Effect of low-dose lidocaine on objective upper extremity strength and immediate pain relief following cervical interlaminar epidural injections: a double-blinded randomized controlled trial

Abstract

BackgroundLow-dose lidocaine is a common diluent for analgesia following cervical interlaminar epidural steroid injection (CIESI). Concerns with this practice exist. A single-arm cohort reported that 20% of patients develop postprocedural upper extremity weakness when using lidocaine as a diluent. Furthermore, a high-cervical spinal block with unintended intrathecal or subdural administration is possible.ObjectiveDetermine if low-dose lidocaine as a diluent during CIESI causes clinically meaningful (1) upper extremity weakness and (2) immediate pain relief when compared with saline.DesignDouble-blinded randomized control trial.MethodsPatients with cervical radicular pain scheduled for CIESI were enrolled. Participants received lidocaine (CIESI-L) or saline (CIESI-S) as a diluent for the epidural injectate. Myotomal strength was measured with dynamometry before and between 20 and 30 min after CIESI. Pre-pain and post-pain scores were obtained. Primary and secondary outcomes were post-CIESI weakness of ≥20% (minimal clinically important difference (MCID)) in >1 myotome and ≥50% pain reduction on the numerical scale.Results120 participants (64 females (53%), mean age, 56 (SD 13.7) years) completed the study and were analyzed (CIESI-L n=60; CIESI-S n=60). There was no significant between-group difference in the proportion of participants with postprocedural weakness, CIESI-L 41.7% (95% CI, 29.8% to 54.5%), CIESL-S 50% (95% CI, 37.5% to 62.5%). Between-group comparison showed no significant difference in pain reduction, relative risk 1.53 (95% CI, 0.82 to 2.86).ConclusionLow-dose lidocaine as a diluent in CIESI does not significantly increase the risk of post-CIESI myotomal weakness when compared with saline, but also does not substantially increase the likelihood of immediate, meaningful pain relief.Trial registration detailsClinicalTrials.gov (NCT03127137); December 26, 2017.

Concurrent Bell’s Palsy and Facial Pain Improving with Multimodal Chiropractic Therapy: A Case Report and Literature Review

“…Recent evidence also suggests that spinal manipulation can help restore sensory-motor congruence [ 42 ], but this mechanism has not been studied specifically in Bell’s palsy. Another potential mechanism relies on the concept of pain-related weakness, whereby muscle strength is inhibited in the presence of pain, and improved in the absence of pain [ 43 ]. It is therefore possible that by alleviating patients’ face and neck pain through spinal manipulation, facial motor function likewise improves.…”

Upper limb weakness and importance of immediate pain relief after cervical epidural steroid injections: more questions than answers?

“…Yet despite this analysis, the risk difference was 9% (32%-19%), which increased to 13% with just another patient success in the L-CIESI group, indicating fragility of the study results. 1 Considering the risk-benefit ratio of steroids, it has been recommended that the lowest possible dose of steroids be used since there is no added benefit from using doses of depo-steroid above 40 mg. 6 Given all the above considerations, the study conclusions should be applicable only to the study population and for immediate post-procedural outcomes, without any inferences on long-term results. We also implore the authors to consider longer follow-up periods to elicit patient-relevant clinical outcomes.…”