Effectiveness of Cervical Epidural Injections in the Management of Chronic Neck and Upper Extremity Pain

Background: Chronic persistent neck pain with or without upper extremity pain is common in thegeneral adult population with prevalence of 48% for women and 38% for men, with persistent complaintsin 22% of women and 16% of men. Multiple modalities of treatments are exploding in managing chronicneck pain along with increasing prevalence. However, there is a paucity of evidence for all modalities oftreatments in managing chronic neck pain.Cervical epidural injections for managing chronic neck pain are one of the commonly performedinterventions in the United States. However, the literature supporting cervical epidural steroids inmanaging 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 typesof 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 andupper extremity pain were reviewed. The quality assessment and clinical relevance criteria utilized were theCochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trialsand 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 developedby the U.S. Preventive Services Task Force (USPSTF).Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 toDecember 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 6months and long-term > 6 months). Secondary outcome measures were improvement in functionalstatus, 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 totalof 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 is 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 andsteroids, fair with local anesthetic only; whereas, it is fair for local anesthetics with or without steroids, foraxial or discogenic pain, pain of central spinal stenosis, and pain of post surgery syndrome.Key words: Cervical disc herniation, cervical axial discogenic pain, cervical central spinal stenosis, cervicalpost surgery syndrome, cervical radiculitis, cervical interlaminar epidural injections, local anesthetic, steroids