More Comments About Spinal Injections (From a Cardiologist)

My comments (From John Mandrola, MD, cardiologist, who blogs at Dr John M.)

This was very surprising. I had no idea that the evidence base for spinal injections was so weak. The concept of putting anti-inflammatory drug right on the source of inflammation makes perfect sense. It hits the problem area without exposing the patient to the risk of systemic exposure to steroids or non-steroidal drugs. You would have thought comparison studies would have strongly favored local injections. But that’s the thing with evidence-based medicine: just because something makes sense, and smart doctors think it so, does not mean it is so.

Spinal injection therapy is an important topic because many of the patients referred for injections are older folks on anticoagulant drugs. Recent studies in the AF literature make it clear that interrupting anticoagulant drugs can be risky. We also know “bridging” patients with (lovenox) shots carries risk. Again we get into net clinical benefit: you don’t mind taking the risk of being off anticoagulation if the benefit is great. This review of the literature on spinal injections suggests otherwise.

The wide-angle overriding view of the matter is always the same in medicine. It’s best to avoid the need for treatment. Human disease is never 100% avoidable, but a healthy and balanced (emphasis especially on balanced) lifestyle reduces the risk of facing tough decisions. And when disease strikes, if it is safe to wait, taking a conservative approach, giving the body time to heal itself, is often just as good as having a sharp object stuck into you.

A final caveat on the JAMA review article. The authors are PhD researchers from a quality healthcare institute. They are not orthopedists. That might have resulted in a biased selection of the literature. An orthopedist/pain interventionalist perspective might have been different.



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