Epidural Steroid Injections, Conservative Treatment, or Combination Treatment for Cervical Radicular Pain: A Multicenter, Randomized, Comparative-Effectiveness Study

Anesthesiology. 2014 Nov;121(5):1045-55. doi: 10.1097/ALN.0000000000000409.

Abstract

Background: Cervical radicular pain is a major cause of disability. No studies have been published comparing different types of nonsurgical therapy.

Methods: A comparative-effectiveness study was performed in 169 patients with cervical radicular pain less than 4 yr in duration. Participants received nortriptyline and/or gabapentin plus physical therapies, up to three cervical epidural steroid injections (ESI) or combination treatment over 6 months. The primary outcome measure was average arm pain on a 0 to 10 scale at 1 month.

Results: One-month arm pain scores were 3.5 (95% CI, 2.8 to 4.2) in the combination group, 4.2 (CI, 2.8 to 4.2) in ESI patients, and 4.3 (CI, 2.8 to 4.2) in individuals treated conservatively (P = 0.26). Combination group patients experienced a mean reduction of -3.1 (95% CI, -3.8 to -2.3) in average arm pain at 1 month versus -1.8 (CI, -2.5 to -1.2) in the conservative group and -2.0 (CI, -2.7 to -1.3) in ESI patients (P = 0.035). For neck pain, a mean reduction of -2.2 (95% CI, -3.0 to -1.5) was noted in combination patients versus -1.2 (CI, -1.9 to -0.5) in conservative group patients and -1.1 (CI, -1.8 to -0.4) in those who received ESI; P = 0.064). Three-month posttreatment, 56.9% of patients treated with combination therapy experienced a positive outcome versus 26.8% in the conservative group and 36.7% in ESI patients (P = 0.006).

Conclusions: For the primary outcome measure, no significant differences were found between treatments, although combination therapy provided better improvement than stand-alone treatment on some measures. Whereas these results suggest an interdisciplinary approach to neck pain may improve outcomes, confirmatory studies are needed.

Publication types

  • Comparative Study
  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Amines / administration & dosage
  • Amines / adverse effects
  • Amines / therapeutic use
  • Analgesics / administration & dosage
  • Analgesics / adverse effects
  • Analgesics / therapeutic use
  • Antidepressive Agents, Tricyclic / administration & dosage
  • Antidepressive Agents, Tricyclic / adverse effects
  • Antidepressive Agents, Tricyclic / therapeutic use
  • Cervical Vertebrae
  • Cyclohexanecarboxylic Acids / administration & dosage
  • Cyclohexanecarboxylic Acids / adverse effects
  • Cyclohexanecarboxylic Acids / therapeutic use
  • Female
  • Follow-Up Studies
  • Gabapentin
  • Humans
  • Injections, Epidural
  • Male
  • Middle Aged
  • Neck Pain / drug therapy*
  • Nortriptyline / administration & dosage
  • Nortriptyline / adverse effects
  • Nortriptyline / therapeutic use
  • Pain Measurement / drug effects
  • Physical Therapy Modalities
  • Prospective Studies
  • Steroids / administration & dosage*
  • Steroids / adverse effects
  • Steroids / therapeutic use*
  • Treatment Outcome
  • gamma-Aminobutyric Acid / administration & dosage
  • gamma-Aminobutyric Acid / adverse effects
  • gamma-Aminobutyric Acid / therapeutic use

Substances

  • Amines
  • Analgesics
  • Antidepressive Agents, Tricyclic
  • Cyclohexanecarboxylic Acids
  • Steroids
  • gamma-Aminobutyric Acid
  • Gabapentin
  • Nortriptyline