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Objective: To determine the effectiveness and risks of fluoroscopically guided cervical transforaminal injection of corticosteroids in the treatment of radicular pain., Design: Systematic review of the literature with comprehensive analysis of the published data., Interventions: Three reviewers with formal training in evidence-based medicine searched the literature on fluoroscopically guided cervical transforaminal injection of steroids (CTFIS). Each reviewer independently assessed the methodology of studies found and appraised the quality of the evidence presented., Outcome Measures: The primary outcome assessed was relief of radicular pain. Other outcomes such as reduction in surgery rate and complications were noted if reported. The evidence on each outcome was appraised in accordance with the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system of evaluating evidence., Results: The searches yielded 16 primary publications on effectiveness. Available evidence, derived mainly from observational studies, suggests that approximately 50% of patients experience 50% relief of radicular pain for at least 4 weeks after CTFIS, and the intervention may have surgery-sparing effects. The literature also contains 21 articles with primary reports of serious complications, including 13 deaths and many catastrophic neurological injuries. The evidence of pain-relieving effects, of surgery-sparing effects, and of risks of CTFIS were all rated as of very low quality according to the GRADE system., Conclusions: In patients with cervical radicular pain, fluoroscopically guided CTFIS may be effective in easing pain and reducing need for surgery. However, the evidence of effectiveness is of very low quality, and the benefits of the procedure are compromised by the risks of serious complications., (Wiley Periodicals, Inc.)

Objective: To determine the effectiveness of lumbar transforaminal injection of steroids in the treatment of radicular pain., Design: Comprehensive review of the literature with systematic analysis of all published data., Interventions: Four reviewers independently assessed 39 publications on the effectiveness of lumbar transforaminal injection of steroids. Each reviewer determined if a publication provided any valid information on effectiveness. Assessments were compared, and the data of each publication were evaluated in terms of the rigor with which they were produced and the evidence they provided of effectiveness., Outcome Measures: The primary outcome sought was the success rate for relief of pain. Improvement in secondary outcomes was noted if reported., Results: For miscellaneous conditions, the available evidence is limited and is neither compelling nor conclusive. For disc herniation, the evidence is sufficiently abundant to show that lumbar transforaminal injection of steroids is not universally effective but, nevertheless, benefits a substantial proportion of patients, and is not a placebo. Success rates are higher in patients with contained herniations that cause only low-grade compression of the nerve., Conclusion: In a substantial proportion of patients with lumbar radicular pain caused by contained disc herniations, lumbar transforaminal injection of corticosteroids is effective in reducing pain, restoring function, reducing the need for other health care, and avoiding surgery. The evidence supporting this conclusion was revealed by comprehensive review of all published data and found to be much more compelling than it would have been if the literature review had been of the limited scope of a traditional "systematic review" of randomized, controlled trials only., (Wiley Periodicals, Inc.)

Abstract: Background context: Although manual therapists believe that they can diagnose symptomatic joints in the neck by manual examination, that conviction is based on only one study. That study claimed that manual examination of the neck had 100% sensitivity and 100% specificity for diagnosing painful zygapophyseal joints. However, the study indicated that its results should be reproduced before they could be generalized. Purpose: The present study was undertaken to answer the call for replication studies. The objective was to determine the sensitivity, specificity, and likelihood ratio of manual examination for the diagnosis of cervical zygapophyseal joint pain. Study design: The study was conducted in a private practice located in a rural town. The practice specialized in musculoskeletal pain problems. Patient sample: The study sample was 173 patients with neck pain in whom cervical zygapophyseal joint pain was suspected on clinical examination, and who were willing to undergo controlled diagnostic blocks of the suspected joint or joints. Outcome measures: The validity of manual diagnosis was determined by calculating its sensitivity, specificity, and positive likelihood ratio. Methods: Patients who exhibited the putatively diagnostic physical signs of cervical zygapophyseal joint pain were referred to a radiologist who performed controlled, diagnostic blocks of the suspected joint, and other joints if indicated. The results of the blocks constituted the criterion standard, against which the clinical diagnosis was compared, by creating contingency tables. Results: Manual examination had a high sensitivity for cervical zygapophyseal joint pain, at the segmental levels commonly symptomatic, but its specificity was poor. Likelihood ratios barely greater than 1.0 indicated that manual examination lacked validity. Although the results obtained were less favorable than those of the previous study, paradoxically they were statistically not different. Conclusions: The present study found manual examination of the cervical spine to lack validity for the diagnosis of cervical zygapophyseal joint pain. It refutes the conclusion of the one previous study. The paradoxical lack of statistical difference between the two studies is accounted for by the small sample size of the previous study. [Copyright &y& Elsevier]

The article highlights the risks of precipitate formation when combining corticosteroids with local anesthetic for use during interventional pain procedures. Topics include the use of interventional procedures for pain, such as transforaminal epidural steroid injections (TFESIs), that involve instilling corticosteroid preparations at specific sites from which pain originates.