{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,3]],"date-time":"2026-09-03T12:06:09Z","timestamp":1788437169237,"version":"build-2803163510"},"reference-count":36,"publisher":"Oxford University Press (OUP)","issue":"2","license":[{"start":{"date-parts":[[2024,9,30]],"date-time":"2024-09-30T00:00:00Z","timestamp":1727654400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"funder":[{"DOI":"10.13039\/100000002","name":"NIH","doi-asserted-by":"publisher","award":["P30AR072583"],"award-info":[{"award-number":["P30AR072583"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000002","name":"NIH","doi-asserted-by":"publisher","award":["UL1TR003096-01"],"award-info":[{"award-number":["UL1TR003096-01"]}],"id":[{"id":"10.13039\/100000002","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100006108","name":"NCATS","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100006108","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,2,2]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Epidural steroid injections (ESIs) are a common and often effective treatment for radicular back pain. While oral glucocorticoids increase fracture incidence, little is known regarding fracture risk after ESI. This study investigated the incidence of fractures among individuals who received ESI and those who did not. We hypothesized that ESI exposure would be associated with an increased incidence of osteoporotic fractures and specifically vertebral fractures. Using 2005-2018 5% Medicare data, individuals with radicular pain who had \u22651 ESI and those who did not (non-ESI) were matched 1:10 by age, sex, and month of radicular pain diagnosis using exposure density sampling (EDS). Using a high-dimensional propensity score (HDPS) calculated based on the top 500 covariates across multiple data dimensions, ESI and non-ESI individuals were matched 1:1. Fractures were identified using validated ICD-9\/10 diagnosis codes. Fracture incidence rate (IR) was calculated by group, and hazard ratios (HR) compared using Cox regression. 25\u2009062 ESI patients and 221\u2009735 non-ESI patients who met eligibility criteria were identified using EDS. Mean age was 76\u00a0yr (74% female). Among ESI-treated individuals, there were 2296 fractures, IR 49.1 (95% CI: 47.2-51.2) per 1000 person yr. For non-ESI individuals, there were 11\u2009917 fractures, IR 35.2 (95% CI: 34.5-35.8). Individuals who received ESI had a greater hazard of fracture at typical osteoporotic sites, HR 1.39 (95% CI 1.33-1.46) by EDS and 1.32 (1.12-1.54) by HDPS, and a greater hazard of vertebral fracture, 1.54 (1.45-1.64) by EDS and 1.69 (1.38-2.07) by HDPS. Patients who received greater cumulative ESI doses (\u22653 in 1\u00a0yr) had a higher risk of fractures within the first 6\u00a0mo of follow-up. ESI exposure in older individuals is associated with an increased risk of fracture, suggesting there may be lasting detrimental skeletal effects of ESI. Further research into strategies to reduce fracture risk in this population is warranted.<\/jats:p>","DOI":"10.1093\/jbmr\/zjae162","type":"journal-article","created":{"date-parts":[[2024,9,29]],"date-time":"2024-09-29T15:15:17Z","timestamp":1727622917000},"page":"176-183","source":"Crossref","is-referenced-by-count":8,"title":["Epidural steroid injections and fracture incidence among older individuals with radiculopathy"],"prefix":"10.1093","volume":"40","author":[{"given":"Huifeng","family":"Yun","sequence":"first","affiliation":[{"name":"Department of Epidemiology , School of Public Health, , 1665 University Boulevard, Birmingham, AL 35233"},{"name":"The University of Alabama at Birmingham , School of Public Health, , 1665 University Boulevard, Birmingham, AL 35233"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1536-706X","authenticated-orcid":false,"given":"Ye","family":"Liu","sequence":"additional","affiliation":[{"name":"Division of Clinical Immunology and Rheumatology , , Faculty Office Tower, 510 20th St S #834, Birmingham, AL 35294"},{"name":"The University of Alabama at Birmingham , , Faculty Office Tower, 510 20th St S #834, Birmingham, AL 35294"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeffrey R","family":"Curtis","sequence":"additional","affiliation":[{"name":"Division of Clinical Immunology and Rheumatology , , Faculty Office Tower, 510 20th St S #834, Birmingham, AL 35294"},{"name":"The University of Alabama at Birmingham , , Faculty Office Tower, 510 20th St S #834, Birmingham, AL 35294"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kenneth","family":"Saag","sequence":"additional","affiliation":[{"name":"Division