Patients ask me all of the time: “Doc, should I just go for a cortisone injection?” With the latest (just a few days ago) announcement, the answer is definitely no (or at least, not yet). For nearly a century now, chiropractors have had this saying: “Chiropractic First, Drugs Second, Surgery Last”. I remember seeing it on a plaque on my chiropractor’s wall when I was a teenager. The FDA’s latest warning seems to add a lot more weight to that old chiropractic saying. According to the FDA, injections of corticosteroids into the epidural space may result in rare but serious adverse events including:
- Loss of Vision
Typically given to reduce inflammation (swelling) associated with painful conditions including back and neck pain, shoulder pain, knee pain, hip pain, etc., however now patients have some serious issues to contemplate prior to considering an epidural injection.
Loss of Vision Stroke Paralysis Death
That’s a lot to think about.
Chiropractic care, especially as given in most modern chiropractic office when combined with physical therapy modalities, rehab exercises, stretching and nutritional counseling, offers a significantly safer and more effective alternative. Chiropractic spinal manipulation (aka chiropractic adjustments) alone have been shown in 3 different studies spanning from 1999-2005 to be more effective than NSAIDs (non-steriodal anti-inflammatory drugs) and acupuncture.
Now I’m not saying NSAIDS or surgery aren’t necessary. In some cases they may be your only hope for relief. However, when you’re suffering from musculoskeletal pain such as back pain, neck pain or sports injuries, your first doctor of choice should be your chiropractic physician. A well trained chiropractic physician will do a thorough history, consultation and physical examination. Through that process he or she will discover the likely cause of your condition and either start you on a regimen conservative treatment or refer you to an appropriate specialist. Typically, you’ll see some improvement within the first 2 weeks and a majority of back pain conditions will resolve within 4-8 weeks. Some patients even experience immediate relief within the first 24 hours. If your condition isn’t resolving, a referral for advanced diagnostic imaging and/or a specialist (ortho or neuro) consultation will be recommended. In the case your condition does warrant a specialist referral, your condition can often be “co-managed” between the ortho/neuro and chiro.
Although I’m pretty sure it wasn’t intended, the FDA’s new warning for Epidural Injections gives new meaning to that old chiropractic saying of Chiropractic First, Drugs Second, Surgery Last.
Below is a copy of the full FDA warning on Epidural Injections and the references I mentioned above.
Todd M. Narson, DC, DACBSP
FDA Safety Announcement
[04-23-2014] The U.S. Food and Drug Administration (FDA) is warning that injection of corticosteroids into the epidural space of the spine may result in rare but serious adverse events, including loss of vision, stroke, paralysis, and death. The injections are given to treat neck and back pain, and radiating pain in the arms and legs. We are requiring the addition of a Warning to the drug labels of injectable corticosteroids to describe these risks. Patients should discuss the benefits and risks of epidural corticosteroid injections with their health care professionals, along with the benefits and risks associated with other possible treatments.
Injectable corticosteroids are commonly used to reduce swelling or inflammation. Injecting corticosteroids into the epidural space of the spine has been a widespread practice for many decades; however, the effectiveness and safety of the drugs for this use have not been established, and FDA has not approved corticosteroids for such use. We started investigating this safety issue when we became aware of medical professionals’ concerns about epidural corticosteroid injections and the risk of serious neurologic adverse events.1 This concern prompted us to review cases in the FDA Adverse Event Reporting System (FAERS) database and in the medical literature (see Data Summary).2-16
To raise awareness of the risks of epidural corticosteroid injections in the medical community, FDA’s Safe Use Initiative convened a panel of experts, including pain management experts to help define the techniques for such injections which would reduce preventable harm. The expert panel’s recommendations will be released when they are finalized.
As part of FDA’s ongoing effort to investigate this issue, we plan to convene an Advisory Committee meeting of external experts in late 2014 to discuss the benefits and risks of epidural corticosteroid injections and to determine if further FDA actions are needed.
Injectable corticosteroids include methylprednisolone, hydrocortisone, triamcinolone, betamethasone, and dexamethasone. This safety issue is unrelated to the contamination of compounded corticosteroid injection products reported in 2012.
Muller R1, Giles LG. Chronic Spinal Pain Syndromes: A Clinical Pilot Trial Comparing Acupuncture, A Nonsteroidal Anti-inflammatory Drug, and Spinal Manipulation. J Manipulative Physiol Ther 1999 (Jul); 22 (6): 376–381
Muller R1, Giles LG. , Long-term follow-up of a randomized clinical trial assessing the efficacy of medication, acupuncture, and spinal manipulation for chronic mechanical spinal pain syndromes. J Manipulative Physiol Ther. 2005 Jan;28(1):3-11.
Giles LG1, Muller R. Chronic spinal pain: a randomized clinical trial comparing medication, acupuncture, and spinal manipulation. Spine (Phila Pa 1976). 2003 Jul 15;28(14):1490-502; discussion 1502-3.
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