1. 2012;15;E405-E434Effectiveness of Cervical Epidural Injections in the Management of Chronic Neck and Upper Extremity Pain
   Systematic Review
   Laxmaiah Manchikanti, MD, Ramsin M. Benyamin, MD, David A. Bryce, MD, Stephanie Geffert, MLIS, Haroon Hameed, MD, Manohar Lal Sharma, MD, Salahadin Abdi, MD, PhD, Frank J.E. Falco, MD, and Sudhir Diwan, MD.

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 was 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.