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Researchers from Johns Hopkins Medicine and other institutions claim to have developed a quick clinical test that predicts which patients with neck pain are more likely to benefit from epidural steroid injections, which deliver drugs directly around the spinal nerves to reduce nerve inflammation and pain.
The unpleasant injections are a typical treatment for neck discomfort. Still, they can cost hundreds of dollars each, involve dangers, and only assist a small percentage of patients, according to research. A new physical exam variation, presented on February 15 in Mayo Clinic Proceedings in 78 adults with neck discomfort, could assist in advising appropriate treatment use. "Until now, it was really a 50/50 coin flip whether an epidural steroid injection would help any given neck pain patient," says Steven P. Cohen, M.D., professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine. "We looked at many different variables and believe we've figured out a quick and reliable way to provide patients with much more accurate, personalized information on their chances of getting better, and actually improve their odds of treatment success." According to the American Medical Association, back and neck pain are among the ailments that incur the highest amounts of total healthcare spending in the United States. Each year, doctors administer more than 10 million epidural steroid injections for back and neck pain. Injected steroids can reduce the swelling and pressure on nerves that contribute to pain. However, the underlying causes of back and neck pain are diverse, and not all patients experience pain relief from the injections. As a result, the procedure is facing increased scrutiny by hospital systems and insurers, fueling a search for ways to better identify patients most likely to benefit. In the new study, Cohen and collaborators adapted Waddell signs -- a group of eight physical signs, named after the physician who developed them, more than 50 years ago, as a tool to identify patients whose back pain may not be due to physical abnormalities that can be treated surgically --for neck pain patients. The signs, which can be assessed in a few minutes by a clinician, include checking for tenderness; overreaction to light stimulation; weakness not clearly explained by any physical injury or abnormality; pain that disappears when the patient is distracted; and pain that extends beyond expected areas of the body. "These physical exam manoeuvres are incredibly simple to perform and easy to identify," says Cohen. For back pain, Waddell signs are used primarily to determine whether back pain is non-organic (not associated with a direct anatomic cause). Previously, many clinicians interpreted these signs as indicative of malingering or psychological factors. More recently, however, researchers have shown that such nonorganic signs may also point to complex underlying causes of pain. In general, studies have shown that back pain patients with more Waddell signs are less likely to benefit from treatment. To conduct their new study, clinicians at The Johns Hopkins Hospital, Walter Reed National Military Medical Center, the District of Columbia Veterans Affairs Medical Center and Seoul National University, in Korea examined 78 neck pain patients for the eight nonorganic physical signs before treating them with epidural steroid injections. Overall, 29 per cent (23) of the patients showed no nonorganic signs; 21 per cent (16) had one nonorganic sign; and 50 per cent (39) of patients had two or more signs before injections. One month later, patients whose pain was still decreased by the epidural steroid injection had, on average, just 1.3 nonorganic signs, while those whose pain was not decreased at the one-month mark had, on average, 3.4 nonorganic signs. Some of the individual Waddell signs were highly correlated with a lack of response to the injections. For example, 55 per cent of injection nonresponders showed apparent overreactions to light touch, while only 11 per cent of those helped by the injections showed this sign. The researchers also found that people with more non-organic signs associated with their neck pain were more likely to report chronic pain in other areas of the body, as well as fibromyalgia and psychiatric conditions. Cohen says it appears that the presence of multiple nonorganic signs is identifying patients who might benefit from other treatment approaches, before trying epidural steroid injections. "But further research must be done to determine the best options." For now, Cohen says the findings can immediately help guide conversations between patients with neck pain and their doctors when weighing the potential risks and benefits of an epidural steroid injection. (ANI)
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