Fluoroscopic cervical epidural injections in chronic axial or disc-related neck pain without disc herniation, facet joint pain, or radiculitis

Journal of Pain Research Dovepress open access to scientific and medical research O r i g i n al R esearc h Journal of Pain Research downloaded from https://www.dovepress.com/ by 79.137.96.48 on 12-Jul-2018 For personal use only. Open Access Full Text Article Fluoroscopic cervical epidural injections in chronic axial or disc-related neck pain without disc herniation, facet joint pain, or radiculitis This article was published in the following Dove Press journal: Journal of Pain Research 3 July 2012 Number of times this article has been viewed Laxmaiah Manchikanti Kimberly A Cash Vidyasagar Pampati Yogesh Malla Pain Management Center of Paducah, Paducah, KY, USA Background: While chronic neck pain is a common problem in the adult population, with a typical 12-month prevalence of 30%–50%, there is a lack of consensus regarding its causes and treatment. Despite limited evidence, cervical epidural injections are one of the commonly performed nonsurgical interventions in the management of chronic neck pain. Methods: A randomized, double-blind, active, controlled trial was conducted to evaluate the effectiveness of cervical interlaminar epidural injections of local anesthetic with or without steroids for the management of chronic neck pain with or without upper extremity pain in patients without disc herniation, radiculitis, or facet joint pain. Results: One hundred and twenty 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 two treatment groups, ie, injection of local anesthetic only (group 1) or local anesthetic mixed with nonparticulate betamethasone (group 2). The primary outcome of significant pain relief and improvement in functional status ($50%) was demonstrated in 72% of group 1 and 68% of group 2. The overall average number of procedures per year was 3.6 in both groups with an average total relief per year of 37–39 weeks in the successful group over a period of 52 weeks. Conclusion: Cervical interlaminar epidural injections of local anesthetic with or without steroids may be effective in patients with chronic function-limiting discogenic or axial pain. Keywords: chronic neck pain, cervical disc herniation, cervical discogenic pain, cervical epidural injections, epidural steroids, local anesthetics Introduction Correspondence: Laxmaiah Manchikanti 2831 Lone Oak Road, Paducah, KY 42003, USA Tel +1 270 554 8373 ext 101 Fax +1 270 554 8987 Email submit your manuscript | www.dovepress.com Dovepress http://dx.doi.org/10.2147/JPR.S32692 Powered by TCPDF (www.tcpdf.org) Chronic pain in the US has reached crisis levels, with an explosion of diagnostic and therapeutic measures.1 Chronic spinal pain is common in the general adult population, with low back and neck pain constituting the majority of the disorders.2–6 All modalities of treatment, including cervical spine surgery and cervical epidural injections, have risen dramatically over the past two decades.3,7–17 Studies of the prevalence of chronic neck pain and its impact on general health have shown that 14% of patients report grade II–IV neck pain, with a high pain intensity leading to disability, with grade 0 referring to no neck pain; grade I representing pain of low intensity and few activity limitations; grade II with pain of high intensity, but few activity limitations; grade III with pain of high intensity and high levels of disability associated with moderate limitations in activities; and grade IV referring to pain with high levels of disability and several activity limitations.5,6 Further, chronic recurrent neck pain is a common problem in the adult population, with a typical 12-month prevalence of 30%–50%.2,4,16 Journal of Pain Research 2012:5 227–236 227 © 2012 Manchikanti et al, publisher and licensee Dove Medical Press Ltd. This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited. Dovepress Journal of Pain Research downloaded from https://www.dovepress.com/ by 79.137.96.48 on 12-Jul-2018 For personal use only. Manchikanti et al Apart from cervical disc herniation, cervical facet joint and discogenic pain are the common causes, resulting in chronic mechanical neck pain with or without upper extremity pain.2,3,16–18 Thus, pain emanating from a degenerative disc may result in discogenic pain secondary to chemical irritation or predominantly axial pain secondary to internal disc disruption.19–21 Axial neck pain may be related to either a disc or facet joint, or be musculoligamentous. However, there is a lack of consensus regarding the causes and treatment of chronic neck pain without disc herniation and radiculitis. Among the various treatments available for managing axial discogenic pain, epidural injections are one of the most common nonsurgical interventions.3,16,22–28 In general, cervical epidural injections are not recommended for axial neck pain, but they are considered to be reasonable in disc herniation with radiculitis and spinal stenosis. The evidence for cervical epidural injections in disc herniation and radiculitis, though debated, is moderate.3 The evidence for epidural injection in axial discogenic pain is based on a single preliminary report of discogenic neck pain after excluding cervical facet joint pain in patients without disc herniation or radiculitis.23 In this trial, 70 patients were included, with 35 patients receiving local anesthetics only and the other 35 receiving local anesthetics with nonparticulate betamethasone. The results showed significant pain relief ($50%) in 80% of the patients in both groups, along with improvement in functional status ($50%) in 69% in group 1 (receiving local anesthetic only) and 80% in group 2 (also receiving steroids). In fact, the results of this preliminary evaluation were similar to those for disc herniation in the cervical spine,22 lumbar spine,29,30 thoracic spine,31 and discogenic pain in the lumbar spine,32,33 and superior to the results for spinal stenosis and post surgery syndrome in the lumbar and cervical spine.24,25,34–36 The underlying mechanism of action of epidurally administered local anesthetics and steroids is not clear, and is believed to be due to the anti-inflammatory properties of corticosteroids, but the evidence also indicates that local anesthetics may be as effective as steroids in managing spinal pain of various origins.22–25,29–39 Based on the clinical and experimental evidence, it appears that local anesthetics and steroids may provide long-term relief.40–47 This study was undertaken to evaluate the role of cervical interlaminar epidural injections of local anesthetics with or without steroids in patients with chronic, function-limiting neck pain with or without upper extremity pain secondary to discogenic pain without disc herniation, radiculitis, or facet joint pain. This report consists of the results of 228 Powered b (...truncated)