scholarly journals Effectiveness of Cervical Epidural Injections in the Management of Chronic Neck and Upper Extremity Pain

2012 ◽  
Vol 4;15 (4;8) ◽  
pp. E405-E434
Author(s):  
Sudhir A. Diwan
Keyword(s):  
Systematic Review ◽  
Neck Pain ◽  
Upper Extremity ◽  
Spinal Stenosis ◽  
Disc Herniation ◽  
Local Anesthetic ◽  
Chronic Neck Pain ◽  
Cervical Disc ◽  
Discogenic Pain ◽  
Epidural Injections

Background: Chronic persistent neck pain with or without upper extremity pain is common in the general adult population with prevalence of 48% for women and 38% for men, with persistent complaints in 22% of women and 16% of men. Multiple modalities of treatments are exploding in managing chronic neck pain along with increasing prevalence. However, there is a paucity of evidence for all modalities of treatments in managing chronic neck pain. Cervical epidural injections for managing chronic neck pain are one of the commonly performed interventions in the United States. However, the literature supporting cervical epidural steroids in managing chronic pain problems has been scant. Study Design: A systematic review of cervical interlaminar epidural injections for cervical disc herniation, cervical axial discogenic pain, cervical central stenosis, and cervical postsurgery syndrome. Objective: To evaluate the effect of cervical interlaminar epidural injections in managing various types of chronic neck and upper extremity pain emanating as a result of cervical spine pathology. Methods: The available literature on cervical interlaminar epidural injections in managing chronic neck and upper extremity pain were reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, and limited based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to December 2011, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. Results: For this systematic review, 34 studies were identified. Of these, 24 studies were excluded and a total of 9 randomized trials, with 2 duplicate studies, met inclusion criteria for methodological quality assessment. For cervical disc herniation, the evidence is good for cervical epidural with local anesthetic and steroids; whereas, it is fair with local anesthetic only. For axial or discogenic pain, the evidence is fair for local anesthetic, with or without steroids. For spinal stenosis, the evidence is fair for local anesthetic, with or without steroids. For postsurgery syndrome, the evidence is fair for local anesthetic, with or without steroids. Limitations: The limitations of this systematic review continue to be the paucity of literature. Conclusion: The evidence is good for radiculitis secondary to disc herniation with local anesthetics and steroids, fair with local anesthetic only; whereas, it is fair for local anesthetics with or without steroids, for axial or discogenic pain, pain of central spinal stenosis, and pain of post surgery syndrome. Key words: Cervical disc herniation, cervical axial discogenic pain, cervical central spinal stenosis, cervical post surgery syndrome, cervical radiculitis, cervical interlaminar epidural injections, local anesthetic, steroids

scholarly journals The Effectiveness of Fluoroscopic Cervical Interlaminar Epidural Injections in Managing Chronic Cervical Disc Herniation and Radiculitis: Preliminary Results of a Randomized, DoubleBlind, Controlled Trial

2010 ◽  
Vol 3;13 (3;5) ◽  
pp. 223-236
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Neck Pain ◽  
Upper Extremity ◽  
Disc Herniation ◽  
Local Anesthetic ◽  
Chronic Neck Pain ◽  
Cervical Disc Herniation ◽  
Cervical Disc ◽  
Epidural Injections ◽  
Group I ◽  
Group Ii

