Transforaminal Epidural Steroid Injections May Improve Cervical Radiculopathy Pain

MRI scan showing disk herniation at the level of cervical vertebrae C6-C7, with impingement on the spinal cord.
Fluoroscopically guided cervical transforaminal epidural steroid injection was found to improve pain in approximately half of patients with cervical radiculopathy in the short and intermediate terms.

Fluoroscopically guided cervical transforaminal epidural steroid injection (CTFESI) was found to improve pain in approximately half of patients with cervical radiculopathy in the short and intermediate terms, according to a systematic review and meta-analysis published in Pain Medicine. However, these findings were based on very low quality evidence from studies lacking comparison groups and should be interpreted accordingly.

CTFESI may alleviate discomfort in patients with refractory cervical radicular pain by targeting the intervertebral foramen and nearby nerve root with highly concentrated corticosteroids.

The authors searched PubMed, Medline, and Cochrane databases through July 2018 for studies in which improvements in pain and function were examined in adult patients with cervical radicular pain caused by degenerative spondylosis or disk herniation. Comparative trials (randomized or nonrandomized) as well as studies lacking an internal control were considered for inclusion. A total of 17 studies were examined in the qualitative synthesis, and 8 of these studies had quantitative data that were evaluated in the meta-analysis. Acceptable comparison groups included patients receiving placebo, sham procedures, or standard treatments. ESI alternatives were excluded. Three independent reviewers were tasked with evaluating publications for inclusion.

The primary outcome was ≥50% self-reported pain reduction from baseline, evaluated ≥4 weeks after the intervention, using a validated scale. Secondary outcomes were spinal surgery avoidance and assessment of function using validated tools. The Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system was used to rate the quality of the evidence and assess the risk for bias. Within-group response rates and comparative effect measures, where applicable, were calculated in the quantitative meta-analysis.

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The included studies were stratified according to etiology — disk herniation, spondylosis, or mixed — with no significant differences in outcomes between these groups. None of the 17 analyzed studies (11 single-group studies and 6 randomized trials) included an internal comparison (control) group that met the authors’ parameters, precluding the assessment of comparative efficacy.

Pooled response rates (primary outcome) were 48% (95% CI, 34%-61%) and 55% (95% CI, 45%-64%) at 1 and 3 months, respectively, in cohort studies. Functional improvements were reported in several studies, but the tools used evaluate these effects were not consistent among studies. Surgical avoidance rates were reported in a few studies and indicated higher avoidance after CTFESI, but most of the evidence was of poor quality. Using the GRADE system, the reviewers rated the overall evidence as being of very low quality.

Review strengths include a thorough literature search, narrow research question, and independent appraisal of all included studies. Review limitations include a lack of co-intervention reporting, small sample sizes, varying levels of methodologic rigor, and lack of internal controls or true comparison groups.

“Determining the ideal concentration and volume of injectate for CTFESI will require high-quality head-to-head [randomized controlled trials] as single-group observational studies cannot provide these answers,” noted the authors.

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Conger A, Cushman DM, Speckman RA, Burnham T, Teramoto M, Mccormick ZL. The effectiveness of fluoroscopically guided cervical transforaminal epidural steroid injection for the treatment of radicular pain; a systematic review and meta-analysis [published online June 10, 2019]. Pain Med. doi:10.1093/pm/pnz127