Behind the meningitis outbreak: a contested treatment for back pain
This article first appeared in the St. Louis Beacon, Oct. 16, 2012 - News of a deadly meningitis outbreak in more than a dozen states has fortunately remained remote for most people in Missouri. So far the state hasn't reported any victims from medicines tied to the illness.
The news seems less remote to Laurie Westfall.
Westfall is the widow of George R. “Buzz” Westfall, who was St. Louis County executive at the time he died from a similar infection in 2003. Westfall has followed news of the recent meningitis outbreak enough to describe similarities to, and distinctions from, the medical procedure that led to more than a dozen fatalities this year, and that apparently led to her husband’s death.
Like Westfall’s death, the recent outbreak highlights risks, normally low, associated with steroid injections for back pain. The medical procedure has skyrocketed in popularity among back-pain specialists, despite criticism from some doctors who argue the risks outweigh the limited benefits.
All the recent victims received “epidural” injections of steroids into or near their spinal canal, the opening through which the spinal cord passes. The shots apparently led to meningitis, or infections of the membranes that surround the spine and brain.
Westfall had epidural steroid injections, too.
“Sure, we understood there are risks,” Westfall said of the shots that sought to ease the chronic back pain of her husband. She is quick, however, to draw a distinction between the unusual, if not rare, infection that killed Buzz Westfall and this year’s cases. His came from bacteria, specifically a staphylococcus or “Staph” infection, and not from the sort of tainted medicine that’s behind this year’s deaths.
“The injection was the site where the infection got in,” Westfall said last week of her husband. “The infection had nothing to do with the (medicine) itself.”
It was fungus-contaminated medicine made by a Massachusetts-based pharmacy company that regulators blame for the recent wave of meningitis. The pharmacy company has closed, but not before some 13,000 patients received injections from questionable steroids. Doctors have reported 203 meningitis cases in 14 states and 15 deaths tied to the tainted medicine, according to federal data posted Sunday.
News reports have largely focused on lax regulation of the company, part of a specialized “compounding” industry that assembles custom medicines for individual patients. But some argue the focus should also be on the steroid injections themselves, which one study suggests have more than doubled in the past decade. Medicare patients alone received nearly 9 million such injections in 2010, according to the study described recently by USA Today and conducted by Dr. Laxmaiah Manchikanti, a Tennessee physician and chairman of the American Society of Interventional Pain Physicians.
Federal regulators already were studying the safety of the shots with a focus on injection techniques that can reduce injuries, the New York Times reported last week. The risk of infection wasn’t part of the study but will be now, the paper was told by Dr. James P. Rathmell of Massachusetts General Hospital, who is involved in the review led by the U.S. Food and Drug Administration.
The shots have grown wildly popular and profitable for the doctors who order them, despite repeated studies that have shown no long-term and little short-term benefits, said Dr. William Landau, a prominent Washington University neurologist. At the least, the benefits are outweighed by the risks of sticking a needle into the fluid that surrounds the human spine, he said.
“If anyone sticks a needle through the skin, there is always a risk of getting an infection inside the body,” Landau said. Those risks are amplified when the injection enters or nears the spinal canal, as do the steroid shots for back pain.
Landau’s criticism partly arises from a paper he co-authored in 2001 that reviewed what was known about the steroid shots for back pain. He titled a related article for "Neurology Today," “Why neurologists should not administer the prescriptive steroid shot in the back.”
He also included his criticism in a book about common misconceptions about the human nervous system: “Clinical Neuromythology and Other Arguments and Essays, Pertinent and Impertinent.”
But local pain specialists defend the use of steroid injections in treating chronic and acute back pain. They say even short-term relief can prove invaluable in jump-starting long-term treatment, which often involves exercise and other physical therapy.
“That tends to be how we use them,” said Dr. Robert Swarm, also at Washington University and director of its Pain Management Center.
The risk of infection such as Westfall’s are extremely rare, Swarm said. The bigger concern is that not all patients will feel relief from the shots. “The lack of benefit is the most common undesirable outcome,” he said. “But most people seem to get at least some benefit from it.”
While there may be some misuse of the shots, which are best used for specific types of back pain, doctors say there are better explanations for the growing popularity of the epidural injections. The nation is aging and back pain is endemic. “More people are disabled by back pain than by anything else,” Swarm said.
At the same time, the medical profession has become more sensitive to patient complaints and has elevated efforts to relieve chronic pain.
The meningitis outbreak shouldn’t cast a harsh light on epidural injections themselves, Swarm said. The focus instead should remain on the pharmacy company and shortcuts that some providers and patients are taking to find affordable medicines. He said misuse of the compounding pharmacy in Massachusetts is similar to patients crossing the Canadian or Mexican border for cheaper drugs.
Another local specialist agreed that the meningitis cases won’t change his use of injections for back pain. “In appropriately selected patients … these injections can be effective,” said Dr. Howard Place, an orthopedic spine surgeon at Saint Louis University.
They don’t work for all patients, even those who have the symptoms that often suggest the shots would be effective. “Some get awesome relief, and others get no relief,” he said.
The recent deaths stem from the medicine used, not the injections themselves, as was the case for Westfall. And what causes the rare case when a Staph infection follows the path of an injection, Place said, can be complicated and difficult to ascertain.
That’s what the Westfall family was told, says Laurie Westfall. She told reporters soon after his death that the family would not consider a lawsuit against any of his doctors.
Westfall reiterated that last week. Buzz’s illness had nothing to do with slipshod medicines or careless doctors, she said. “My husband received excellent care.”
David LaGesse is a freelance writer based in St. Louis.