Background: Chronic neck pain is a common problem in the adult population with a typical 12- month prevalence of 30% to 50%. Cervical disc herniation and radiculitis is one of the common conditions described responsible for chronic neck and upper extremity pain. Cervical epidural injections for managing chronic neck pain with disc herniation are one of the commonly performed non-surgical interventions in the United States. However, the literature supporting cervical interlaminar epidural steroids in managing chronic neck pain is scant. Study Design: A randomized, double-blind, controlled trial. Setting: A private interventional pain management practice and specialty referral center in the United States. Objectives: To evaluate the effectiveness of cervical interlaminar epidural injections of local anesthetic with or without steroids in providing effective and long-lasting relief in the management of chronic neck pain and upper extremity pain in patients with disc herniation and radiculitis, and to evaluate the differences between local anesthetic with or without steroids. Methods: Patients were randomly assigned to one of 2 groups: Group I patients received cervical interlaminar epidural injections of local anesthetic (lidocaine 0.5%, 5 mL); Group II patients received cervical interlaminar epidural injections with 0.5% lidocaine, 4 mL, mixed with 1 mL of nonparticulate betamethasone. Outcomes Assessment: Multiple outcome measures were utilized. They included the Numeric Rating Scale (NRS), the Neck Disability Index (NDI), employment status, and opioid intake. Assessments were done at baseline and 3, 6, and 12 months post-treatment. Significant pain relief was defined as 50% or more; significant improvement in disability score was defined as a reduction of 50% or more. Results: Significant pain relief (≥ 50%) was demonstrated in 77% of patients in both groups. Functional status improvement was demonstrated by a reduction (> 50%) in the NDI scores in 74% of Group I and 71% of Group II at 12 months. The overall average procedures per year were 3.7 ± 1.1 in Group I and 4.0 ± 0.91 in Group II; the average total relief per year was 39.45 ± 11.59 weeks in Group I and 41.06 ± 11.56 weeks in Group II over the 52 week study period in the patients defined as successful. The initial therapy was considered to be successful if a patient obtained consistent relief with 2 initial injections lasting at least 4 weeks. All others were considered failures. Limitations: The study results are limited by the lack of a placebo group and a preliminary report of 70 patients, 35 in each group. Conclusion: Cervical interlaminar epidural injections with local anesthetic with or without steroids might be effective in 77% of patients with chronic function-limiting neck pain and upper extremity pain secondary to cervical disc herniation and radiculitis. Key words: Chronic neck pain, cervical disc herniation, upper extremity pain, cervical epidural injections, epidural steroids, local anesthetics

scholarly journals https://painphysicianjournal.com/current

2020 ◽  
Vol 4;23 (7;4) ◽  
pp. 335-348
Author(s):  
Nicholas Van Halm-Lutterodt
Keyword(s):  
Systematic Review ◽  
Pain Relief ◽  
Neck Pain ◽  
Functional Status ◽  
Spinal Stenosis ◽  
Local Anesthetic ◽  
Meta Analysis ◽  
Chronic Neck Pain ◽  
Epidural Injections ◽  
Significant Difference

Background: Chronic neck pain is reportedly considered the fourth leading cause of disability. Cervical interlaminar epidural injections are among the commonly administered nonsurgical interventions for managing chronic neck pain, secondary to disc herniation and radiculitis, spinal stenosis, or chronic neck pain of discogenic origin. Objectives: To systematically review the differences in the effectiveness of cervical epidural injections with local anesthetics with or without steroids for the management of chronic neck pain. Study Design: Systematic review and meta-analysis. Methods: A comprehensive search of the literature of randomized controlled trials (RCTs) that compared epidural injections with local anesthetic with or without steroids was performed, including a search of PubMed, EMBASE, and Cochrane databases for all years up to May 2019. Meta-analysis was done for pain relief based on the Numeric Rating Scale, functional status based on the Neck Disability Index, and opioid intake dosage. Results: Four studies met the inclusion criteria. A total of 370 patients were divided into 2 groups: the experimental group received cervical epidural injection with steroid and local anesthetic, and the control group received injection with local anesthetic only. Regrading pain relief, no significant difference was observed between both groups (weighted mean difference [WMD], –0.006; 95% confidence interval (CI), –0.275 to 0.263; P = 0.963; I2 = 0.0% at 12 months). There was also no significant difference in the improvement of the functional status (WMD, 0.159; 95% CI, –1.231 to 1.549; P = 0.823; I2 = 9.8% at 12 months). Similarly, there was no significant difference in opioid dosage (WMD, –0.093; 95% CI, –5.952 to 5.766; P = 0.975; I2 = 0.0% at 12 months). Limitations: Only a few studies on this premise were found in the literature. There was also a lack of heterogeneity of the included RCT studies. Conclusions: The addition of steroids to anesthetic injectates was not associated with better pain and functional score outcomes compared with anesthetic injectate alone in patients with chronic neck pain. Key words: Chronic neck pain, cervical radiculopathy, cervical disc disease, spinal stenosis, facet joint pathology, cervical epidural injections, steroid injections, local anesthetic injections, systematic review, meta-analysis, randomized control trial

