The value of short-term pain relief in predicting the long-term outcome of ‘indirect’ cervical epidural steroid injections
The predictive value of short-term arm pain relief after ‘indirect’ cervical epidural steroid injection (ESI) for the 1-month treatment response has been previously demonstrated. It remained to be answered whether the long-term response could be estimated by the early post-interventional pain course as well.
Prospective observational study, following a cohort of n = 45 patients for a period of 24 months after ‘indirect’ ESI for radiculopathy secondary to a single-level cervical disk herniation (CDH). Arm and neck pain on the visual analog scale (VAS), health-related quality of life with the Short Form-12 (SF-12), and functional outcome with the Neck Pain and Disability (NPAD) Scale were assessed. Any additional invasive treatment after a single injection (second injection or surgery) defined treatment outcome as ‘non-response’.
At 24 months, n = 30 (66.7%) patients were responders and n = 15 (33.3%) were non-responders. Non-responders exited the follow-up at 1 month (n = 10), at 3 months (n = 4), and at 6 months (n = 1). No patients were injected again or operated on between the 6- and 24-month follow-up. Patients with favorable treatment response at 24 months had significantly lower VAS arm pain (p < 0.05) than non-responders at days 6, 8–11, and at the 3-month follow-up. The previously defined cut-off of > 50% short term pain reduction was not a reliable predictor of the 24-month responder status. SF-12 and NPAD scores were better among treatment responders in the long term.
Patients who require a second injection or surgery after ‘indirect’ cervical ESI for a symptomatic CDH do so within the first 6 months. Short-term pain relief cannot reliably predict the long-term outcome.
KeywordsArm pain Cervical disk herniation Epidural injection Long-term outcome Neck pain Nerve root Radicular pain
The authors thank their study nurse, Cornelia Lüthi, for her outstanding diligence in pursuing follow-up. The authors thank Jessica Reid and Meagan MacArthur for proof-reading the manuscript.
Compliance with ethical standards
Written informed consent was obtained from all included patients. The study was conducted in accordance with the ethical standards of the Cantonal Ethical Review Board St. Gallen, Switzerland (EKSG 13/061) with the Helsinki Declaration (1964, amended most recently in 2008) of the World Medical Association and registered under clinicaltrials.gov (Identifier: NCT01945554).
Conflict of interest
Dr. Holger Joswig receives speaker honoraria from UCB Canada and travel grants from Medtronic. All other authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript.
The study was conducted in accordance with the ethical standards of the Cantonal Ethical Review Board St. Gallen, Switzerland (EKSG 13/061) and with the Helsinki Declaration (1964, amended most recently in 2008) of the World Medical Association.
Written informed consent was obtained from all included patients.
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