title: Epidural steroid injections, conservative treatment, or combination treatment for cervical radicular pain: a multicenter, randomized, comparative-effectiveness study.
abstract: BACKGROUND
  Cervical radicular pain is a major cause of disability. No studies have been published comparing different types of nonsurgical therapy.
  
  
  METHODS
  A comparative-effectiveness study was performed in 169 patients with cervical radicular pain less than 4 yr in duration. Participants received nortriptyline and/or gabapentin plus physical therapies, up to three cervical epidural steroid injections (ESI) or combination treatment over 6 months. The primary outcome measure was average arm pain on a 0 to 10 scale at 1 month.
  
  
  RESULTS
  One-month arm pain scores were 3.5 (95% CI, 2.8 to 4.2) in the combination group, 4.2 (CI, 2.8 to 4.2) in ESI patients, and 4.3 (CI, 2.8 to 4.2) in individuals treated conservatively (P = 0.26). Combination group patients experienced a mean reduction of -3.1 (95% CI, -3.8 to -2.3) in average arm pain at 1 month versus -1.8 (CI, -2.5 to -1.2) in the conservative group and -2.0 (CI, -2.7 to -1.3) in ESI patients (P = 0.035). For neck pain, a mean reduction of -2.2 (95% CI, -3.0 to -1.5) was noted in combination patients versus -1.2 (CI, -1.9 to -0.5) in conservative group patients and -1.1 (CI, -1.8 to -0.4) in those who received ESI; P = 0.064). Three-month posttreatment, 56.9% of patients treated with combination therapy experienced a positive outcome versus 26.8% in the conservative group and 36.7% in ESI patients (P = 0.006).
  
  
  CONCLUSIONS
  For the primary outcome measure, no significant differences were found between treatments, although combination therapy provided better improvement than stand-alone treatment on some measures. Whereas these results suggest an interdisciplinary approach to neck pain may improve outcomes, confirmatory studies are needed.
authors.affiliation: From the Departments of Anesthesiology and Critical Care Medicine, and Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, Maryland; and Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland (S.P.C.); Department of Anesthesiology, University Hospital, Case Western Reserve School of Medicine, Cleveland, Ohio (S.H.); Department of Anesthesia, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Y.S.); Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, Maryland (P.F.P.); Pain Treatment Center, Department of Surgery, Regional Medical Center, Landstuhl, Germany (R.L.W.); Louis Stokes Cleveland VA Medical Center, Department of Anesthesiology, Case Western University, Cleveland, Ohio (E.V.); Department of Anesthesiology, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical University, New York, New York (J.H.Y.H.); Anesthesia Service, Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland (C.K., S.R.G., A.V.V.); Departments of Internal Medicine and Neurology, District of Columbia VA Hospital, Washington, D.C. (Z.Z.); Pain Treatment Center, Department of Anesthesiology, San Antonio Military Medical Center, San Antonio, Texas (K.B.G.); Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland (S.R.G., A.V.V.); and Departments of Anesthesiology and Neurology, Penn State Hershey Medical Center, Hershey, Pennsylvania (D.M.G., Y.V.).
authors.forename: Steven P
authors.initials: SP
authors.lastname: Cohen
authors.forename: Salim
authors.initials: S
authors.lastname: Hayek
authors.forename: Yevgeny
authors.initials: Y
authors.lastname: Semenov
authors.forename: Paul F
authors.initials: PF
authors.lastname: Pasquina
authors.forename: Ronald L
authors.initials: RL
authors.lastname: White
authors.forename: Elias
authors.initials: E
authors.lastname: Veizi
authors.forename: Julie H Y
authors.initials: JH
authors.lastname: Huang
authors.forename: Connie
authors.initials: C
authors.lastname: Kurihara
authors.forename: Zirong
authors.initials: Z
authors.lastname: Zhao
authors.forename: Kevin B
authors.initials: KB
authors.lastname: Guthmiller
authors.forename: Scott R
authors.initials: SR
authors.lastname: Griffith
authors.forename: Aubrey V
authors.initials: AV
authors.lastname: Verdun
authors.forename: David M
authors.initials: DM
authors.lastname: Giampetro
authors.forename: Yakov
authors.initials: Y
authors.lastname: Vorobeychik
mesh_terms: D000328:Adult; D000588:Amines / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D000700:Analgesics / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D000929:Antidepressive Agents, Tricyclic / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D002574:Cervical Vertebrae; D003509:Cyclohexanecarboxylic Acids / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D005260:Female; D005500:Follow-Up Studies; D000077206:Gabapentin; D006801:Humans; D007268:Injections, Epidural; D008297:Male; D008875:Middle Aged; D019547:Neck Pain / Q000188:drug therapy*; D009661:Nortriptyline / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D010147:Pain Measurement / Q000187:drug effects; D026741:Physical Therapy Modalities; D011446:Prospective Studies; D013256:Steroids / Q000008:administration & dosage* / Q000009:adverse effects / Q000627:therapeutic use*; D016896:Treatment Outcome; D005680:gamma-Aminobutyric Acid / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use
chemical_list: D000588:Amines; D000700:Analgesics; D000929:Antidepressive Agents, Tricyclic; D003509:Cyclohexanecarboxylic Acids; D013256:Steroids; D005680:gamma-Aminobutyric Acid; D000077206:Gabapentin; D009661:Nortriptyline