scholarly journals Systematic Review of the Effectiveness of Cervical Epidurals in the Management of Chronic Neck Pain

2009 ◽  
Vol 1;12 (1;1) ◽  
pp. 137-157
Author(s):  
Ramsin Benyamin
Keyword(s):  
Systematic Review ◽  
Neck Pain ◽  
Upper Extremity ◽  
Outcome Measures ◽  
Randomized Trials ◽  
Chronic Neck Pain ◽  
Cervical Disc ◽  
Epidural Injections ◽  
Level Ii

Background: Chronic neck pain is a common problem in the adult population with a typical 12-month prevalence of 30% to 50%, and 14% of the patients reporting grade II to IV neck pain with high pain intensity and disability that has a substantial impact on health care and society. Cervical epidural injections for managing chronic neck pain are one of the commonly performed interventions in the United States. However, the literature supporting cervical epidural steroids in managing chronic pain problems has been scant and no systematic review dedicated to the evaluation of cervical interlaminar epidurals has been performed in the past. Study Design: A systematic review of cervical interlaminar epidural injections. Objective: To evaluate the effect of cervical interlaminar epidural injections in managing various types of chronic neck and upper extremity pain emanating as a result of cervical spine pathology. Methods: The available literature of cervical interlaminar epidural injections in managing chronic neck and upper extremity pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies. The level of evidence was classified as Level I, II, or III based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF) for therapeutic interventions. Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE from 1966 to November 2008, and manual searches of bibliographies of known primary and review articles. Outcome Measures: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. Results: The indicated evidence is Level II-1 in managing chronic neck and upper extremity pain. Limitations: The limitations of this systematic review include the paucity of literature and lack of randomized trials performed under fluoroscopy. Conclusion: The results of this systematic evaluation of cervical interlaminar epidural injection showed significant effect in relieving chronic intractable pain of cervical origin and also providing long-term relief with an indicated evidence level of Level II-1. Key words: Cervical disc herniation, cervical post surgery syndrome, cervical spinal stenosis, cervical radiculitis, cervical interlaminar epidural injections, local anesthetic steroids, chronic discogenic pain

Cervical Interlaminar Epidural Injections In The Treatment Of Cervical Disc Herniation, Post Surgery Syndrome, Or Discogenic Pain: Cost Utility Analysis From Randomized Trials

2019 ◽  
Vol 5 (22;5) ◽  
pp. 421-431
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Neck Pain ◽  
Disc Herniation ◽  
Cost Utility ◽  
Cost Utility Analysis ◽  
Cervical Disc Herniation ◽  
Cervical Disc ◽  
Utility Analysis ◽  
Discogenic Pain ◽  
Epidural Injections ◽  
Post Surgery

