Chronic neck pain without a disc protrusion or facet indications (negative blocks) gets no respect. One can have pain from internal disc disruptions in a neck disc and have nothing to show for it. Now it looks like the patient’s pain can be cut in half for months with just injections of local, epidurally.
Cervical Epidural Injections in Chronic Discogenic Neck Pain Without Disc Herniation or Radiculitis: Preliminary Results of a Randomized, Double-Blind, Controlled Trial
Laxmaiah Manchikanti, MD, Kimberly A. Cash, RT, Vidyasagar Pampati, MSc, Bradley W. Wargo, DO, and Yogesh Malla, MD
Pain Physician 2010; 13:E265-E278 free article here
- randomized, double-blind, active control trial.
- 70 patients – half got lidocaine epidural 0.5% 5 mls
– “half got 0.5% lidocaine, 4 mL, mixed with 1 mL or 6 mg of non-particulate betamethasone”
Suddenly I see problems – if something is non-particulate it means its duration of action is maybe 4 hours which is not likely to do anything. I once had a patient who was injected with soluble decadron for a tennis elbow – needless to say, it helped his elbow squat.
There is a concern that particulate cortisone may dangerously work its way into spinal blood vessels and plug them up – but that has been only shown to happen with laterally injected nerve roots – NOT epidually:
Safety Considerations in Epidural Steroid Injections: Particulate versus Nonparticulate Steroids
article here if link not work try cached here
However, they stated:
“The concern of arterial embolic infarcts has not been reported with this approach and thus particulate steroids should be safe. Because particulate steroids may be slightly more efficacious,21,22 it is reasonable to use them for interlaminar injections, whether for cervical, thoracic or lumbar injections.”
However, using a cortisone injection that lasts only 4 hours is, as far as I am concerned, the same as not using any cortisone at all – and should show no difference in effectiveness – which is what it showed!
results on pain:
Big surprise – Plain dilute local lidocaine can cause persistent over 50% relief for over a year. What is no surprise is that adding a cortisone that lasts only 4 hours didn’t help any extra. Interestingly, those it did not work on, relapsed within days- 1-2 weeks, the responders seemed to have long term results
Most epidurals are done with particulate (white looking) cortisone that lasts weeks and has been shown to have a better result on inflammation – particularly if you lie patients down with the bad side down so cortisone can settle on that side (see – Steroid Epidurals – Why Some Work And Some Not So Well)
Comments – I heard of a man in his forties with teenage children who went to Vancouver for special neck imaging. After, they told him there was nothing that could be done for his pain. He went back home and killed himself. This story makes me sick considering how much this simple measure (and maybe more so if they added real cortisone) could help. Never give up – there are always new things coming out.
Also – point to people in chronic pain – depression is a form of chronic pain – chronic pain and depression share many of the same circuits. This is why antidepressants help both pain and depression. Untreated depression in chronic pain is a huge tragedy – please, please please get your depression treated. In Saskatchewan, there is also a chronic pain program that can help you learn to cope:
Any comments?