Some people suffer from back pain, others SUFFER from back pain. Almost 1 in every 33 office visits is for back pain meaning that for an average primary care doctor there will be a person complaining about back pain in the office almost every day. When I was in medical school I was taught that 80% of low back pain would resolve no matter what the medical approach so the best approach was “Do nothing, Doctor” followed by “Say… I know your back hurts but…” Since then, health care costs have skyrocketed in part because of back pain and it turns out that, though pain may not be lethal, the treatment of back pain has tragically been lethal recently for seven people.
How has the strategy changed since I was in medical school? This paper does a nice job of outlining the problem. First, folks want to know “Why is my back hurting.” Docs, not wanting to stand in the way of self knowledge, have obliged by ordering imaging studies…lots and lots of them. In the last 12 years, the number of MRIs (a test done using a strong magnet) done for low back pain and paid for by Medicare has quadrupled. Why is this a problem? Turns out that one picture is not only worth a thousand words but often a procedure as well. Why is this?
Positive findings, such as herniated disks, are common in asymptomatic people.20–22 In a randomized trial23 there was a trend toward more surgery and higher costs among patients receiving early spinal MRI than those receiving plain films, but no better clinical outcomes. Six other randomized trials, involving a total of 1804 patients from primary care without features suggesting a serious underlying disease, compared some form of lumbar spine imaging with none.24–29 In these studies, imaging was not associated with an advantage in subsequent pain, function, quality of life, or overall improvement.
In addition, people want to have no pain. Prescriptions of narcotics have doubled for back pain in the last 12 years, with unclear benefit to the patient (but a clear increase in narcotic availability in the community). If the medicine is seen as ineffective, they think maybe surgery will fix it. The number of surgeries have tripled, with the following result:
Higher spine surgery rates are sometimes associated with worse outcomes. In the state of Maine, the best surgical outcomes occurred where surgery rates were lowest; the worst results occurred in areas where rates were highest
In an effort to stave off surgery in these patients who want their pain to go away, many patients have turned to injections done by pain specialists directly into the spinal canal to try and eliminate the pain. Medicare payment for this procedure, too, has tripled in the last 12 years (although the Medicare population has only gone up by 10%) with the following result:
Epidural corticosteroid injections may offer temporary relief of sciatica, but both European and American guidelines, based on systematic reviews, conclude they do not reduce the rate of subsequent surgery.57,58 This conclusion is based on multiple randomized trials comparing epidural steroid injections with placebo injections, and monitoring of subsequent surgery rates.59–62 Facet joint injections with corticosteroids seem no more effective than saline injections.
Which brings us to the deaths (covered here). They occurred during the application of steroids in the spinal canal for this purpose. The steroid used for these injections can be bought from standard supply houses. The folks who are dead (or are at risk of dying as they might be growing a fungus that will kill them and there is nothing that anyone can do) had steroids injected in them that were made under less than optimal conditions by a “compounding pharmacy.” Even though this pharmacy shipped 18,000 vials of this steroid, it is considered a “mom and pop” operation thus is not under the control of the FDA. No one is sure if this particular steroid was used because it was considered to be better or if it was cheaper for the physicians office (thus maximizing the doctor’s profit). What is certain is that without an injection, there would be no risk at all.