Background: Neck pain is one of the major conditions attributing to overall disability in the United States. There have been multiple publications assessing clinical and cost effectiveness of multiple modalities of interventions in managing chronic neck pain. Even then, the literature has been considered sparse in relation to cervical interlaminar epidural injections in managing chronic neck pain. In contrast, cost utility studies of lumbar interlaminar injections, caudal epidural injections, cervical and lumbar facet joint nerve blocks, percutaneous adhesiolysis demonstrated costs of less than $3,500 for quality-adjusted life year (QALY). Objectives: To assess the cost utility of cervical interlaminar epidural injections in managing chronic neck and/or upper extremity pain secondary to cervical disc herniation, post-surgery syndrome in neck, and axial or discogenic neck pain. Study Design: Analysis based on 3 previously published randomized trials of the effectiveness of cervical interlaminar epidural injections assessing their role in disc herniation, cervical post-surgery syndrome, and axial or discogenic pain. Setting: A contemporary, private, specialty referral interventional pain management center in the United States. Methods: Cost utility of cervical interlaminar epidural injections with or without steroids in managing cervical disc herniation, cervical post-surgery syndrome, and cervical discogenic or axial neck back pain was conducted with data derived from 3 randomized controlled trials (RCTs) that included a 2-year follow-up, with inclusion of 356 patients. The primary outcome was significant improvement defined as at least 50% in pain reduction and disability status. Direct payment data from all carriers from 2018 was utilized for the assessment of procedural costs. Overall costs, including drug costs, were determined by multiplication of direct procedural payment data by a factor of 1.67 to accommodate for indirect payments respectively for disc herniation, discogenic pain, and cervical post-surgery syndrome. Results: The results of the 3 RCTs showed direct cost utility for one year of QALY of $2,412.31 for axial or discogenic pain without disc herniation, $2,081.07 for disc herniation, and $2,309.20 for post surgery syndrome, with an average cost per one year QALY of $2,267.57, with total estimated overall costs with addition of indirect costs of $3,475.38, $4,028.55, $3,856.36, and $3,785.89 respectively. Limitations: The limitation of this cost utility analysis includes that it is a single center evaluation. Indirect costs were extrapolated. Conclusion: This cost utility analysis of cervical interlaminar epidural injections in patients nonresponsive to conservative management in the treatment of disc herniation, post surgery syndrome and axial or discogenic neck pain shows $2,267.57 for direct costs with a total cost of $3,785.89 per QALY. Key words: Cervical interlaminar epidural injections, chronic neck pain, cervical disc herniation, cervical discogenic pain, post surgery syndrome, cost utility analysis, cost effectiveness analysis, quality-adjusted life years

scholarly journals The Effectiveness of Lumbar Interlaminar Epidural Injections in Managing Chronic Low Back and Lower Extremity Pain

2012 ◽  
Vol 4;15 (4;8) ◽  
pp. E363-E404
Author(s):  
Ramsin Benyamin
Keyword(s):  
Lower Extremity ◽  
Spinal Stenosis ◽  
Disc Herniation ◽  
Local Anesthetic ◽  
Chronic Low Back Pain ◽  
Randomized Trials ◽  
Low Back ◽  
Discogenic Pain ◽  
Epidural Injections ◽  
Lower Extremity Pain

Background: Intervertebral disc herniation, spinal stenosis, intervertebral disc degeneration without disc herniation, and post lumbar surgery syndrome are the most common diagnoses of chronic persistent low back and lower extremity symptoms, resulting in significant economic, societal, and health care impact. Epidural injections are one of the most commonly performed interventions in the United States in managing chronic low back pain. However the evidence is highly variable among different techniques utilized – namely interlaminar, caudal, and transforaminal – and for various conditions, namely – intervertebral disc herniation, spinal stenosis, and discogenic pain without disc herniation or radiculitis. Multiple systematic reviews conducted in the evaluation of the effectiveness of interlaminar epidural injections have been marred with controversy. Consequently, the debate continues with regards to the effectiveness, indications, and medical necessity of interlaminar epidural injections. Study Design: A systematic review of lumbar interlaminar epidural injections with or without steroids. Objective: To evaluate the effect of lumbar interlaminar epidural injections with or without steroids in managing various types of chronic low back and lower extremity pain emanating as a result of disc herniation or radiculitis, spinal stenosis, and chronic discogenic pain. Methods: The available literature on lumbar interlaminar epidural injections with or without steroids in managing various types of chronic low back pain with or without lower extremity pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, or limited based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to December 2011, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. Results: Overall, 82 lumbar interlaminar trials were identified. All non-randomized studies without fluoroscopy and randomized trials not meeting the inclusion criteria were excluded. Overall, 15 randomized trials and 11 non-randomized studies were included in the analysis. Analysis was derived mainly from fluoroscopically-guided randomized trials and non-randomized studies. The evidence is good for radiculitis secondary to disc herniation with local anesthetics and steroids, fair with local anesthetic only; whereas it is fair for radiculitis secondary to spinal stenosis with local anesthetic and steroids, and fair for axial pain without disc herniation with local anesthetic with or without steroids, with fluoroscopically-guided epidural injections. Limitations: The limitations of this study include that we were unable to perform meta-analysis for disc herniation, and the paucity of evidence for discogenic pain and spinal stenosis. Further, methodological criteria have been highly variable along with sample sizes. The studies were heterogenous. Conclusion: The evidence based on this systematic review is good for lumbar epidural injections under fluoroscopy for radiculitis secondary to disc herniation with local anesthetic and steroids, fair with local anesthetic only; whereas it is fair for radiculitis secondary to spinal stenosis with local anesthetic and steroids, and fair for axial pain without disc herniation with local anesthetic with or without steroids. Key words: Chronic low back pain, lower extremity pain, disc herniation, radiculitis, spinal stenosis, discogenic pain, lumbar interlaminar epidural injections, fluoroscopy