of Clinical Immunology and Rheumatology , , Faculty Office Tower, 510 20th St S #834, Birmingham, AL 35294"},{"name":"The University of Alabama at Birmingham , , Faculty Office Tower, 510 20th St S #834, Birmingham, AL 35294"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giavanna","family":"D\u2019Erasmo","sequence":"additional","affiliation":[{"name":"Division of Endocrinology\/Metabolic Bone Disease Service , , Department of Medicine, 535 East 70th Street, New York, NY 10021"},{"name":"Hospital for Special Surgery , , Department of Medicine, 535 East 70th Street, New York, NY 10021"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Katherine","family":"Haseltine","sequence":"additional","affiliation":[{"name":"Division of Endocrinology\/Metabolic Bone Disease Service , , Department of Medicine, 535 East 70th Street, New York, NY 10021"},{"name":"Hospital for Special Surgery , , Department of Medicine, 535 East 70th Street, New York, NY 10021"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1463-5774","authenticated-orcid":false,"given":"Emily M","family":"Stein","sequence":"additional","affiliation":[{"name":"Division of Endocrinology\/Metabolic Bone Disease Service , , Department of Medicine, 535 East 70th Street, New York, NY 10021"},{"name":"Hospital for Special Surgery , , Department of Medicine, 535 East 70th Street, New York, NY 10021"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2024,9,30]]},"reference":[{"issue":"11","key":"2026032800261233000_ref1","first-page":"832","article-title":"What are the most common conditions in primary care?: systematic review","volume":"64","author":"Finley","year":"2018","journal-title":"Can Fam Physician"},{"issue":"9178","key":"2026032800261233000_ref2","doi-asserted-by":"publisher","first-page":"581","DOI":"10.1016\/S0140-6736(99)01312-4","article-title":"Epidemiological features of chronic low-back pain","volume":"354","author":"Andersson","year":"1999","journal-title":"Lancet"},{"issue":"suppl_2","key":"2026032800261233000_ref3","doi-asserted-by":"publisher","first-page":"21","DOI":"10.2106\/JBJS.E.01273","article-title":"Lumbar disc disorders and low-back pain: socioeconomic factors and consequences","volume":"88","author":"Katz","year":"2006","journal-title":"JBJS"},{"issue":"6","key":"2026032800261233000_ref4","doi-asserted-by":"publisher","first-page":"656","DOI":"10.1001\/jama.299.6.656","article-title":"Expenditures and health status among adults with back and neck problems","volume":"299","author":"Martin","year":"2008","journal-title":"JAMA"},{"issue":"12","key":"2026032800261233000_ref5","doi-asserted-by":"publisher","first-page":"e013042","DOI":"10.1136\/bmjopen-2016-013042","article-title":"Retrospective cohort study of usage patterns of epidural injections for spinal pain in the US fee-for-service Medicare population from 2000 to 2014","volume":"6","author":"Manchikanti","year":"2016","journal-title":"BMJ Open"},{"issue":"5","key":"2026032800261233000_ref6","doi-asserted-by":"publisher","first-page":"373","DOI":"10.7326\/M15-0934","article-title":"Epidural corticosteroid injections for radiculopathy and spinal stenosis: a systematic review and meta-analysis","volume":"163","author":"Chou","year":"2015","journal-title":"Ann Intern Med"},{"issue":"10","key":"2026032800261233000_ref7","doi-asserted-by":"publisher","first-page":"1319","DOI":"10.1007\/s00198-007-0394-0","article-title":"Glucocorticoid-induced osteoporosis: pathophysiology and therapy","volume":"18","author":"Canalis","year":"2007","journal-title":"Osteoporos Int"},{"issue":"13","key":"2026032800261233000_ref8","doi-asserted-by":"publisher","first-page":"941","DOI":"10.1056\/NEJMoa002304","article-title":"Effects of inhaled glucocorticoids on bone density in premenopausal women","volume":"345","author":"Israel","year":"2001","journal-title":"N Engl J Med"},{"issue":"8","key":"2026032800261233000_ref9","doi-asserted-by":"crossref","first-page":"1095","DOI":"10.1002\/acr.23279","article-title":"American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis","volume":"69","author":"Buckley","year":"2017","journal-title":"Arthritis Care Res"},{"issue":"4","key":"2026032800261233000_ref10","doi-asserted-by":"publisher","first-page":"409","DOI":"10.1002\/pmrj.12042","article-title":"Systemic absorption and side effects of locally injected glucocorticoids","volume":"11","author":"Stout","year":"2019","journal-title":"PM&R"},{"issue":"5","key":"2026032800261233000_ref11","doi-asserted-by":"publisher","first-page":"876","DOI":"10.1097\/j.pain.0000000000001158","article-title":"Systemic