In this post we continue our discussion on conservative treatment of neck pain.
Interventional Pain Management
Epidural steroid injections (ESI) and facet injections are often prescribed in the conservative management of neck pain. They are not only used to provide relief to the patient, but also are used for diagnostic purposes (i.e. to help the surgeon tease out which nerve is being irritated prior to committing the patient to surgery.) There is mixed evidence that supports the use of ESI in cervical radiculopathy. 80% of patients who underwent ESI in a recent study by Lee et al (Spine 2012, 37(12):1041-7) were able to avoid surgery for cervical radiculopathy. There was no control group in this study, though, so it’s impossible to tell if these people would have gotten better on their own without the injections. Another recent study (Anderberg et al, 2007) showed no benefit of injections containing steroids plus a local anesthetic when compared to injections of saline and local anesthetic. While this data on ESI for cervical radiculopathy is mixed there is no data that supports use of ESI in neck pain. There is, however, good evidence that supports of the use of facet rhizotomies (where the nerves carrying pain signals from the facet joints are burned using specialized probes) in providing long-term relief for patients with chronic neck pain.
In review, to examine the benefits of these conservative treatments it helps to address them in the context of two questions:
•Question #1: do these conservative treatments help patients feel less pain and disability? The short answer is yes, sort of. While anecdotally we may know these treatments help ease some patients’ pain, ultimately there just isn’t good data out there to support their efficacy. Part of the issue is that it’s very difficulty to randomize and blind patients to treatment groups to study these various treatments. For example, how do you compare acupuncture, in which the patient is stuck with dozens of needles, to a sham treatment (i.e. how do you blind someone to make them think they’re being stuck with needles?)
•Question #2: do these conservative treatments help patients avoid eventual surgery? The short answer is no. Aside from the previously mentioned study on ESI, there’s even less data to support that any of these conservative treatments will ultimately prevent the patient from having surgery.
In the end, given the lack of good data on these treatments, it’s impossible to say whether these conservative treatments are helping you heal more quickly are or are just distracting you while you heal on your own. Consider the words of Voltaire: “The art of medicine consists in amusing the patient while nature cures the disease.”
J. Alex Thomas, M.D.