scholarly journals Lumbar Interlaminar Epidural Injections in Managing Chronic Low Back and Lower Extremity Pain: A Systematic Review

2009 ◽  
Vol 1;12 (1;1) ◽  
pp. 163-188 ◽  
Author(s):  
Allan T. Parr
Keyword(s):  
Systematic Review ◽  
Lower Extremity ◽  
Spinal Stenosis ◽  
Disc Herniation ◽  
Low Back ◽  
Short Term ◽  
Discogenic Pain ◽  
Epidural Injections ◽  
Lower Extremity Pain

Background: Low back pain with or without lower extremity pain is the most common problem among chronic pain disorders with significant economic, societal, and health impact. Epidural injections are one of the most commonly performed interventions in the United States in managing chronic low back pain. However the evidence is highly variable among different techniques utilized – namely interlaminar, caudal, transforaminal – and for various conditions, namely – intervertebral disc herniation, spinal stenosis, and discogenic pain without disc herniation or radiculitis. Study Design: A systematic review of lumbar interlaminar epidural injections with or without steroids. Objective: To evaluate the effect of lumbar interlaminar epidural injections with or without steroids in managing various types of chronic low back and lower extremity pain emanating as a result of disc herniation or radiculitis, spinal stenosis, and chronic discogenic pain. Methods: Review of the literature and methodologic quality assessment were performed according to the Cochrane Musculoskeletal Review Group Criteria as utilized for interventional techniques for randomized trials and the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies. The level of evidence was classified as Level I, II, or III based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF) for therapeutic interventions. Data sources included relevant literature of the English language identified through searches of PubMed and EMBASE from 1966 to November 2008, and manual searches of bibliographies of known primary and review articles. Results of analysis were performed for multiple conditions separately. Outcome Measures: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. Results: The available literature included only blind epidural injections without fluoroscopy. The indicated evidence is positive (Level II-2) for short-term relief of pain of disc herniation or radiculitis utilizing blind interlaminar epidural steroid injections with lacking of evidence with Level III for long-term relief for disc herniation and radiculitis. The evidence is lacking with Level III for short and long-term relief for spinal stenosis and discogenic pain without radiculitis or disc herniation utilizing blind epidural injections. Limitations: The limitations of this study include paucity of literature, lack of quality evidence, lack of fluoroscopic procedures, and lack of applicable evidence in contemporary interventional pain management practices. Conclusion: The evidence based on this systematic review is limited for blind interlaminar epidurals in managing all types of pain except for short-term relief of pain secondary to disc herniation and radiculitis. This evidence does not represent contemporary interventional pain management practices and also the evidence may not be extrapolated to fluoroscopically directed lumbar interlaminar epidural injections. Key words: Chronic low back pain, lower extremity pain, disc herniation, radiculitis, spinal stenosis, discogenic pain, lumbar interlaminar epidural injections, caudal epidural injections, transforaminal epidural injections, epidural steroids, local anesthetic

scholarly journals Do Cervical Epidural Injections Provide LongTerm Relief in Neck and Upper Extremity Pain? A Systematic Review

