Intradiscal steroid injection may alleviate chronic low back pain

Intradiscal steroid injections may offer short-term pain relief in patients with discogenic low back pain and end plate Modic changes, according to results of a level 1 study published in The Spine Journal.

“If these results are independently reproducible, this study will be a major landmark in the treatment of persistent low back pain,” Eugene J. Carragee, MD, editor in chief of The Spine Journal, stated in a press release. In an accompanying editorial, Carragee noted that the results are likely to be considered controversial. “From an editorial perspective, it is strongly recommended that prior to general application of these isolated findings, a confirmatory trial should be carefully, independently and expeditiously performed,” he stated.

Three treatments

Lead study author Peng Cao, MD, PhD, of the Shanghai Institute of Traumatology and Orthopedics at Jiao Tong University in Shanghai, China, and colleagues examined 120 patients with discogenic chronic low back pain (CLBP) and MRI evidence of end plate Modic changes at a single level. The investigators allocated the patients into two groups — group A and group B — based on their types of Modic changes. Patients in both groups were randomized to receive one of the following intradiscal injections:

saline;
betamethasone dipropionate and betamethasone sodium phosphate (Diprospan, Schering-Plough Labo N.V., Belgium); and
Diprospan mixed with the herbal extract songemile.

The investigators evaluated the patients using the Oswestry Disability Index (ODI) and visual analog scale (VAS) at 3- and 6-months post injection.

According to the release, the investigators found no improvement in ODI or VAS scores at 3 or 6 months among patients in group A who were treated with saline. However, the investigators discovered significant improvements in these scores among group A patients who received either steroid treatment. A comparison of the steroid-treated groups revealed no significant differences in pain relief and functional recovery. The study showed similar results among patients in group B. In addition, the investigators found no significant difference in the improvement of VAS or ODI scores between the patients in group A vs. group B at different time points after the interventions.

In their study abstract, Cao and colleagues concluded that “intradiscal injection of corticosteroids could be a short-term, efficient alternative for discogenic low back pain patients with end plate Modic changes on MRI who were still unwilling to accept surgical operation when conservative treatment failed.”

Reactions

In an accompanying commentary, Robert D. Fraser, MBBS, MD, FRACS, urged caution in interpreting the study and noted that the results are “so disparate” from others investigating spine disorders. He also raised issue with the infection prevention protocols used in the study and safety of the treatment with long-term and repeated use. He notes that “it would it would be quite inappropriate to develop treatment protocols based on this study.”

In another commentary, Connor O’ Neill, MD, also expressed concern that unknown characteristics of the study participants — such as work status and insurance type — could impact outcomes. However, he is willing “to offer intradiscal steroids to CLBP patients with Modic changes, but only if they are psychosocially intact, do not have other serious pain disorders, are not involved in the workers’ compensation system and are bad enough that they are seriously considering spinal fusion.”

References:
Cao P, et al. Intradiscal injection therapy for degenerative chronic discogenic low back pain with end plate Modic changes. Spine J. 2011; 11(2):100-106. Epub 2010 Sep 20.
www.spine.org

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