Surgery Prevention by Transforaminal Injection of Epidural Steroids for Cervical Radicular Pain (SPIES)

• ClinicalTrials.gov Identifier: NCT02226159
• Recruitment Status: Active, not recruiting
• First Posted: August 27, 2014
• Results First Posted: October 20, 2020
• Last Update Posted: October 20, 2020
• Sponsor: OrthoCarolina Research Institute, Inc.
• Collaborator: Charlotte Surgery Center an affiate of SCA
• Information provided by (Responsible Party): OrthoCarolina Research Institute, Inc.

Tracking Information

• First Submitted Date: August 25, 2014
• First Posted Date: August 27, 2014
• Results First Submitted Date: September 1, 2020
• Results First Posted Date: October 20, 2020
• Last Update Posted Date: October 20, 2020
• Actual Study Start Date: August 2014
• Actual Primary Completion Date: May 2019 (Final data collection date for primary outcome measure)

Current Primary Outcome Measures (submitted: September 25, 2020)

Avoidance of Neck Surgery [ Time Frame: 12 months after the first injection ]

The primary outcome variable is the avoidance of surgery. Treatment success is defined as the avoidance of surgery, while treatment failure is defined as having surgery due to failure of the injection treatment to alleviate pain and improve function over the 12 months they are being followed for purposes of this study. Avoided neck surgery noted as 'Yes'; avoided neck surgery 'No' the patient had neck surgery.

Original Primary Outcome Measures (submitted: August 25, 2014)

Avoidance of Neck Surgery [ Time Frame: 12 months after the first injection ]

The primary outcome variable is the avoidance of surgery. Treatment success is defined as the avoidance of surgery, while treatment failure is defined as having surgery due to failure of the injection treatment to alleviate pain and improve function over the 12 months they are being followed for purposes of this study.

Current Secondary Outcome Measures (submitted: September 25, 2020)

• Disability [ Time Frame: 4 weeks ]
  Neck Disability Index (NDI) - The NDI consists of 10 questions. Each of the 10 items is scored from 0 (minimum) - 5(maximum). The maximum score is therefore 50. The obtained score can be multiplied by 2 to produce a percentage score (i.e. a score of 50 indicates 100% disability). Scores are reported as the percentage (i.e. 100 is the max score for data presented).
• Numeric Pain Scre [ Time Frame: 4 weeks ]
  Verbal Numeric Pain Scale (VNPS) -Scaled 0-10 with 10 being worst imaginable pain and 0 being no pain
• Patient Satisfaction [ Time Frame: 4 weeks ]
  Patient satisfaction with the treatment. Scale is an inverse of verbal numeric pain score. A 0 on VNPS equates to a 10 on patient satisfaction, 10 on VNPS equates to 0 on patient satisfaction
• Disability [ Time Frame: 12 weeks ]
  Neck Disability Index- The NDI consists of 10 questions. Each of the 10 items is scored from 0 (minimum) - 5(maximum). The maximum score is therefore 50. The obtained score can be multiplied by 2 to produce a percentage score (i.e. a score of 50 indicates 100% disability). Scores are reported as the percentage (i.e. 100 is the max score for data presented).
• Disability [ Time Frame: 6 Months ]
  Neck Disability Index- The NDI consists of 10 questions. Each of the 10 items is scored from 0 (minimum) - 5(maximum). The maximum score is therefore 50. The obtained score can be multiplied by 2 to produce a percentage score (i.e. a score of 50 indicates 100% disability). Scores are reported as the percentage (i.e. 100 is the max score for data presented).
• Disability [ Time Frame: 12 Months ]
  Neck Disability Index- The NDI consists of 10 questions. Each of the 10 items is scored from 0 (minimum) - 5(maximum). The maximum score is therefore 50. The obtained score can be multiplied by 2 to produce a percentage score (i.e. a score of 50 indicates 100% disability). Scores are reported as the percentage (i.e. 100 is the max score for data presented).
• Numeric Pain Score [ Time Frame: 12 weeks ]
  Verbal Numeric Pain Scale-Scaled 0-10 with 10 being worst imaginable pain and 0 being no pain
• Numeric Pain Score [ Time Frame: 6 Months ]
  Verbal Numeric Pain Scale-Scaled 0-10 with 10 being worst imaginable pain and 0 being no pain
• Numeric Pain Score [ Time Frame: 12 Months ]
  Verbal Numeric Pain Scale-Scaled 0-10 with 10 being worst imaginable pain and 0 being no pain
• Patient Satisfaction [ Time Frame: 12 weeks ]
  Patient satisfaction with the treatment. Scale is an inverse of verbal numeric pain score. A 0 on VNPS equates to a 10 on patient satisfaction, 10 on VNPS equates to 0 on patient satisfaction
• Patient Satisfaction [ Time Frame: 6 months ]
  Patient satisfaction with the treatment. Scale is an inverse of verbal numeric pain score. A 0 on VNPS equates to a 10 on patient satisfaction, 10 on VNPS equates to 0 on patient satisfaction
• Patient Satisfaction [ Time Frame: 12 months ]
  Patient satisfaction with the treatment. Scale is an inverse of verbal numeric pain score. A 0 on VNPS equates to a 10 on patient satisfaction, 10 on VNPS equates to 0 on patient satisfaction

