Epidural steroid injections may be associated with reduced bone mineral density and an increased risk for vertebral fracture, according to a systematic review published in Pain Medicine.

In this systematic review and critical literature appraisal, researchers evaluated 8 studies (n=7233) that reported on the effects of epidural steroid injections on bone mineral density, osteoporosis, vertebral fracture, or osteopenia.

Studies were required to have a control group or baseline comparisons. All epidural steroid injection dosages were converted to methyl-prednisolone equivalents, and low bone mineral density was defined by the presence of osteopenia or osteoporosis, evaluated using the World Health Organization-2 criteria (6 studies) or the International Society of Clinical Densitometry criteria (1 study).

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Of the 8 studies evaluated, 5 focused on postmenopausal women only, and 3 included men and women of any age. The follow-up ranged from 6 to 60 months, and the steroids used included triamcinolone, dexamethasone, methyl-prednisolone, and betamethasone, with doses ranging from 10 to 120 mg. The mean number of injections across all studies was 14.7. The mean cumulative injection dose in methyl-prednisolone equivalents ranged from 80 to 8130 mg.

Across all studies, mean changes in bone mineral density ranged from 0.06% to 1.25% in the lumbar spine and from −2.87% to 0.45% in the femoral neck. Among patients who received epidural steroid injections, low bone mineral density was reported by 52.5% to 96.2% of patients in the lumbar spine and by 29% to 93.5% of patients in the femoral neck.

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In postmenopausal women, cumulative doses of triamcinolone >200 mg during a 1-year period or >400 mg during a 3-year period were associated with reduced bone mineral density. In 1 study, each additional epidural steroid injection was shown to increase the risk for fracture (relative risk, 1.21; 95% CI, 1.08-1.30).

The study authors concluded that “[Epidural steroid injections] seem to decrease [bone mineral density], both locally (lumbar spine) and systemically (femoral neck) in doses as low as 80 mg of [methyl-prednisolone] equivalents and to increase the risk of vertebral fracture.”

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Kerezoudis P, Rinaldo L, Alvi MA, et al. The effect of epidural steroid injections on bone mineral density and vertebral fracture risk: A systematic review and critical appraisal of current literature [published online January 2, 2018]. Pain Med. doi: 10.1093/pm/pnx324