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Cervical radicular painRecommendationsDescriptionStrength of recommendationLevel of evidenceInterlaminar epidural corticosteroid administration could be used in addition to conservative treatment in patients with cervical radicular pain WeakModerateDescriptionStrength of recommendationLevel of evidenceTransforaminal epidural preservative free dexamethasone* could be considered for the treatment of subacute cervical radicular pain.Very weakVery lowDescriptionStrength of recommendationLevel of evidencePulsed Radiofrequency treatment adjacent to the cervical ganglion spinale (dorsal root ganglion (DRG)) should be used for the treatment of patients with cervical radicular painModerateModerateDescriptionStrength of recommendationLevel of evidenceRadiofrequency treatment adjacent to the cervical ganglion spinale (dorsal root ganglion (DRG)) could be used for the treatment of patients with cervical radicular painWeakModerateDescriptionStrength of recommendationLevel of evidenceSpinal cord stimulation for cervical radicular pain could be considered for the treatment of patients with cervical radicular pain.Very weakNot graded* Preservative free dexamethasone is not a pharmaceutical specialty but only as a compounded available in the BeneluxClinical questionWhat is the place for interventional pain treatments in the management algorithm of cervical radicular pain?Researched treatment optionsIn patients with cervical radicular pain. We studied the following treatments:Interlaminar epidural corticosteroid administrationTransforaminal epidural corticosteroid administrationRF treatment adjacent to the cervical ganglion spinale (DRG)Pulsed RF treatment adjacent to the cervical ganglion spinale (DRG)Spinal cord stimulationAny comparators including sham, no treatment or other active treatment techniques were eligible. Inclusion was not restricted based on outcome. MethodsFor the search strategy and the methodology we refer to the introductionResults of literature searchTwo systematic reviews published between 2010 and 2015 for cervical pain were identified. The first ADDIN EN.CITE <EndNote><Cite><Author>Engel</Author><Year>2014</Year><RecNum>12049</RecNum><DisplayText><style face="superscript">1</style></DisplayText><record><rec-number>12049</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="1472107312">12049</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Engel, A.</author><author>King, W.</author><author>MacVicar, J.</author><author>Standards Division of the International Spine Intervention, Society</author></authors></contributors><auth-address>Continental Anesthesia, Oak Brook, Illinois, USA.</auth-address><titles><title>The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: a systematic review with comprehensive analysis of the published data</title><secondary-title>Pain Med</secondary-title></titles><periodical><full-title>Pain Med</full-title></periodical><pages>386-402</pages><volume>15</volume><number>3</number><keywords><keyword>Adrenal Cortex Hormones/*administration &amp; dosage/therapeutic use</keyword><keyword>Fluoroscopy</keyword><keyword>Humans</keyword><keyword>Injections, Epidural/*methods</keyword><keyword>Lumbar Vertebrae/surgery</keyword><keyword>Pain/*drug therapy</keyword><keyword>Radiculopathy/drug therapy</keyword><keyword>Steroids/*administration &amp; dosage/therapeutic use</keyword><keyword>Cervical</keyword><keyword>Injection</keyword><keyword>Radicular Pain</keyword><keyword>Steroids</keyword><keyword>Transforaminal</keyword></keywords><dates><year>2014</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1526-4637 (Electronic)&#xD;1526-2375 (Linking)</isbn><accession-num>24308846</accession-num><urls><related-urls><url> studied fluoroscopy guided transforaminal epidural corticosteroid administration. The second reviewed the evidence of radiofrequency treatment. PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaHVhPC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA 5Interlaminar epidural corticosteroid administrationLiterature reviewThe recommendations formulated in the previous guideline were based on a systematic review ADDIN EN.CITE <EndNote><Cite><Author>Benyamin</Author><Year>2009</Year><RecNum>4485</RecNum><DisplayText><style face="superscript">6</style></DisplayText><record><rec-number>4485</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">4485</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Benyamin, R. M.</author><author>Singh, V.</author><author>Parr, A. T.</author><author>Conn, A.</author><author>Diwan, S.</author><author>Abdi, S.