The value of short-term pain relief in predicting the long-term outcome of 'indirect' cervical epidural steroid injections

Clinical Efficacy of Epidural Injections of Local Anesthetic Alone or Combined with Steroid for Neck Pain: A Systematic Review and Meta-Analysis

Aims

To compare the effectiveness of cervical epidural injections of local anesthetic with vs. without a steroid.

Methods

Three databases (PubMed, Embase, and Cochrane library) were used to search and assess all clinical randomized controlled trials regarding the clinical efficacy of epidural injections from January 01, 2009, to October 31, 2020. Cochrane review criteria and the Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment instrument were used to evaluate the methodologic quality of the included studies. Qualitative and quantitative analyses were performed according to best evidence synthesis principles and by single-arm meta-analysis, respectively.

Results

Based on the search criteria, 4 RCTs were qualitatively and quantitatively analyzed in the single-arm meta-analysis. Treatment with lidocaine alone or with the steroid resulted in decreases of 4.46 and 4.29 points, respectively, in pain scores and of 15.8 and 14.46 points, respectively, in functional scores at 6 months. Similar trends were observed at the 1-year follow-up: pain scores decreased by 4.27 and 4.14 points, while functional scores decreased by 15.94 and 14.44 points in patients with neck pain who received lidocaine without or with the steroid, respectively. In the 3 studies that reported 2-year follow-up data, patients with neck pain treated with lidocaine or lidocaine + steroid showed 4.2- and 4.14-point decreases, in pain score and 15.92- and 14.89-point decreases, respectively, in functional scores.

Conclusions

The studies showed level I (strong) evidence for short- and long-term improvements in pain relief and functionality with cervical epidural injections of local anesthetic alone or with a steroid in the management of neck pain.

Repeat epidural steroid injections for radicular pain due to lumbar or cervical disc herniation

Aims

The aim of this study was to determine the efficacy of repeat epidural steroid injections as a form of treatment for patients with insufficiently controlled or recurrent radicular pain due to a lumbar or cervical disc herniation.

Patients and Methods

A cohort of 102 patients was prospectively followed, after an epidural steroid injection for radicular symptoms due to lumbar disc herniation, in 57 patients, and cervical disc herniation, in 45 patients. Those patients with persistent pain who requested a second injection were prospectively followed for one year. Radicular and local pain were assessed on a visual analogue scale (VAS), functional outcome with the Oswestry Disability Index (ODI) or the Neck Pain and Disability Index (NPAD), as well as health-related quality of life (HRQoL) using the 12-Item Short-Form Health Survey questionnaire (SF-12).

Results

A second injection was performed in 17 patients (29.8%) with lumbar herniation and seven (15.6%) with cervical herniation at a mean of 65.3 days (sd 46.5) and 47 days (sd 37.2), respectively, after the initial injection. All but one patient, who underwent lumbar microdiscectomy, responded satisfactorily with a mean VAS for leg pain of 8.8 mm (sd 10.3) and a mean VAS for arm pain of 6.3 mm (sd 9) one year after the second injection, respectively. Similarly, functional outcome and HRQoL were improved significantly from the baseline scores: mean ODI, 12.3 (sd 12.4; p < 0.001); mean NPAD, 19.3 (sd 24.3; p = 0.041); mean SF-12 physical component summary (PCS) in lumbar herniation, 46.8 (sd 7.7; p < 0.001); mean SF-12 PCS in cervical herniation, 43 (sd 6.8; p = 0.103).

Conclusion

Repeat steroid injections are a justifiable form of treatment in symptomatic patients with lumbar or cervical disc herniation whose symptoms are not satisfactorily relieved after the first injection. Cite this article: Bone Joint J 2018;100-B:1364–71.