?"I've seen the needle and the damage done," sang Neil Young in his '60s anthem about drug abuse. Steroid injections by doctors for back pain don't compare to the destructive types of pain relief used by junkies, but as the above lyric went on, "a little bit of it in everyone." As I have previously written in this column, pain and methods used to relieve it are a huge health problem in our country.
Back pain has been with us since pre-biblical times (lumbago), and is almost ubiquitous. Eighty percent or more of Americans suffer at least one episode, and recurrent back pain is common. Not only are we paying a lot more attention to it lately, but paying a lot more for it – more than $80 billion annually. It is one reason why the narcotic Vicodin is our No. 1 prescription drug. Methods to relieve it vary tremendously, from icy cold packs, hanging boots, chiropractic and acupuncture, to full-bore erector-set metal cages screwed in to fuse your spine by well-meaning surgeons.
Epidural steroid injections fall in between.
Most back pain is due to muscle or ligament strain, and goes away. When a sudden incapacitating back pain occurs, and a doctor diagnoses true nerve irritation as its cause, epidural steroid injection relieves the symptoms quickly. But similar relief may often be obtained from oral non-steroidal anti-inflammatories like ibuprofen, and tincture of time.
Any time a sharp object penetrates the skin and approaches the spinal canal's outer sleeve – "dura" – which contains the spinal fluid and extends along exiting nerves, harm can occur. Bleeding into the canal can inflame the inner lining (meninges). A big bleed can cause pressure on the spinal cord and paralysis. Infection by viruses, bacteria and fungus can be introduced. These events are rare, but recognized. Patients are warned about the rare risks of very common "minimally invasive" procedures, yet most of those in pain will take the chance for the promise of relief.
Fungal meningitis from an epidural steroid injection is almost unheard of, and recently captured media attention partly because it was caused by allegedly poor quality control of steroid mixture by a northeastern pharmacy. Steroid injections are almost always "mixed" from vials prepared by heavily regulated manufacturers in sterile conditions. Fungal spores exist in the air, so contamination is theoretically possible, and like air traffic accidents, can still occur in the best of circumstances. Fungi are so common that many of us breathe them in and get "infected" without ever knowing.
Our immune systems respond promptly, preventing disease most of the time. Valley Fever, caused by the fungus Coccidiomycosis, is particularly common in Southern and Central California.
However, spinal fluid is somewhat sequestered from our blood stream's immune armies, thus is more vulnerable to organisms that get there and attack the meninges. Severe headache, seizures and potentially brain damage, even death can result. Bacterial meningitis is most dangerous, but fungal meningitis can be equally serious.
Fortunately, it is extremely uncommon from spinal injections. The media attention given the latest outbreak does, however, emphasize that our approach to pain, and especially back pain, may be too frivolous. Even chiropractors have rarely caused paralysis by too forceful neck manipulation.
Lumbago has long been with us and has never killed anyone.
But the needle can.
Dr. Michael Brant-Zawadzki is executive medical director of the Hoag Hospital Neurosciences Institute.
Hoag has urgent care health facilities or hospitals in Newport Beach, Costa Mesa, Irvine, Tustin, Huntington Beach, Fountain Valley, Aliso Viejo, Orange and Anaheim Hills.
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