</author></authors></contributors><auth-address>Millennium Pain Center, Bloomington, IL 61701, USA. ramsinbenyamin@</auth-address><titles><title>Systematic review of the effectiveness of cervical epidurals in the management of chronic neck pain</title><secondary-title>Pain Physician</secondary-title></titles><periodical><full-title>Pain Physician</full-title></periodical><pages>137-57</pages><volume>12</volume><number>1</number><keywords><keyword>Analgesics/*therapeutic use</keyword><keyword>Cervical Vertebrae/drug effects</keyword><keyword>Chronic Disease</keyword><keyword>Humans</keyword><keyword>Injections, Epidural/*methods</keyword><keyword>Neck Pain/*drug therapy</keyword></keywords><dates><year>2009</year><pub-dates><date>Jan-Feb</date></pub-dates></dates><accession-num>19165300</accession-num><urls><related-urls><url> that analyzed 3 RCT’sPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5TdGF2PC9BdXRob3I+PFllYXI+MTk5MzwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA 7-9 comparing interlaminar epidural corticosteroid injections with intramuscular injection, continuous infusion and interlaminar corticosteroid injection plus morphine.Since the publication of the previous guideline ADDIN EN.CITE <EndNote><Cite><Author>Van Zundert</Author><Year>2009</Year><RecNum>5526</RecNum><DisplayText><style face="superscript">10</style></DisplayText><record><rec-number>5526</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">5526</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Van Zundert, J.</author><author>Huntoon, M.</author><author>Patijn, J.</author><author>Lataster, A.</author><author>Mekhail, N.</author><author>van Kleef, M.</author></authors></contributors><auth-address>Department of Anesthesiology and Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium.</auth-address><titles><title>4. Cervical radicular pain</title><secondary-title>Pain Pract</secondary-title></titles><periodical><full-title>Pain Pract</full-title></periodical><pages>1-17</pages><volume>10</volume><number>1</number><edition>2009/10/08</edition><dates><year>2009</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>1533-2500 (Electronic)&#xD;1530-7085 (Linking)</isbn><accession-num>19807874</accession-num><urls><related-urls><url> [pii]&#xD;10.1111/j.1533-2500.2009.00319.x</electronic-resource-num><language>eng</language></record></Cite></EndNote>10 no systematic reviews were published. One RCT PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Db2hlbjwvQXV0aG9yPjxZZWFyPjIwMTQ8L1llYXI+PFJl

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ADDIN EN.CITE.DATA 5 compared interlaminar epidural corticosteroid administration, conservative treatment including medical and physical therapies and a combination of epidural corticosteroid and conservative treatment. At the latest (6-month) follow up patients in the combination group may have had a better outcome than patients in the conservative treatment and corticosteroid groups. Obviously this pragmatic study was not blinded, and patient satisfaction weighed heavily in the outcome variable. The direct comparison between the conservative treatment and corticosteroid groups may be less influenced by placebo effects: both groups knew they did not get the full treatment. No appreciable differences were found. To some degree the better 6-month results in the combination group may also be interpreted as earlier rather than better recovery; in the two other groups more patients exited the study early because of lack of effect, and spontaneous recovery in these groups thus was discounted.ConclusionQuality of the evidence DescriptionModerateThere is evidence of moderate quality that interlaminar epidural corticosteroid administration in combination with conservative treatment gives a greater pain reduction than conservative treatment or epidural corticosteroid alone at 3 months follow-up.Cohen et al. 2014ConsiderationsA new search until end February 2018 identified a systematic review ADDIN EN.CITE <EndNote><Cite><Author>House</Author><Year>2018</Year><RecNum>12726</RecNum><DisplayText><style face="superscript">15</style></DisplayText><record><rec-number>12726</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="1521037739">12726</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>House, L. M.</author><author>Barrette, K.</author><author>Mattie, R.</author><author>McCormick, Z. L.</author></authors></contributors><auth-address>Department of Anesthesia and Perioperative Care, University of California San Francisco, 513 Parnassus Avenue, 436, San Francisco, CA 94143, USA.&#xD;Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, Stanford University, 450 Broadway Street, M/C 6342, Redwood City, CA 94063, USA.&#xD;Department of Anesthesiology, University of California San Francisco, 521 Parnassus Avenue, San Francisco, CA 94143, USA.&#xD;Division of Physical Medicine and Rehabilitation, University of Utah, 30 N 1900 E, Rm 1C441, Salt Lake City, UT 84132, USA. Electronic address: Zachary.mccormick@ucsf.edu.</auth-address><titles><title>Cervical Epidural Steroid Injection: Techniques and Evidence</title><secondary-title>Phys Med Rehabil Clin N Am</secondary-title></titles><periodical><full-title>Phys Med Rehabil Clin N Am</full-title></periodical><pages>1-17</pages><volume>29</volume><number>1</number><edition>2017/11/28</edition><keywords><keyword>Epidural</keyword><keyword>Evidence-based medicine</keyword><keyword>Injections</keyword><keyword>Neck pain</keyword></keywords><dates><year>2018</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1558-1381 (Electronic)&#xD;1047-9651 (Linking)</isbn><accession-num>29173656</accession-num><urls><related-urls><url>, which in turn included a new RCT.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY0Nvcm1pY2s8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFy

