A Krez1, Y Liu1, S Kanbour1, S Clare1, S Waldman2, E M Stein3. 1. Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA. 2. Department of Anesthesiology, Critical Care, & Pain Management, Hospital for Special Surgery, New York, NY, USA. 3. Endocrinology and Metabolic Bone Disease Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA. steine@hss.edu.
Abstract
This literature review summarized studies that evaluated the effects of epidural steroid injections (ESIs) on skeletal health. While evidence is limited, studies suggest that ESIs may cause bone loss. Better understanding of these skeletal consequences will help foster strategies to prevent bone loss in the growing population of patients receiving ESIs. PURPOSE: Approximately nine million epidural steroid injections (ESIs) are administered annually in the United States to treat radicular back pain. ESIs often provide pain relief and functional improvement. While the overall incidence of adverse events resulting from ESIs is low, their effects on the skeleton are poorly understood. This is an important consideration given the profound skeletal impact of other forms of glucocorticoids. METHODS: Ovid MEDLINE and PubMed search results since 2010, including older, frequently referenced publications were reviewed. RESULTS: Systemic absorption of glucocorticoids occurs after ESI, which can cause hyperglycemia and endogenous cortisol suppression. The majority of studies investigating the skeletal effects of ESIs are retrospective. Several have found a relationship between low areal bone mineral density (BMD) by dual-energy x-ray absorptiometry and ESI exposure, but this finding is not uniform. Recently a dose-response relationship between ESI exposure and low spine volumetric BMD by computed tomography has been reported. Few studies have investigated the relationship between ESI exposure and fracture risk. Results of these studies are conflicting, and most have not been adequately powered to detect fracture outcomes. CONCLUSIONS: While evidence is limited, studies suggest that ESIs may cause bone loss, particularly those investigating volumetric BMD. Larger doses appear to confer greater risk. Further prospective studies are needed to investigate the relationship between ESI and fracture risk. Better understanding of the skeletal consequences of ESIs will help foster strategies to prevent bone loss in the growing population of patients receiving this treatment.
This literature review summarized studies that evaluated the effects of epidural steroid injections (ESIs) on skeletal health. While evidence is limited, studies suggest that ESIs may cause bone loss. Better understanding of these skeletal consequences will help foster strategies to prevent bone loss in the growing population of patients receiving ESIs. PURPOSE: Approximately nine million epidural steroid injections (ESIs) are administered annually in the United States to treat radicular back pain. ESIs often provide pain relief and functional improvement. While the overall incidence of adverse events resulting from ESIs is low, their effects on the skeleton are poorly understood. This is an important consideration given the profound skeletal impact of other forms of glucocorticoids. METHODS: Ovid MEDLINE and PubMed search results since 2010, including older, frequently referenced publications were reviewed. RESULTS: Systemic absorption of glucocorticoids occurs after ESI, which can cause hyperglycemia and endogenous cortisol suppression. The majority of studies investigating the skeletal effects of ESIs are retrospective. Several have found a relationship between low areal bone mineral density (BMD) by dual-energy x-ray absorptiometry and ESI exposure, but this finding is not uniform. Recently a dose-response relationship between ESI exposure and low spine volumetric BMD by computed tomography has been reported. Few studies have investigated the relationship between ESI exposure and fracture risk. Results of these studies are conflicting, and most have not been adequately powered to detect fracture outcomes. CONCLUSIONS: While evidence is limited, studies suggest that ESIs may cause bone loss, particularly those investigating volumetric BMD. Larger doses appear to confer greater risk. Further prospective studies are needed to investigate the relationship between ESI and fracture risk. Better understanding of the skeletal consequences of ESIs will help foster strategies to prevent bone loss in the growing population of patients receiving this treatment.
