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Anesthesiology. 2014 Nov;121(5):1045-55. doi: 10.1097/ALN.0000000000000409.

Epidural steroid injections, conservative treatment, or combination treatment for cervical radicular pain: a multicenter, randomized, comparative-effectiveness study.

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From the Departments of Anesthesiology and Critical Care Medicine, and Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland; and Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland (S.P.C.); Department of Anesthesiology, University Hospital, Case Western Reserve School of Medicine, Cleveland, Ohio (S.H.); Department of Anesthesia, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Y.S.); Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, Maryland (P.F.P.); Pain Treatment Center, Department of Surgery, Regional Medical Center, Landstuhl, Germany (R.L.W.); Louis Stokes Cleveland VA Medical Center, Department of Anesthesiology, Case Western University, Cleveland, Ohio (E.V.); Department of Anesthesiology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical University, New York, New York (J.H.Y.H.); Anesthesia Service, Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland (C.K., S.R.G., A.V.V.); Departments of Internal Medicine and Neurology, District of Columbia VA Hospital, Washington, D.C. (Z.Z.); Pain Treatment Center, Department of Anesthesiology, San Antonio Military Medical Center, San Antonio, Texas (K.B.G.); Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland (S.R.G., A.V.V.); and Departments of Anesthesiology and Neurology, Penn State Hershey Medical Center, Hershey, Pennsylvania (D.M.G., Y.V.).



Cervical radicular pain is a major cause of disability. No studies have been published comparing different types of nonsurgical therapy.


A comparative-effectiveness study was performed in 169 patients with cervical radicular pain less than 4 yr in duration. Participants received nortriptyline and/or gabapentin plus physical therapies, up to three cervical epidural steroid injections (ESI) or combination treatment over 6 months. The primary outcome measure was average arm pain on a 0 to 10 scale at 1 month.


One-month arm pain scores were 3.5 (95% CI, 2.8 to 4.2) in the combination group, 4.2 (CI, 2.8 to 4.2) in ESI patients, and 4.3 (CI, 2.8 to 4.2) in individuals treated conservatively (P = 0.26). Combination group patients experienced a mean reduction of -3.1 (95% CI, -3.8 to -2.3) in average arm pain at 1 month versus -1.8 (CI, -2.5 to -1.2) in the conservative group and -2.0 (CI, -2.7 to -1.3) in ESI patients (P = 0.035). For neck pain, a mean reduction of -2.2 (95% CI, -3.0 to -1.5) was noted in combination patients versus -1.2 (CI, -1.9 to -0.5) in conservative group patients and -1.1 (CI, -1.8 to -0.4) in those who received ESI; P = 0.064). Three-month posttreatment, 56.9% of patients treated with combination therapy experienced a positive outcome versus 26.8% in the conservative group and 36.7% in ESI patients (P = 0.006).


For the primary outcome measure, no significant differences were found between treatments, although combination therapy provided better improvement than stand-alone treatment on some measures. Whereas these results suggest an interdisciplinary approach to neck pain may improve outcomes, confirmatory studies are needed.

[Indexed for MEDLINE]

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