Johns Hopkins Medicine (JHMI.edu)
October 23, 2014
A multicenter study of 169 men and women with a common form of neck pain suggests that both spinal steroid injections and conservative treatment with physical therapy and painkillers work equally well to relieve pain in the short term. But over time, a combination of the two appears to offer the most relief.
Results of the study, led by pain specialists at the Johns Hopkins University School of Medicine, are described online on October 21st in the journal Anesthesiology.
"We believe this is the largest study ever done evaluating epidural steroid injections for neck pain and the first that compares injections, conservative therapy and a combination of the two in this patient population," says Steven P. Cohen, M.D., a professor of anesthesiology and critical care medicine in the Johns Hopkins University School of Medicine and the director of the Johns Hopkins Blaustein Pain Treatment Center.
Cohen says a few very small studies previously compared epidural steroid injections to other treatments, but they only recruited patients with low back pain, did not consistently compare ideal treatments or combination treatments, and did not record long-term follow-up reports of pain status.
Experts estimate that up to two-thirds of adults will experience significant neck pain in their lifetimes. Injecting steroids into the space around spinal nerves in the neck to reduce inflammation and pain is the most commonly performed procedure in pain clinics throughout the United States, yet studies on its effectiveness for neck pain have generated mixed results, Cohen notes. "We designed our study to answer the question that primary care doctors face when they see patients with neck pain: Should I send them for a series of injections, try conservative measures first or do both?" he says.
For the study, the researchers recruited 169 individuals over age 18 from eight academic, military and VA medical centers, all of who were diagnosed with neck pain from a herniated disc or narrowing of the spinal canal (stenosis) that inflamed or pinched nerves in their neck and caused pain that radiated to their arms. The participants were separated into three groups, or treatment arms, that reflected the treatment choices: steroid injections, physical therapy and pain medications (gabapentin and/or nortriptyline), or a combination of both.
After one month, the research team found no significant differences in outcomes between groups receiving epidural steroid injections and those getting conservative treatments, although combination therapy provided better improvement than stand-alone treatment on some measures of pain, Cohen says. Three months post-treatment, 56.9 percent of patients treated with combination therapy experienced meaningful relief in their arm pain and were satisfied with treatment, compared to 26.8 percent in the conservative therapy group and 36.7 percent in the group receiving injections alone.
Cohen says combination therapy, also known as multimodal therapy, has become a cornerstone in rehabilitation medicine, because without reinforcement with physical therapy, relief from injections is usually temporary and less pronounced.
"All of this suggests that epidural steroid injections should not be a first-line, stand-alone treatment, but they may improve outcomes when used in conjunction with a multidisciplinary treatment approach that includes physical therapy and exercise," Cohen says.
He cautions that additional studies are needed to determine precisely why the combination group fared the best. One possibility is that the increased benefit was due to the impact of physical therapy combined with the epidural steroid injections; another is that the pain drugs and epidural steroid injections leveraged each others' effects. A third possibility is that all three components - physical therapy, drugs and injections - complement each other.
"This study could not have been done in a way that neither patients nor their doctors would know which subjects got what treatment," Cohen notes, "so it is also possible that those in the combination group had a higher ‘placebo' response rate. In other words, patients assigned to that group may have felt as if they had won the lottery - ‘I'm getting all of the treatments.'"
The research was funded by the Center for Rehabilitation Sciences Research.