Original Secondary Outcome Measures (submitted: August 25, 2014)

• Disability [ Time Frame: 4 weeks, 12 weeks, 6 months, 12 months following 1st injection ]
  Neck Disability Index
• Pain [ Time Frame: 4 weeks, 12 weeks, 6 months, 12 months following 1st injection ]
  Numeric Pain Scale
• Patient Satisfaction [ Time Frame: 4 weeks, 12 weeks, 6 months, 12 months following 1st injection ]
  Patient satisfaction with the treatment

• Current Other Pre-specified Outcome Measures: Not Provided
• Original Other Pre-specified Outcome Measures: Not Provided

Descriptive Information

• Brief Title: Surgery Prevention by Transforaminal Injection of Epidural Steroids for Cervical Radicular Pain
• Official Title: Surgery Prevention by Transforaminal Injection of Epidural Steroids for Cervical Radicular Pain (SPIES): a Randomized, Controlled Trial

Brief Summary

Cervical radicular pain is a common cause of disability and pain in the upper extremity and neck with an annual incidence of 83.2/100,000 (1). The initial treatment is conservative and includes relative rest, use of anti-inflammatory and analgesic medication, as well as physical therapy and home exercise. For patients who have persistent and significant symptoms, interventional pain management and surgical management are considered. Cervical epidural injections are the mainstay of the interventional, non-surgical modalities. They can be considered to provide short and long-term relief when disc herniation, foraminal stenosis or central canal stenosis pathology is identified. We are not aware of any published prospective, randomized, controlled, double-blinded studies demonstrating the efficacy of cervical transforaminal epidural steroid injections. However, the North American Spine Society (NASS) Review and Recommendation Statement states that based on the literature and expert opinion, a minimum of one or two cervical epidural steroid injections would be very appropriate in the treatment of a specific episode of cervical radicular pain.

The purpose of this study is to determine the effectiveness of cervical transforaminal epidural steroid injections in decreasing the need for an operation in patients with cervical radicular pain, otherwise considered to be operative candidates.

Detailed Description

Cervical radicular pain is a common cause of disability and pain in the upper extremity and neck with an annual incidence of 83.2/100,000 (1). The initial treatment is conservative and includes relative rest, use of anti-inflammatory and analgesic medication, as well as physical therapy and home exercise. For patients who have persistent and significant symptoms, interventional pain management and surgical management are considered. Cervical epidural injections are the mainstay of the interventional, non-surgical modalities. They can be considered to provide short and long-term relief when disc herniation, foraminal stenosis or central canal stenosis pathology is identified.