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ADDIN EN.CITE.DATA 16 The latter compared the efficacy of interlaminar epidural steroid injection with an injection through a catheter advanced to side and level of the pathology. It showed no significant difference in clinical outcomes. Both techniques were associated with clinically meaningful improvement across outcome domains of pain, function, disability, and medication use. These effects persisted to 6-month follow-up.The recent RCT adds information about the added value of interlaminar epidural corticosteroid injection compared to conservative treatment and compared to epidural corticosteroid injection plus conservative treatment. A study of the closed claims of interventional pain treatments revealed that cervical interventions represent 22% of the chronic pain claims, 59% of them were related to spinal cord injury due to direct needle trauma. This is more common in patients who received sedation or general anesthesia. ADDIN EN.CITE <EndNote><Cite><Author>Rathmell</Author><Year>2011</Year><RecNum>11406</RecNum><DisplayText><style face="superscript">11</style></DisplayText><record><rec-number>11406</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="1430723468">11406</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rathmell, J. P.</author><author>Michna, E.</author><author>Fitzgibbon, D. R.</author><author>Stephens, L. S.</author><author>Posner, K. L.</author><author>Domino, K. B.</author></authors></contributors><auth-address>Harvard Medical School, Boston, Massachusetts, USA. jprathmell@</auth-address><titles><title>Injury and liability associated with cervical procedures for chronic pain</title><secondary-title>Anesthesiology</secondary-title></titles><periodical><full-title>Anesthesiology</full-title></periodical><pages>918-26</pages><volume>114</volume><number>4</number><keywords><keyword>Adult</keyword><keyword>Anesthesia/*adverse effects</keyword><keyword>Anesthesiology</keyword><keyword>Cervical Vertebrae/injuries</keyword><keyword>Chronic Disease</keyword><keyword>Databases, Factual</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Insurance Claim Review</keyword><keyword>Male</keyword><keyword>*Malpractice</keyword><keyword>Middle Aged</keyword><keyword>Neck Pain/*therapy</keyword><keyword>Needlestick Injuries/*etiology</keyword><keyword>Societies, Medical</keyword><keyword>Spinal Cord Injuries/*etiology</keyword><keyword>United States</keyword></keywords><dates><year>2011</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>1528-1175 (Electronic)&#xD;0003-3022 (Linking)</isbn><accession-num>21386702</accession-num><urls><related-urls><url> The workgroup “safe use of epidural steroids” formulated recommendations to improve the safety of epidural steroid injections. PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5CZW56b248L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFyPjxS

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ADDIN EN.CITE.DATA 12, 13 All cervical interlaminar epidural steroid injections should be performed using image guidance, with appropriate anteroposterior, lateral, or contralateral oblique views and a test dose of contrast mediumCervical interlaminar epidural steroid injections are recommended to be performed at C7-T1, but preferably not higher than the C6-7 level. No cervical interlaminar epidural steroid injection should be undertaken, at any segmental level, without preprocedural review of prior imaging studies demonstrating sufficient epidural spatial dimensions for needle placement at the target levelSufficient epidural spatial dimensions is not defined according to personal communications with the authors. This treatment is an “off label” use of corticosteroids, therefore (written) informed consent is mandatory. The new information does not influence the level of evidence. The risk for serious complications and the limited clinical effect justify downgrading the recommendationRecommendationDescriptionStrength of recommendationLevel of evidenceInterlaminar epidural corticosteroid administration could be used in addition to conservative treatment in patients with cervical radicular pain WeakModerateTransforaminal epidural corticosteroid administrationLiterature reviewSince the previous guideline reporting a negative randomized trial ADDIN EN.CITE <EndNote><Cite><Author>Anderberg</Author><Year>2007</Year><RecNum>1633</RecNum><DisplayText><style face="superscript">14</style></DisplayText><record><rec-number>1633</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">1633</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Anderberg, L.