Feeling No Pain … in the Neck

Published in Hopkins Medicine - Spring/Summer 2023

A quick clinical test developed by researchers at Johns Hopkins Medicine and several other institutions could predict which people with neck pain are more likely to benefit from epidural steroid injections, which deliver drugs directly around the spinal nerves to stop nerve inflammation and reduce pain.

The uncomfortable injections are a common treatment for neck pain but can cost hundreds of dollars each, carry risks, and help only a minority of patients, studies show. 

“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, professor of anesthesiology and critical care medicine. “We 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.”

The researchers reported their results in Mayo Clinic Proceedings.

For their study, Cohen and collaborators adapted Waddell signs — eight physical signs used 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 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 maneuvers 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 nonorganic (not associated with a direct anatomic cause). In general, studies have shown that back pain patients with more Waddell signs are less likely to benefit from treatment.

To conduct their 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 patients with neck pain for the eight nonorganic physical signs before treating them with epidural steroid injections. 

Some of the individual Waddell signs were highly correlated with a lack of response to the injections. For example, 55% of those who did not respond to injections showed apparent overreactions to light touch, while only 11% 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 non-organic signs identifies 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. 

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