Primum Non Nocere

Abstract

Primum non nocere , or “first do no harm,” is the well-known maxim from the Hippocratic corpus advocating that a physician’s first priority should be to avoid precipitating further injury, or inadvertent worsening of conditions, in patients who are under his or her care. With this founding precept of the health-care tradition in mind, I commend the efforts of Dr. Mandel and his colleagues in bringing to our attention the potential for epidural steroid injections to elevate the risk of vertebral body fracture in elderly individuals. Although this association has been alluded to in previous publications, to the best of my knowledge the study by Mandel et al. is the first scientifically rigorous effort to quantify the fracture risk associated with epidural steroid administration. The study was conducted with use of a propensity-matched cohort with an average age of sixty-six years. Comparison between the patients who received epidural steroid and the controls in the primary analysis revealed that the risk of fracture increased by 21% per episode of steroid administration. Moreover, in the secondary analysis in which the possibility of multiple fractures in a single patient was considered, a significant elevation in the risk of subsequent vertebral fracture following steroid administration was again demonstrated. The identification of this significant association, as well as the quantification of risk inherent with each injection event, represent novel contributions to the literature. It is necessary to appreciate these findings, however, …