Long-term follow-up of the International Subarachnoid-Hemorrhage Aneurysm Trial.

in pain but that this was not significantly different from the improvement in patients who underwent physical therapy plus pharmacotherapy or patients who underwent a combination of physical therapy, pharmacotherapy, and epidural steroid injections over a 6-month period. In this study, Cohen et al randomly assigned 169 consecutive subjects with cervical radiculopathy from 7 treatment facilities to 3 equal groups. The first group received cervical epidural steroid injections only; the second group underwent physical therapy plus pharmacotherapy; and the third group underwent a combination of physical therapy, pharmacotherapy, and epidural steroid injections. All patientswere.18 years old, had a history of cervical radicular pain that was no less than 1 month and no more than 4 years, rated their arm or neck pain$4, and had magnetic resonance imaging demonstrating an anatomic correlate to their symptoms. Patients with myelopathy and patients who had undergone prior surgery were among those who were excluded. The patients in the epidural steroid group received an interlaminar injection of a 3-mL solution containing 60 mg depomethylprednisolone and normal saline at either the C6-7 or C7-T1 interspace under fluoroscopic guidance. The injection could then be repeated at 3 months and again at 6 months if the patient experienced only partial improvement or if symptoms initially resolved but later recurred. The patients in the pharmacotherapy plus physical therapy group were started on gabapentin and/or nortriptyline. The medication and dose were determined at the treating physician’s discretion, and the doses were uptitrated over 16 to 24 days to reach a therapeutic range. Physical therapy began within 1 week of the initial evaluation, but patients who had previously tried and failed physical therapy could opt out of parts of the regimen that had not worked before or could even opt out of the entire regimen altogether. The patients who were in the third combination group received epidural steroid injections, pharmacotherapy with gabapentin and/or nortriptyline, and physical therapy according to the same standards as patients in the other 2 groups. The results of this study showed that all 3 groups experienced a modest reduction in both arm and neck pain. Although the largest improvements were seen in the combination group, the difference was not significant. The authors did find, however, that at 3 months patients in the combination therapy group were significantly more likely to have a positive “categorical outcome,” meaning that the patient responded positively to a questionnaire about pain and satisfaction and had a 2-point improvement in arm pain. When this same outcome measure was taken again at 6 months, however, a significant difference was no longer appreciable. However, the authors speculate that perhaps their study was underpowered because the beneficial effect of combination therapy was less than expected during the design of the study. It seems more likely that there truly is not a statistical significance between the 3 treatment groups and that the nonsignificant trend toward subjectively better outcomes in the combination group may be explained simply by the placebo effect of receiving a shot. This is concordant with previous studies that have not shown a lasting benefit of epidural steroid injections over conservative treatment in the lumbar spine. This study therefore suggests that the use of epidural steroid injections in the treatment of degenerative neck pain and cervical radiculopathy should be limited to a smaller group of patients who are also receiving physical therapy and pharmacotherapy. Additionally, given that there is no proven benefit to this procedure, which does carry risk, it may be that there is no role at all for epidural injections in the treatment of cervical radiculopathy. Rather than receiving multiple rounds of epidural injections, patients may benefit from referral to a spine surgeon for definitive decompression when conservative measures fail within the appropriate time period.