effects of epidural steroid injections for spinal stenosis","volume":"159","author":"Friedly","year":"2018","journal-title":"Pain"},{"issue":"8","key":"2026032800261233000_ref12","doi-asserted-by":"publisher","first-page":"e3281","DOI":"10.1210\/clinem\/dgac287","article-title":"Epidural steroid injections acutely suppress bone formation markers in postmenopausal women","volume":"107","author":"Clare","year":"2022","journal-title":"J Clin Endocrinol Metab"},{"issue":"6","key":"2026032800261233000_ref13","doi-asserted-by":"publisher","first-page":"105604","DOI":"10.1016\/j.jbspin.2023.105604","article-title":"Risk and management of osteoporosis due to inhaled, epidural, intra-articular or topical glucocorticoids","volume":"90","author":"Anastasilakis","year":"2023","journal-title":"Joint Bone Spine"},{"issue":"9","key":"2026032800261233000_ref14","doi-asserted-by":"publisher","first-page":"3405","DOI":"10.1210\/jc.2018-00558","article-title":"Lower spine volumetric bone density in patients with a history of epidural steroid injections","volume":"103","author":"Liu","year":"2018","journal-title":"J Clin Endocrinol Metab"},{"issue":"26","key":"2026032800261233000_ref15","doi-asserted-by":"publisher","first-page":"e16080","DOI":"10.1097\/MD.0000000000016080","article-title":"Effect of medications and epidural steroid injections on fractures in postmenopausal women with osteoporosis","volume":"98","author":"Kim","year":"2019","journal-title":"Medicine"},{"issue":"4","key":"2026032800261233000_ref16","doi-asserted-by":"publisher","first-page":"E435","DOI":"10.36076\/ppj.2018.4.E435","article-title":"Effects of epidural steroid injections on bone mineral density and bone turnover markers in patients taking anti-osteoporotic medications","volume":"21","author":"Nah","year":"2018","journal-title":"Pain Physician"},{"issue":"11","key":"2026032800261233000_ref17","doi-asserted-by":"publisher","first-page":"961","DOI":"10.2106\/JBJS.L.00844","article-title":"A retrospective analysis of vertebral body fractures following epidural steroid injections","volume":"95","author":"Mandel","year":"2013","journal-title":"JBJS"},{"key":"2026032800261233000_ref18","volume-title":"Chronic Condition Data Warehouse [Internet]"},{"issue":"2","key":"2026032800261233000_ref19","doi-asserted-by":"publisher","first-page":"e001208","DOI":"10.1161\/JAHA.114.001208","article-title":"Statin use following hospitalization among Medicare beneficiaries with a secondary discharge diagnosis of acute myocardial infarction","volume":"4","author":"Yun","year":"2015","journal-title":"J Am Heart Assoc"},{"issue":"5","key":"2026032800261233000_ref20","doi-asserted-by":"publisher","first-page":"S505","DOI":"10.1016\/8756-3282(95)00258-4","article-title":"The worldwide problem of osteoporosis: insights afforded by epidemiology","volume":"17","author":"Riggs","year":"1995","journal-title":"Bone"},{"issue":"10","key":"2026032800261233000_ref21","doi-asserted-by":"publisher","first-page":"1798","DOI":"10.1002\/jbmr.3807","article-title":"The design and validation of a new algorithm to identify incident fractures in administrative claims data","volume":"34","author":"Wright","year":"2019","journal-title":"J Bone Miner Res"},{"issue":"1","key":"2026032800261233000_ref22","doi-asserted-by":"publisher","first-page":"62","DOI":"10.1056\/NEJMcp1012926","article-title":"Clinical practice. Glucocorticoid-induced bone disease","volume":"365","author":"Weinstein","year":"2011","journal-title":"N Engl J Med"},{"issue":"4","key":"2026032800261233000_ref23","doi-asserted-by":"publisher","first-page":"512","DOI":"10.1097\/EDE.0b013e3181a663cc","article-title":"High-dimensional propensity score adjustment in studies of treatment effects using health care claims data","volume":"20","author":"Schneeweiss","year":"2009","journal-title":"Epidemiology"},{"issue":"1","key":"2026032800261233000_ref24","doi-asserted-by":"publisher","first-page":"30","DOI":"10.1155\/2014\/870145","article-title":"Relationship between bone mineral density and the frequent administration of epidural steroid injections in postmenopausal women with low back pain","volume":"19","author":"Kim","year":"2014","journal-title":"Pain Res Manage"},{"issue":"3","key":"2026032800261233000_ref25","first-page":"229","article-title":"Changes in bone mineral density in postmenopausal women treated with epidural steroid injections for lower back pain","volume":"15","author":"Kang","year":"2012","journal-title":"Pain Physician"},{"issue":"1","key":"2026032800261233000_ref26","doi-asserted-by":"publisher","first-page":"12","DOI":"10.1007\/s10067-002-0648-3","article-title":"Lack