Cervical epidural injections can be performed by two different approaches, transforaminal and interlaminar. Transforaminal epidural injections allow delivery of medication to the ventral epidural space, while the interlaminar approach reaches the ventral epidural space in only 28% of injections (2-4). The results of cervical epidural injections remain controversial and their efficacy in decreasing the need for surgery in patients who would otherwise be operative candidates has not been thoroughly investigated. Studies have been limited by small sample sizes, lack of control groups, and lack of randomization. Kolstad et al reported that 23% (5/21) of patients waiting for cervical disc surgery cancelled surgery when assessed at four months after having a series of two cervical epidural injections (6). Lin et al reported that 63% (44/70) of patients who were deemed to be surgical candidates were able to avoid surgery with an average of 13-month follow up (7). Lee et al reported that over 80% of 98 patients evaluated with cervical radiculopathy were able to avoid surgery with a 2-year follow-up (8). Anderberg et al reported that there was no short-term difference in symptoms of cervical radiculopathy between patients who received transforaminal injections of steroid with local anesthetic versus saline with local anesthetic. However, this study did not evaluate whether the injections were successful in the patients avoiding surgery (11).

In terms of lumbar transforaminal epidural injections, Riew et al demonstrated that steroid injections obviated the need for surgery in patients with lumbar radiculopathy. Moreover, Reiw et al showed that steroid combined with local anesthetic was more effective than local anesthetic alone in a prospective, randomized, controlled, double-blinded study (9). Riew et al later studied the efficacy of cervical transforaminal epidural injections in the same fashion, but the findings were not statistically significant (p<0.35) and not published (10).

We are not aware of any published prospective, randomized, controlled, double-blinded studies demonstrating the efficacy of cervical transforaminal epidural steroid injections. However, the North American Spine Society (NASS) Review and Recommendation Statement states that based on the literature and expert opinion, a minimum of one or two cervical epidural steroid injections would be very appropriate in the treatment of a specific episode of cervical radicular pain. This literature also suggests that a maximum of four injections can be used within six months, assuming there was a positive response and improvement seen with the previous injections.

• Study Type: Interventional
• Study Phase: Phase 4
• Study Design: Allocation: Randomized; Intervention Model: Parallel Assignment; Masking: Triple (Participant, Investigator, Outcomes Assessor); Primary Purpose: Treatment
• Condition: Pain, Radiating

Intervention

• Drug: Lidocaine
• Drug: Lidocaine with Dexamethasone
  Other Names:

  • Lidocaine
  • Dexamethasone

Study Arms

• Active Comparator: Lidocaine
  Cervical transforaminal injection: 1.0 cc Lidocaine 1.0% with 1.0 cc normal saline
  Intervention: Drug: Lidocaine
• Experimental: Lidocaine with Dexamethasone
  Cervical transforaminal injection: 1.0 cc Lidocaine 1.0% with 1.0 cc of Dexamethasone (10 mg/cc)
  Intervention: Drug: Lidocaine with Dexamethasone

