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Cervical nerve root block offers patients few benefits in avoiding radiculopathy surgery
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Surgeons know the associated risks with cervical nerve root blocks to treat radiculopathy and avoid surgery, but until now, researchers had not evaluated their efficacy.
K. Daniel Riew, MD, and his colleagues, performed a prospective, randomized, controlled and double-blind study to identify the actual benefits of cervical nerve root blocks.
Out of 45 patients enrolled in the study, only six patients (13%) avoided surgery for radiculopathy over a minimum of 20 months after nerve root block.
"There are significant risks that are associated with [cervical nerve root] blocks, including case reports of fatal spinal cord infarction and ... injury to the vertebral artery," Riew said at the North American Spine Society annual meeting. "And the results of these led a number of practitioners to feel that it is no longer safe to use central nerve root blocks."
Riew and his colleagues, however, studied the risks with cervical nerve root blocks and found that the procedure is safe. He continued, "In order for us to counsel our patients on the risk-benefit analysis and ratio of this particular procedure we now have to ask how effective are these injections at helping to avoid an operation?"
Researchers offered enrollment to all patients who presented with cervical radicular pain at an academic spine center over a 2-year period. Forty-five patients agreed to participate in the IRB-approved, OREF-funded study. The overall study group included 20 men and 25 women. They were an average 49±10 years of age.
Inclusion requirements included failed nonoperative treatment for more than 6 weeks, radiographic compression, requested operative intervention and being deemed a good surgical candidate by the operating surgeon.
Surgeons referred the patients to a radiologist who prospectively randomized them to receive selective nerve root blocks with bupivacaine alone or bupivacaine with the corticosteroid betamethasone. The demographics of the two patient groups were comparable, Riew said. The surgeon and patients were both blinded to the medication.
"The patients of their own discretion could choose up to three additional blocks over any given 6-month period or they could opt to receive surgery at any time," Riew said. "The definition of failure was proceeding with the surgery."
An independent, experienced spine surgeon who was not involved in the patient care prospectively reviewed all data over the next 3.5 years.
Patient follow-up ranged from 20 months to 32 months. During that period, four of the 25 patients (16%) who received only bupivacaine and two of the 20 patients (10%) who received bupivacaine and betamethasone (P=.35) did not proceed with surgery.
Most patients did not receive more than four injections, but one patient did receive six injections over 45 months, Riew said. However, the researchers found no complications associated to the nerve block injections.
Riew acknowledged that the actual benefits from the nerve block medication may not have led to the surgery avoidance, but that it could be attributed to placebo effects or the patient's desire to delay surgery until the problem resolved.
For more information:
- Riew KD. Can cervical nerve root blocks prevent surgery for cervical radiculopathy? A prospective, randomized, controlled, double-blind study. #4. Presented at the North American Spine Society 21st Annual Meeting. Sept. 26-30, 2006. Seattle.
- K. Daniel Riew, MD, is the Mildred B. Simon Distinguished Professor and Chief of Cervical Spine Surgery in the Department of Orthopaedic Surgery at Washington University School of Medicine, 1 Barnes-Jewish Hospital Plaza, suite 1130, West Pavilion, St. Louis, MO. 63110. (314) 747-2565, fax. (314) 747-2599 riewd@wustl.edu. He does not have any financial conflict of interest, nor is he a paid consultant for any type of product mentioned in the article.