Nonorganic (Behavioral) Signs and Their Association With Epidural Corticosteroid Injection Treatment Outcomes and Psychiatric Comorbidity in Cervical Radiculopathy: A Multicenter Study

Cohen, Steven P.; Doshi, Tina L.; Dolomisiewicz, Edward; Reece, David E.; Zhao, Zirong; Anderson-White, Mirinda; Kasuke, Angelia; Wang, Eric J.; Hsu, Annie; Davis, Shelton A.; Yoo, Yongjae; Pasquina, Paul F.; Moon, Jee Youn

doi:10.1016/j.mayocp.2022.11.022

Cited by 3 publications

(4 citation statements)

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“…This is consistent with other studies demonstrating an inverse relationship between disease burden (including duration of pain and disability) and treatment effect for neck and back pain. 34,35 The recent emphasis on personalized medicine and phenotyping has led to attempts to identify likely responders, which may improve the cost-effectiveness and risk:benefit ratios. Studies performed in diabetic neuropathy suggest an “irritable nociceptor” phenotype may be more likely to respond to both topical and intravenous lidocaine, but whether higher baseline pain thresholds predispose to failure for mechanical pain is unknown.…”

Section: Discussionmentioning

confidence: 99%

“…We found no significant effect for baseline PPT, but reasons other than sensitized nociceptors can cause low PPTs, including nonorganic pathology, nociplastic pain, and secondary gain, all of which are associated with treatment failure. 31,34,35 The trend toward younger age being associated with a positive lidocaine treatment outcome may be attributed to the higher contribution of myofascial pain (greater muscle mass) in younger individuals compared to the degenerative processes such as facetogenic and discogenic neck pain that predominate in the elderly. 6…”

Section: Discussionmentioning

confidence: 99%

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Multicenter, Randomized, Placebo-controlled Crossover Trial Evaluating Topical Lidocaine for Mechanical Cervical Pain

Cohen,

Larkin,

Weitzner

et al. 2023

Anesthesiology

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Background There are few efficacious treatments for mechanical neck pain, with controlled trials suggesting efficacy for muscle relaxants and topical non-steroidal anti-inflammatory drugs. Although studies evaluating topical lidocaine for back pain have been disappointing, the more superficial location of the cervical musculature suggests a possible role for topical local anesthetics. Methods We performed a randomized, double-blind, placebo-controlled crossover trial at 4 U.S. military, Veterans Administration, academic and private practice sites in which 76 patients were randomized to receive either placebo followed by lidocaine patch for 4-week intervals (group 1) or a lidocaine-placebo patch sequence. The primary outcome measure was mean reduction in average neck pain, with a positive categorical outcome designated as a ≥2-point reduction in average neck pain coupled with a ≥5/7 score on the Patient Global Impression of Change scale at the 4-week endpoint. Results For the primary outcome, the median reduction in average neck pain score was -1.0 (IQR -2.0, 0.0) for the lidocaine phase vs. -0.5 (IQR -2.0,.0) for placebo treatment (p=0.17). 27.7% of patients experienced a positive outcome during lidocaine treatment vs. 14.9% during the placebo phase (p=0.073). There were no significant differences between treatments for secondary outcomes, though a carryover effect on pain pressure threshold was observed for the lidocaine phase (p=0.015). 27.5% of patients in the lidocaine group and 20.5% in the placebo group experienced minor reactions, the most common of which was pruritis (p=0.036). Conclusions The differences favoring lidocaine were small and non-significant, but the trend towards superiority of lidocaine suggests more aggressive phenotyping and applying formulations with greater penetrance may provide clinically meaningful benefit.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Multicenter, Randomized, Placebo-controlled Crossover Trial Evaluating Topical Lidocaine for Mechanical Cervical Pain

Cohen,

Larkin,

Weitzner

et al. 2023

Anesthesiology

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“…Medical imaging such as fluoroscopy is recommended for all techniques to improve accuracy of needle placement in the epidural space. 62,63 Interlaminar epidural corticosteroid administration…”

Section: Interventional Pain Managementmentioning

confidence: 99%

“…In one study evaluating cervical interlaminar steroid injections for cervical radicular pain, the presence of non‐herniated disk pathology, higher baseline disability, and nonorganic signs were associated with negative outcome. Medical imaging such as fluoroscopy is recommended for all techniques to improve accuracy of needle placement in the epidural space 62,63 …”

Section: Treatmentsmentioning

confidence: 99%

2. Cervical radicular pain

et al. 2023

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IntroductionCervical radicular pain is pain perceived in the upper limb, caused by irritation or compression of a cervical spine nerve, the roots of the nerve, or both.MethodsThe literature on the diagnosis and treatment of cervical radicular pain was retrieved and summarized.ResultsThe diagnosis is made by combining elements from the patient's history, physical examination, and supplementary tests. The Spurling and shoulder abduction tests are the two most common examinations used to identify cervical radicular pain. MRI without contrast, CT scanning, and in some cases plain radiography can all be appropriate imaging techniques for nontraumatic cervical radiculopathy. MRI is recommended prior to interventional treatments. Exercise with or without other treatments can be beneficial. There is scant evidence for the use of paracetamol, nonsteroidal anti‐inflammatory drugs, and neuropathic pain medications such as gabapentin, pregabalin, tricyclic antidepressants, and anticonvulsants for the treatment of radicular pain. Acute and subacute cervical radicular pain may respond well to epidural corticosteroid administration, preferentially using an interlaminar approach. By contrast, for chronic cervical radicular pain, the efficacy of epidural corticosteroid administration is limited. In these patients, pulsed radiofrequency treatment adjacent to the dorsal root ganglion may be considered.ConclusionsThere is currently no gold standard for the diagnosis of cervical radicular pain. There is scant evidence for the use of medication. Epidural corticosteroid injection and pulsed radiofrequency adjacent to the dorsal root ganglion may be considered. [Correction added on 12 June 2023, after first online publication: The preceding sentence was corrected.]

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