Researchers from Johns Hopkins Medicine and several other institutions have devised a rapid clinical test that can predict the people suffering from neck pain are most likely to be benefited from epidural steroid injections. They provide drugs directly to the spinal nerves in order to prevent nerve inflammation and decrease the pain. The painful injections are the most common method of solution for pain in the neck however they can cost hundreds dollars per injection; come with risks and only help just a small percentage of patients, research shows. A new variant of the physical exam, described in February. 15th within Mayo Clinic Proceedings in a study of 78 patients suffering from neck pain, can assist in the selection of the treatment.
Up until now, it was always a coin flip to determine whether an epidural steroid injection could help a neck pain sufferer. We examined many factors and believe that we’ve come up with a fast and reliable method to provide patients with more precise and personalized information about their odds of getting better and increase the chances of success in treatment.”
Steven P. Cohen, M.D., professor of anesthesiology as well as critical care medicineat the Johns Hopkins University School of Medicine
Based on the American Medical Association, back and neck pain is among the diseases that cost the largest percentage of healthcare expenditures across the United States. Every year doctors administer more than 10 million epidural steroids to treat back and neck discomfort. The steroids injected can help reduce inflammation and pressure on the nerves that cause pain. But the root factors that cause back as well as neck pain can be diverse so not every patient will receive pain relief from the injections. This is why the procedure is now under greater scrutiny from hospital systems as well as insurers, leading to a hunt for methods to help discern patients who are most likely benefit from.
In the study of the moment, Cohen and collaborators adapted Waddell signs — a set of eight physical indicators, named for the doctor who developed them over 50 years ago, to serve as an aid in identifying patients with back discomfort is not caused by physical issues which can be treated surgically for neck pain sufferers. The signs, which are evaluated in just a few minutes by a physician to check for tenderness; an overreaction to stimulation with light or a weakness that cannot be due to any physical condition or injury and pain that subsides in the event of distraction and pain that is beyond the normal parts within the body.
“These physical exam exercises are extremely easy to master and simple to spot,” says Cohen.
For back discomfort, Waddell signs are used in order to determine if back pain is not organic (not connected to an or anatomic cause). Many clinicians previously believed that these signs were an indication of malingering or psychological reasons. However, in recent years researchers have discovered that these non-organic signs could indicate more complicated underlying reasons for back pain. The majority of studies have proven that back pain sufferers with more Waddell indicators tend to not receive treatment.
For their latest study, doctors from The Johns Hopkins Hospital, Walter Reed National Military Medical Center as well as The District of Columbia Veterans Affairs Medical Center and Seoul National University, in Korea assessed the necks of 78 patients for the nonorganic physical signs prior to administering epidural injections of steroid. In total 29 percent (23) of patients had no signs that were nonorganic while 21 percent (16) showed one nonorganic sign. 50 percent (39) percent of the patients showed at least two signs prior to the injections.
A month after the injection those whose pain still reduced by epidural injection of steroid had in average 1.3 nonorganic symptoms, whereas those who’s pain had not reduced at the one-month date had, on average 3.4 nonorganic symptoms.
Certain of the Waddell indicators were closely associated with the lack of response to injections. For instance 55% of nonresponders to injections displayed apparent hyperreactivity to touch. However, less than 11% who were helped by injections displayed this indication. The study also revealed that those who had more signs that were not organic and related to neck discomfort were more likely to experience chronic pain in different regions of the body including fibromyalgia as well as mental health issues.
Cohen believes there is evidence that multiple non-organic indicators are helping to identify patients who may benefit from alternative treatments before attempting epidural injections of steroid. “But further study must be conducted to identify the best treatment options.”
At present, Cohen says the findings will immediately guide discussions between neck pain sufferers and their medical professionals in weighing the possible advantages and risks of an epidural injector of steroid.
Other researchers who participated in this study are Tina Doshi, Mirinda Anderson-White, Eric Wang and Annie Hsu from Johns Hopkins; Edward Dolomisiewicz, David Reece, Angelia Kasuke Shelton Davis and Paul Pasquina from the Water Reed National Military Medical Center, Uniformed Services University of the Health Sciences; Zirong Zhao from the District of Columbia Veterans Affairs Medical Center; and Yongjae Yoo and Jeeyoun Moon, both of Seoul National University.
The research was financed partly by the U.S. Department of Defense.
Johns Hopkins Medicine
Cohen, S.P., and. (2023) Nonorganic (Behavioral) Signs and their Relationship with Epidural Corticosteroid Injection Treatment Outcomes and Psychiatric Co-morbidity in Cervical Radiculopathy. A Multicenter Study. Mayo Clinic Proceedings. doi.org/10.1016/j.mayocp.2022.11.022.
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