2015 ◽  
Vol 18;1 (1;1) ◽  
pp. 39-60 ◽  
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Upper Extremity ◽  
Spinal Stenosis ◽  
Disc Herniation ◽  
Joint Pain ◽  
Facet Joint ◽  
High Quality ◽  
Discogenic Pain ◽  
Epidural Injections ◽  
Post Surgery ◽  
Facet Joint Pain

Background: The high prevalence of chronic persistent neck pain not only leads to disability but also has a significant economic, societal, and health impact. Among multiple modalities of treatments prescribed in the management of neck and upper extremity pain, surgical, interventional and conservative modalities have been described. Cervical epidural injections are also common modalities of treatments provided in managing neck and upper extremity pain. They are administered by either an interlaminar approach or transforaminal approach. Objectives: To determine the long-term efficacy of cervical interlaminar and transforaminal epidural injections in the treatment of cervical disc herniation, spinal stenosis, discogenic pain without facet joint pain, and post surgery syndrome. Methods: The literature search was performed from 1966 to October 2014 utilizing data from PubMed, Cochrane Library, US National Guideline Clearinghouse, previous systematic reviews, and cross-references. The evidence was assessed based on best evidence synthesis with Level I to Level V. Results: There were 7 manuscripts meeting inclusion criteria. Of these, 4 assessed the role of interlaminar epidural injections for managing disc herniation or radiculitis, and 3 assessed these injections for managing central spinal stenosis, discogenic pain without facet joint pain, and post surgery syndrome. There were 4 high quality manuscripts. A qualitative synthesis of evidence showed there is Level II evidence for each etiology category. The evidence is based on one relevant, high quality trial supporting the efficacy of cervical interlaminar epidural injections for each particular etiology. There were no randomized trials available assessing the efficacy of cervical transforaminal epidural injections. Limitations: Paucity of available literature, specifically conditions other than disc herniation. Conclusion: This systematic review with qualitative best evidence synthesis shows Level II evidence for the efficacy of cervical interlaminar epidural injections with local anesthetic with or without steroids, based on at least one high-quality relevant randomized control trial in each category for disc herniation, discogenic pain without facet joint pain, central spinal stenosis, and post surgery syndrome. Key words: Chronic neck pain, cervical disc herniation, cervical spinal stenosis, cervical post surgery syndrome, cervical discogenic pain, cervical epidural injections, interlaminar epidural injections, transforaminal epidural injections, steroids, local anesthetic

scholarly journals Fluoroscopic Cervical Interlaminar Epidural Injections in Managing Chronic Pain of Cervical Postsurgery Syndrome: Preliminary Results of a Randomized, Double-Blind, Active Control Trial

2012 ◽  
Vol 1;15 (1;1) ◽  
pp. 13-26
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Pain Relief ◽  
Neck Pain ◽  
Upper Extremity ◽  
Local Anesthetic ◽  
Chronic Neck Pain ◽  
Double Blind ◽  
Epidural Injections ◽  
Group I ◽  
Group Ii ◽  
Neck Disability

