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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Systematic review of the effectiveness of cervical epidurals in the management of chronic neck pain

R Benyamin, V Singh, AT Parr, A Conn, S Diwan, and S Abdi.

Review published: 2009.

CRD summary

This review concluded that cervical interlaminar epidural injections had a significant effect in relieving chronic intractable pain of cervical origin and also provided long-term relief. Due to some limitations in the review reporting and the small amount of evidence from randomised trials, the conclusions of this review need to be considered cautiously.

Authors' objectives

To evaluate the effectiveness of cervical epidural injections with or without steroids in the management of chronic neck and upper extremity pain.

Searching

PubMed, EMBASE (1966 to November 2008) and The Cochrane Library were searched for studies published in English. Systematic and narrative reviews were handsearched. Search terms were reported.

Study selection

Randomised and observational studies of cervical epidural injections with or without steroids in patients with chronic mechanical or whiplash-related neck pain with or without radicular findings for at least three months were eligible for inclusion. Reports of complications were included. Outcomes were pain relief, functional assessment, psychological improvement, return to work and opioid intake and had to be measured after at least six months.

The included randomised controlled trials compared: epidural steroid and lidocaine injections to the same injections in posterior neck muscles; a single injection of bupivacaine and methylprednisolone to a continuous epidural; and a lidocaine with triamcinolone acetonide injection to a local anaesthetic with steroid and morphine sulphate.

Studies were selected by two reviewers. Disagreements were resolved by referral to a third reviewer.

Assessment of study quality

Study validity was assessed using modified Cochrane criteria for randomised controlled trials (RCTs), which covered a number of items related to the study population, interventions, effect measures and data presentation and analysis. These were combined to give weighted score with a maximum of 100. Observational studies were assessed using criteria from the Agency for Healthcare Quality which covered the study question, population, comparability of subjects, exposure or intervention, outcome measures, statistical analysis, results, discussion and source of funding. These were combined to give a weighted score with a maximum of 100. Only studies that scored at least 50 points were included in the synthesis.

The authors did not state how many reviewers performed the validity assessment.

Data extraction

Studies were classed as positive if the primary outcome showed a statistically significant benefit for injections compared with a placebo or active control (for RCTs) or if the injection showed positive results (for observational studies). Proportions of patients with pain relief at three, six and 12 months were extracted. Pain relief was classed as short-term if less than six months and long-term if longer than six months.

The authors did not report how many reviewers performed the data extraction.

Methods of synthesis

Results were presented as a narrative, grouped by study design. Studies performed under fluoroscopy were given priority.

Results of the review

Three RCTs (n=226) and five observational studies (n=273) were included in the synthesis. Two of the observational studies were retrospective, two were prospective and one was a chart review. RCTs scored between 50 and 56 for quality and observational studies scored between 28 and 48.

Pain relief: All three trials showed positive results for short-term pain relief (less than six months) and two reported positive results for long-term pain relief. Long-term results were not available in the third trial.

The individual observational studies concluded that: patients with radicular symptoms had the best pain relief and in contradiction to those with axial neck pain; 64% of patients had a good or excellent response to a cervical epidural steroid injection; 62% of patients had significant pain relief and 20% had complete relief; 83% had successful pain relief after three months; and 41.4% of patients had excellent pain relief six months post-injection.

Details of complications associated with interlaminar epidural steroid injections were reported in the paper.

Authors' conclusions

The authors concluded that cervical interlaminar epidural injections had a significant effect in relieving chronic intractable pain of cervical origin and also provided long-term relief.

CRD commentary

This review specified study inclusion criteria for interventions, participants and outcomes, but had broad inclusion criteria for study designs. Restricting the search to studies published in English increased the possibility of language bias. The assessment of study validity was very thorough and covered a large number of criteria for both randomised trials and observational studies. Study selection was performed independently by two reviewers, which helped reduce risks of errors or bias in the process; it was not reported whether validity assessment and data extraction were performed the same way. The presentation of results as positive or negative without supporting effect sizes, 95% confidence intervals and p-values made it difficult to judge the reliability of the information presented. Due to some limitations in the review reporting and the small amount of evidence from randomised trials, the conclusions of this review need to be considered cautiously.

Implications of the review for practice and research

The authors did not stated any implications for practice or research.

Funding

No external funding.

Bibliographic details

Benyamin R, Singh V, Parr AT, Conn A, Diwan S, Abdi S. Systematic review of the effectiveness of cervical epidurals in the management of chronic neck pain. Pain Physician 2009; 12(1): 137-157. [PubMed: 19165300]

Indexing Status

Subject indexing assigned by NLM

MeSH

Analgesics /therapeutic use; Cervical Vertebrae /drug effects; Chronic Disease; Humans; Injections, Epidural /methods; Neck Pain /drug therapy

AccessionNumber

12009104468

Database entry date

03/11/2010

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 19165300