Abstract
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
Highlights
The high prevalence of chronic persistent neck pain leads to disability and has a significant economic, societal, and health impact
Outcomes Assessment Criteria for Significant Improvement No descriptions of outcomes OR < 20% change in pain rating or functional status Pain rating with a decrease of 2 or more points or more than 20% reduction OR functional status improvement of more than 20% Pain rating with decrease of ≥ 2 points AND ≥ 20% change or functional status improvement of ≥ 20% Pain rating with a decrease of 3 or more points or more than 50% reduction OR functional status improvement with a 50% or 40% reduction in disability score Significant improvement with pain and function ≥ 50% or 3 points and 40% reduction in disability scores 12
Description of Drop Out Rate No description of dropouts, despite reporting of incomplete data or ≥ 20% withdrawal Less than 20% withdrawal in one year in any group Less than 30% withdrawal at 2 years in any group 14
Summary
The high prevalence of chronic persistent neck pain leads to disability and 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 common modalities of treatments provided in managing neck and upper extremity pain. They are administered by either an interlaminar approach or transforaminal approach
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