Background: Cervical postsurgery syndrome is common with increasing cervical surgical interventions. Cervical spine surgery may fail in a certain proportion of patients with continued pain secondary to pseudoarthrosis, adjacent segment degeneration, inadequate decompression, iatrogenic instability, facet joint arthritis, deformity, and spinal stenosis. Among the various treatments available for managing cervical postsurgery syndrome, epidural steroid injections are one of the most common nonsurgical interventions. However there have not been any systematic evaluations regarding the effectiveness of cervical epidural injections in cervical postsurgery syndrome. Study Design: A randomized, double-blind, active control trial. Setting: A specialty referral, private interventional pain management practice in the United States. Objectives: To evaluate the effectiveness of cervical interlaminar epidural injections of local anesthetic with or without steroids in providing effective and long-lasting relief in the management of chronic neck pain and upper extremity pain in patients with cervical postsurgery syndrome, and to evaluate the differences between local anesthetic with or without steroids. Methods: Patients were randomly assigned to one of 2 groups: Group I patients received cervical interlaminar epidural injections of local anesthetic (lidocaine 0.5%, 5 mL); Group II patients received cervical interlaminar epidural injections with 0.5% lidocaine, 4 mL, mixed with 1 mL of nonparticulate betamethasone. The study was designed to include 120 patients with 60 patients in each group. This analysis includes 56 patients. Randomization was performed by computer-generated, random allocation sequence by simple randomization. Outcomes Assessment: Outcome measures included the Numeric Rating Scale (NRS), the Neck Disability Index (NDI), employment status, and opioid intake. Assessments at baseline and 3, 6, and 12 months posttreatment. Significant pain relief was defined as 50% or more; significant improvement in NDI was defined as a reduction of 50% or more. Results: Significant pain relief (≥ 50%) was demonstrated in 71% of patients in Group I and 68% of patients in Group II. Functional status improvement was demonstrated by a reduction (> 50%) in the NDI scores in 71% of Group I and 64% of Group II at 12 months. The overall average procedures per year were 4.0 ± 0.7 in Group I and 4.1 ± 1.0 in Group II; the average total relief per year was 39.6 ± 11.8 weeks in Group I and 41.2 ± 15.8 weeks in Group II over the 52 week study period in the patients defined as successful. In the successful group, the combined pain relief and neck disability improvement was seen in 87% in Group I and 72% of the patients in Group II. Limitations: The study results are limited by the lack of a placebo group and a preliminary report of 56 patients, 28 in each group. Conclusion: Cervical interlaminar epidural injections with local anesthetic with or without steroids were effective in 67% of patients overall and 87% in Group I and 72% in Group II, in successful group patients with chronic function-limiting neck pain and upper extremity pain secondary to cervical postsurgery syndrome. Key words: Chronic neck pain, upper extremity pain, cervical disc herniation, cervical spinal stenosis, cervical postsurgery syndrome, cervical epidural injections, epidural steroids, local anesthetics.

scholarly journals Cervical Epidural Injections in Chronic Discogenic Neck Pain Without Disc Herniation or Radiculitis: Preliminary Results of a Randomized, Double-Blind, Controlled Trial

2010 ◽  
Vol 4;13 (4;7) ◽  
pp. E265-E278
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Neck Pain ◽  
Disc Herniation ◽  
Local Anesthetic ◽  
Facet Joint ◽  
Chronic Neck Pain ◽  
Double Blind ◽  
Epidural Injections ◽  
Group I ◽  
Group Ii ◽  
Facet Joint Pain

