The growing outbreak of fungal meningitis has led some people to question the widespread use of epidural steroid injections for pain. Steroids contaminated with a fungus are suspected of transmitting the infection.
By Wednesday, the outbreak had grown to 137 patients in 10 states, with 12 deaths. That number could grow, given that 13,000 patients were treated with three recalled lots of steroids, CDC spokesman Curtis Allen says.
Yet doctors say steroid injections, which decrease inflammation, are a mainstay of treatment for chronic pain, particularly for patients suffering from sciatica caused by a herniated disc. About 700,000 people get the injections each year, says Timothy Deer, a West Virginia physician and member of the American Academy of Pain Medicine's board of directors. Doctors commonly use laser-guided X-rays to place the injections in exactly the right spot.
That makes the injections safe, with a risk of complications of a fraction of 1%, said William Blau, a professor of anesthesiology at the University of North Carolina's School of Medicine. The injections can help restore people in pain to normal functioning, and help them avoid potentially addictive medications, such as narcotics, or invasive procedures, such as back surgery or surgery to place an implantable pain-control device, Deer says.
Physical therapy is usually an important part of treatment, given in conjunction with shots, Deer says.
Doctors also use steroid injections to ease pain in joints such as the knees. Knee injections typically don't lead to meningitis, but could cause a more limited infection in the joint itself, Allen says. Contaminated injections near the spine can lead to meningitis, however, if fungus enter the spinal fluid, which provides an express route to the brain.
Steroid shots "dramatically and immediately decrease inflammation around irritated nerve roots," said David Zvara, chairman of anesthesiology at UNC-Chapel Hill. "Getting an injection like this hastens the healing process and can mean the difference between several lost days of work with back pain and returning to normal functioning within a day or two."
Pain specialists can help people decide whether an injection is the best therapy, Zvara said.
"In most cases, an irritated nerve root will heal on its own over several days or weeks, he said. "The steroid injection hastens this process dramatically. For some, back pain can be debilitating, resulting in lost work and suffering. Seeing a physician and potentially receiving a steroid injection in conjunction with other analgesics and muscle relaxants can be enormously beneficial," Zvara says.
"Patients must determine if the back pain is due to a surgical problem such as a herniated disc or a tumor as the steroid injection may reduce some of the discomfort, but it will not reverse the underlying cause."
Epidural steroid injections are administered somewhat like the epidural pain relievers given to many women in labor, injected at the base of the spine near the spinal fluid, Blau said. Women in labor, however, receive continuous pain relief through a catheter, rather than a one-time shot.
In some ways, epidurals have advantages over taking steroid pills. Because they're shot directly into the spinal area, steroid injections tend to cause fewer side effects than pills, which circulate throughout the body. Some of the main side effects from long-term steroid use are immune suppression and a worsening of osteoporosis, which can increase the risk of bone fractures, Blau said.
The meningitis outbreak has led some patient advocates to call for more scrutiny of specialty pharmacies, such as the Massachusetts company that made the contaminated shots. Pharmacies that make their own drugs are regulated by state boards, and are not inspected by the Food and Drug Administration the way large pharmaceutical companies are, says William Schaffner, an expert in infectious disease at the Vanderbilt University School of Medicine.
"Our loss and that of others should be a wake-up call to our country," said George Cary, 65, of Howell, Mich., whose wife, Lilian Cary, 67, died Sept. 30, after receiving the steroid injections for back pain. He also received the steroid injections but remains healthy. "The apparent lack of suitable inspections should not have happened."
Contributing: Detroit Free Press
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