum using minimally-invasive lumbar decompression ( mild®)was assessed, with a focus on earlier intervention. Patients & methods: Records of 145 patients treated with mild after receiving 0–1 epidural steroid injections (ESIs) or 2+ ESIs were retrospectively reviewed. Pain assessments as measured by visual analog scale (VAS) scores were recorded at baseline and 1-week and 3-month follow-ups. Results: Improvements in VAS scores at follow-ups compared with baseline were significant in both groups. No statistically significant differences were found between the two groups. Conclusion: Multiple ESIs prior to mild showed no benefit. A modified algorithm to perform mild immediately upon diagnosis or after the failure of the first ESI is recommended.

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Botulinum Neurotoxins and Chronic Low Back Pain

Jabbari

2022

Botulinum Toxin Treatment of Pain Disorders

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The skeletal consequences of epidural steroid injections: a literature review

Cited by 10 publications

References 55 publications

Corticosteroid Injections and Risk of Fracture

Corticosteroid Injections and Risk of Fracture

Minimally Invasive Direct Decompression for Lumbar Spinal Stenosis: Impact of Multiple Prior Epidural Steroid Injections

Botulinum Neurotoxins and Chronic Low Back Pain

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