of relationships between cumulative methylprednisolone dose and bone mineral density in healthy men and postmenopausal women with chronic low back pain","volume":"22","author":"Dubois","year":"2003","journal-title":"Clin Rheumatol"},{"issue":"3","key":"2026032800261233000_ref27","doi-asserted-by":"publisher","first-page":"569","DOI":"10.1093\/pm\/pnx324","article-title":"The effect of epidural steroid injections on bone mineral density and vertebral fracture risk: a systematic review and critical appraisal of current literature","volume":"19","author":"Kerezoudis","year":"2018","journal-title":"Pain Med"},{"issue":"6","key":"2026032800261233000_ref28","first-page":"441","article-title":"Low bone mineral density, but not epidural steroid injection, is associated with fracture in postmenopausal women with low back pain","volume":"15","author":"Yi","year":"2012","journal-title":"Pain Physician"},{"issue":"5","key":"2026032800261233000_ref29","first-page":"E293","article-title":"Risk of osteoporotic fracture after steroid injections in patients with Medicare","volume":"46","author":"Ong","year":"2017","journal-title":"Am J Orthop"},{"issue":"4","key":"2026032800261233000_ref30","doi-asserted-by":"publisher","first-page":"E349","DOI":"10.36076\/ppj.2013\/16\/E349","article-title":"Assessment of the growth of epidural injections in the medicare population from 2000 to 2011","volume":"16","author":"Manchikanti","year":"2013","journal-title":"Pain Physician"},{"issue":"4","key":"2026032800261233000_ref31","doi-asserted-by":"publisher","first-page":"424","DOI":"10.1177\/2192568218824956","article-title":"A 2-year cost analysis of maximum nonoperative treatments in patients with symptomatic lumbar stenosis or spondylolisthesis that ultimately required surgery","volume":"9","author":"Adogwa","year":"2019","journal-title":"Global Spine J"},{"key":"2026032800261233000_ref32","doi-asserted-by":"publisher","first-page":"e580","DOI":"10.1016\/j.wneu.2018.08.131","article-title":"Gender differences in use of prolonged nonoperative therapies before index lumbar surgery","volume":"120","author":"Davison","year":"2018","journal-title":"World Neurosurg"},{"issue":"4","key":"2026032800261233000_ref33","first-page":"361","article-title":"Interlaminar versus transforaminal epidural injections for the treatment of symptomatic lumbar intervertebral disc herniations","volume":"9","author":"Schaufele","year":"2006","journal-title":"Pain Physician"},{"issue":"4","key":"2026032800261233000_ref34","doi-asserted-by":"publisher","first-page":"907","DOI":"10.1097\/ALN.0b013e31829c2ddd","article-title":"Epidural injections for spinal pain: a systematic review and meta-analysis evaluating the \u201ccontrol\u201d injections in randomized controlled trials","volume":"119","author":"Bicket","year":"2013","journal-title":"Anesthesiology"},{"issue":"2","key":"2026032800261233000_ref35","doi-asserted-by":"publisher","first-page":"129","DOI":"10.2217\/pmt.14.53","article-title":"Epidural steroid injections: an updated review on recent trends in safety and complications","volume":"5","author":"Bicket","year":"2015","journal-title":"Pain Manag"},{"issue":"29","key":"2026032800261233000_ref36","doi-asserted-by":"publisher","first-page":"e21220","DOI":"10.1097\/MD.0000000000021220","article-title":"Efficacy and safety of epidural steroid injection following discectomy for patients with lumbar disc herniation: a protocol","volume":"99","author":"Cai","year":"2020","journal-title":"Medicine"}],"container-title":["Journal of Bone and Mineral Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/jbmr\/advance-article-pdf\/doi\/10.1093\/jbmr\/zjae162\/60136141\/zjae162.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/jbmr\/article-pdf\/40\/2\/176\/60136141\/zjae162.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/jbmr\/article-pdf\/40\/2\/176\/60136141\/zjae162.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,28]],"date-time":"2026-03-28T04:26:20Z","timestamp":1774671980000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/jbmr\/article\/40\/2\/176\/7796637"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,9,30]]},"references-count":36,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2024,9,30]]},"published-print":{"date-parts":[[2025,2,2]]}},"URL":"https:\/\/doi.org\/10.1093\/jbmr\/zjae162","relation":{},"ISSN":["0884-0431","1523-4681"],"issn-type":[{"value":"0884-0431","type":"print"},{"value":"1523-4681","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2025,2]]},"published":{"date-parts":[[2024,9,30]]}}}