Publications *

• Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain. 1994 Apr;117 ( Pt 2):325-35.
• Stojanovic MP, Vu TN, Caneris O, Slezak J, Cohen SP, Sang CN. The role of fluoroscopy in cervical epidural steroid injections: an analysis of contrast dispersal patterns. Spine (Phila Pa 1976). 2002 Mar 1;27(5):509-14.
• Strub WM, Brown TA, Ying J, Hoffmann M, Ernst RJ, Bulas RV. Translaminar cervical epidural steroid injection: short-term results and factors influencing outcome. J Vasc Interv Radiol. 2007 Sep;18(9):1151-5.
• Lieberman R, Dreyfuss P, Baker R. Fluoroscopically guided interlaminar cervical epidural injections. Arch Phys Med Rehabil. 2003 Oct;84(10):1568-9; author reply 1569.
• Manchikanti L, Falco FJ, Diwan S, Hirsch JA, Smith HS. Cervical radicular pain: the role of interlaminar and transforaminal epidural injections. Curr Pain Headache Rep. 2014 Jan;18(1):389. doi: 10.1007/s11916-013-0389-9. Review.
• Kolstad F, Leivseth G, Nygaard OP. Transforaminal steroid injections in the treatment of cervical radiculopathy. A prospective outcome study. Acta Neurochir (Wien). 2005 Oct;147(10):1065-70; discussion 1070. Epub 2005 Jun 9.
• Lin EL, Lieu V, Halevi L, Shamie AN, Wang JC. Cervical epidural steroid injections for symptomatic disc herniations. J Spinal Disord Tech. 2006 May;19(3):183-6.
• Lee SH, Kim KT, Kim DH, Lee BJ, Son ES, Kwack YH. Clinical outcomes of cervical radiculopathy following epidural steroid injection: a prospective study with follow-up for more than 2 years. Spine (Phila Pa 1976). 2012 May 20;37(12):1041-7. doi: 10.1097/BRS.0b013e31823b4d1f.
• Riew KD, Yin Y, Gilula L, Bridwell KH, Lenke LG, Lauryssen C, Goette K. The effect of nerve-root injections on the need for operative treatment of lumbar radicular pain. A prospective, randomized, controlled, double-blind study. J Bone Joint Surg Am. 2000 Nov;82(11):1589-93.
• Anderberg L, Annertz M, Persson L, Brandt L, Säveland H. Transforaminal steroid injections for the treatment of cervical radiculopathy: a prospective and randomised study. Eur Spine J. 2007 Mar;16(3):321-8. Epub 2006 Jul 12.

Recruitment Information

• Recruitment Status: Active, not recruiting
• Actual Enrollment (submitted: October 1, 2019): 65
• Original Estimated Enrollment (submitted: August 25, 2014): 60
• Estimated Study Completion Date: December 2020
• Actual Primary Completion Date: May 2019 (Final data collection date for primary outcome measure)

Eligibility Criteria

Inclusion Criteria:

• Subjects who have cervical radicular pain without significant neurologic deficit (neurologic deficit is defined as manual muscle testing less than 3/5), MRI/CT findings of neural compression (neural compression is defined as disc herniation or central or foraminal spinal stenosis),
• Failed 6 weeks of conservative treatment (conservative treatment is defined as relative rest, home exercise, physical therapy, and use of anti-inflammatory and/or analgesic medications),
• Deemed to be good operative candidates by spine surgeons (patients with MRI/CT findings of neural compression with concordant symptoms) and had agreed to possible operative intervention

Exclusion Criteria:

• History of

  1. acute trauma,
  2. diabetes (type I or type II),
  3. active infection
• Active progressive neurological deficit (neurologic is deficit defined as manual muscle testing less than 3/5),
• Medical condition that may affect the cervical spine neurological exam and/or pain assessment (e.g. peripheral neuropathy),
• Bilateral disease,
• More than one cervical level requiring injection,
• Bleeding disorders or other medical contraindications to the injection procedure,
• Absence of substantial radicular pain (radicular pain is defined as arm pain greater than neck pain),
• Involvement in workers' compensation claim, or any litigation related to neck injury.
• Patients who are pregnant, or who plan to become pregnant in the next 12 months

Sex/Gender

• Sexes Eligible for Study: All

• Ages: 18 Years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Contacts: Contact information is only displayed when the study is recruiting subjects
• Listed Location Countries: United States

Administrative Information

• NCT Number: NCT02226159
• Other Study ID Numbers: 9086-14019
• Has Data Monitoring Committee: Yes
• U.S. FDA-regulated Product: Not Provided
• IPD Sharing Statement: Not Provided
• Responsible Party: OrthoCarolina Research Institute, Inc.
• Study Sponsor: OrthoCarolina Research Institute, Inc.
• Collaborators: Charlotte Surgery Center an affiate of SCA

Investigators

• Principal Investigator: Sam Bhagia, MD; OrthoCarolina Research Institute, Inc.

• PRS Account: OrthoCarolina Research Institute, Inc.
• Verification Date: September 2020