Entities:
Keywords:
Bone loss; Epidural steroid injection; Fracture; Radicular low back pain
Authors: Roger Chou; Robin Hashimoto; Janna Friedly; Rongwei Fu; Christina Bougatsos; Tracy Dana; Sean D Sullivan; Jeffrey Jarvik Journal: Ann Intern Med Date: 2015-09-01 Impact factor: 25.391
Authors: Christopher J L Murray; Charles Atkinson; Kavi Bhalla; Gretchen Birbeck; Roy Burstein; David Chou; Robert Dellavalle; Goodarz Danaei; Majid Ezzati; A Fahimi; D Flaxman; Sherine Gabriel; Emmanuela Gakidou; Nicholas Kassebaum; Shahab Khatibzadeh; Stephen Lim; Steven E Lipshultz; Stephanie London; Michael F MacIntyre; A H Mokdad; A Moran; Andrew E Moran; Dariush Mozaffarian; Tasha Murphy; Moshen Naghavi; C Pope; Thomas Roberts; Joshua Salomon; David C Schwebel; Saeid Shahraz; David A Sleet; Jerry Abraham; Mohammed K Ali; Charles Atkinson; David H Bartels; Kavi Bhalla; Gretchen Birbeck; Roy Burstein; Honglei Chen; Michael H Criqui; Eric L Ding; E Ray Dorsey; Beth E Ebel; Majid Ezzati; S Flaxman; A D Flaxman; Diego Gonzalez-Medina; Bridget Grant; Holly Hagan; Howard Hoffman; Nicholas Kassebaum; Shahab Khatibzadeh; Janet L Leasher; John Lin; Steven E Lipshultz; Rafael Lozano; Yuan Lu; Leslie Mallinger; Mary M McDermott; Renata Micha; Ted R Miller; A A Mokdad; A H Mokdad; Dariush Mozaffarian; Mohsen Naghavi; K M Venkat Narayan; Saad B Omer; Pamela M Pelizzari; David Phillips; Dharani Ranganathan; Frederick P Rivara; Thomas Roberts; Uchechukwu Sampson; Ella Sanman; Amir Sapkota; David C Schwebel; Saeid Sharaz; Rupak Shivakoti; Gitanjali M Singh; David Singh; Mohammad Tavakkoli; Jeffrey A Towbin; James D Wilkinson; Azadeh Zabetian; Jerry Abraham; Mohammad K Ali; Miriam Alvardo; Charles Atkinson; Larry M Baddour; Emelia J Benjamin; Kavi Bhalla; Gretchen Birbeck; Ian Bolliger; Roy Burstein; Emily Carnahan; David Chou; Sumeet S Chugh; Aaron Cohen; K Ellicott Colson; Leslie T Cooper; William Couser; Michael H Criqui; Kaustubh C Dabhadkar; Robert P Dellavalle; Daniel Dicker; E Ray Dorsey; Herbert Duber; Beth E Ebel; Rebecca E Engell; Majid Ezzati; David T Felson; Mariel M Finucane; Seth Flaxman; A D Flaxman; Thomas Fleming; Mohammad H Forouzanfar; Greg Freedman; Michael K Freeman; Emmanuela Gakidou; Richard F Gillum; Diego Gonzalez-Medina; Richard Gosselin; Hialy R Gutierrez; Holly Hagan; Rasmus Havmoeller; Howard Hoffman; Kathryn H Jacobsen; Spencer L James; Rashmi Jasrasaria; Sudha Jayarman; Nicole Johns; Nicholas Kassebaum; Shahab Khatibzadeh; Qing Lan; Janet L Leasher; Stephen Lim; Steven E Lipshultz; Stephanie London; Rafael Lozano; Yuan Lu; Leslie Mallinger; Michele Meltzer; George A Mensah; Catherine Michaud; Ted R Miller; Charles Mock; Terrie E Moffitt; A A Mokdad; A H Mokdad; A Moran; Mohsen Naghavi; K M Venkat Narayan; Robert G Nelson; Casey Olives; Saad B Omer; Katrina Ortblad; Bart Ostro; Pamela M Pelizzari; David Phillips; Murugesan Raju; Homie Razavi; Beate Ritz; Thomas Roberts; Ralph L Sacco; Joshua Salomon; Uchechukwu Sampson; David C Schwebel; Saeid Shahraz; Kenji Shibuya; Donald Silberberg; Jasvinder A Singh; Kyle Steenland; Jennifer A Taylor; George D Thurston; Monica S Vavilala; Theo Vos; Gregory R Wagner; Martin A Weinstock; Marc G Weisskopf; Sarah Wulf Journal: JAMA Date: 2013-08-14 Impact factor: 56.272