Background: Chronic neck pain is a common problem in the adult population with a typical 12- month prevalence of 30% to 50%. However, there is a lack of consensus regarding the causes and treatments of chronic neck pain. Despite limited evidence, cervical epidural injections are one of the commonly performed nonsurgical interventions in the management of chronic neck pain. Study Design: A randomized, double-blind, active control trial. Setting: An interventional pain management practice, a specialty referral center, a private practice setting in the United States. Objectives: To evaluate the effectiveness of cervical interlaminar epidural injections with local anesthetic with or without steroids in the management of chronic neck pain with or without upper extremity pain in patients without disc herniation or radiculitis or facet joint pain. Methods: Patients without disc herniation or radiculitis and negative for facet joint pain by means of controlled diagnostic medial branch blocks were randomly assigned to one of 2 groups: injection of local anesthetic only or local anesthetic mixed with non-particulate betamethasone. Seventy patients were included in this analysis. Randomization was performed by computer-generated random allocation sequence by simple randomization. Outcomes Assessment: Multiple outcome measures were utilized including the Numeric Rating Scale (NRS), the Neck Disability Index (NDI), employment status, and opioid intake with assessment at 3, 6, and 12 months post-treatment. Significant pain relief or functional status was defined as a 50% or more reduction. Results: Significant pain relief (≥ 50%) was demonstrated in 80% of patients in both groups and functional status improvement (> 50%) in 69% of Group I and 80% of Group II. The overall average procedures per year were 3.9 ± 1.01 in Group I and 3.9 ± 0.8 in Group II with an average total relief per year of 40.3 ± 14.1 weeks in Group I and 42.1 ± 9.9 weeks in Group II over a period of 52 weeks in the successful group. Limitations: The results of this study are limited by the lack of a placebo group and that it is a preliminary report of 70 patients, with 35 patients in each group. Conclusion: Cervical interlaminar epidural injections with local anesthetic with or without steroids may be effective in patients with chronic function-limiting discogenic. Key words: Chronic neck pain, cervical disc herniation, cervical discogenic pain, cervical epidural injections, epidural steroids, local anesthetics

scholarly journals Caudal Epidural Injections in the Management of Chronic Low Back Pain: A Systematic Appraisal of the Literature

2012 ◽  
Vol 3;15 (3;5) ◽  
pp. E158-E198
Author(s):  
Allan T. Parr
Keyword(s):  
Low Back Pain ◽  
Back Pain ◽  
Spinal Stenosis ◽  
Disc Herniation ◽  
Local Anesthetic ◽  
Chronic Low Back Pain ◽  
Low Back ◽  
Discogenic Pain ◽  
Epidural Injections ◽  
Caudal Epidural

Background: Epidural injections with local anesthetics and steroids are one of the most commonly used interventions in managing chronic low back pain and lower extremity pain of various causes. However, despite their extensive use, debate continues on their effectiveness due to the lack of well-designed, randomized, controlled studies to determine the effectiveness of epidural injections in general, and caudal epidural injections in particular. Study Design: A systematic review of caudal epidural injections with or without steroids in managing chronic pain secondary to lumbar disc herniation or radiculitis, post lumbar laminectomy syndrome, spinal stenosis, and discogenic pain without disc herniation or radiculitis. Objective: To evaluate the effect of caudal epidural injections with or without steroids in managing various types of chronic low back pain with or without lower extremity pain emanating as a result of disc herniation or radiculitis, post lumbar laminectomy syndrome, spinal stenosis, and chronic discogenic pain. Methods: The available literature on caudal epidural injections with or without steroids in managing various types of chronic low back pain with or without lower extremity pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for fluoroscopic observational studies. The level of evidence was classified as good, fair, or poor based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to December 2011, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures of improvement in functional status, psychological status, return to work, and reduction in opioid intake were utilized. Results: For this systematic review, 73 studies were identified. Of these, 51 were excluded and a total of 16 studies met inclusion criteria for methodological quality assessment with 11 randomized trials and 5 nonrandomized studies. For lumbar disc herniation, the evidence is good for short- and long-term relief of chronic pain secondary to disc herniation or radiculitis with local anesthetic and steroids and fair relief with local anesthetic only. In managing chronic axial or discogenic pain, spinal stenosis, and post surgery syndrome, the indicated evidence is fair. Limitations: The limitations of this study include the paucity of literature, specifically for chronic pain without disc herniation. Conclusion: There was good evidence for short- and long-term relief of chronic pain secondary to disc herniation or radiculitis with local anesthetic and steroids and fair relief with local anesthetic only. Further, this systematic review also provided indicated evidence of fair for caudal epidural injections in managing chronic axial or discogenic pain, spinal stenosis, and post surgery syndrome. Key words: Chronic low back pain, lower extremity pain, lumbar disc herniation, lumbar radiculitis, lumbar discogenic pain, post lumbar laminectomy or surgery syndrome, spinal stenosis, caudal epidural injections, steroids, local anesthetic

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