</author><author>Annertz, M.</author><author>Persson, L.</author><author>Brandt, L.</author><author>Saveland, H.</author></authors></contributors><auth-address>Department of Neurosurgery, University Hospital, 22185, Lund, Sweden. leif.anderberg@med.lu.se</auth-address><titles><title>Transforaminal steroid injections for the treatment of cervical radiculopathy: a prospective and randomised study</title><secondary-title>Eur Spine J</secondary-title></titles><periodical><full-title>Eur Spine J</full-title></periodical><pages>321-8</pages><volume>16</volume><number>3</number><keywords><keyword>Adrenal Cortex Hormones/administration &amp; dosage/*therapeutic use</keyword><keyword>Adult</keyword><keyword>Aged</keyword><keyword>Back Pain/drug therapy</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Injections, Spinal</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Prospective Studies</keyword><keyword>Radiculopathy/*drug therapy</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2007</year><pub-dates><date>Mar</date></pub-dates></dates><accession-num>16835737</accession-num><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>14 a systematic review was published ADDIN EN.CITE <EndNote><Cite><Author>Engel</Author><Year>2014</Year><RecNum>12049</RecNum><DisplayText><style face="superscript">1</style></DisplayText><record><rec-number>12049</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="1472107312">12049</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Engel, A.</author><author>King, W.</author><author>MacVicar, J.</author><author>Standards Division of the International Spine Intervention, Society</author></authors></contributors><auth-address>Continental Anesthesia, Oak Brook, Illinois, USA.</auth-address><titles><title>The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: a systematic review with comprehensive analysis of the published data</title><secondary-title>Pain Med</secondary-title></titles><periodical><full-title>Pain Med</full-title></periodical><pages>386-402</pages><volume>15</volume><number>3</number><keywords><keyword>Adrenal Cortex Hormones/*administration &amp; dosage/therapeutic use</keyword><keyword>Fluoroscopy</keyword><keyword>Humans</keyword><keyword>Injections, Epidural/*methods</keyword><keyword>Lumbar Vertebrae/surgery</keyword><keyword>Pain/*drug therapy</keyword><keyword>Radiculopathy/drug therapy</keyword><keyword>Steroids/*administration &amp; dosage/therapeutic use</keyword><keyword>Cervical</keyword><keyword>Injection</keyword><keyword>Radicular Pain</keyword><keyword>Steroids</keyword><keyword>Transforaminal</keyword></keywords><dates><year>2014</year><pub-dates><date>Mar</date></pub-dates></dates><isbn>1526-4637 (Electronic)&#xD;1526-2375 (Linking)</isbn><accession-num>24308846</accession-num><urls><related-urls><url> review had a number of limitations, including a restriction to English-language publications only. However, the conclusions of the authors appeared to be reasonable. They concluded that fluoroscopically guided cervical transforaminal injection of steroids may be effective in easing pain and reducing need for surgery but the evidence is of very low quality. The authors also stated that the benefits of the procedures are compromised by the risks of serious complications. We identified two trials published subsequent to the review.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Xb288L0F1dGhvcj48WWVhcj4yMDE1PC9ZZWFyPjxSZWNO

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ADDIN EN.CITE.DATA 3 Given the known complication risks of transforaminal injections authors advised to try facet injections before transforaminal injections. Implicitly they hypothesize that cervical radicular pain is either often caused by inflammatory mediators diffusing out of degenerated facet joints, or that the facet joint space will act as a reservoir supplying steroids to the inflamed roots. This new hypothesis needs confirmation. The second trial tested a lower than normal concentration of local anesthetic given with the steroid and did not find any decrease in effectiveness. ADDIN EN.CITE <EndNote><Cite><Author>Woo</Author><Year>2015</Year><RecNum>12024</RecNum><DisplayText><style face="superscript">4</style></DisplayText><record><rec-number>12024</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="1470658585">12024</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Woo, J. H.</author><author>Park, H. S.</author></authors></contributors><auth-address>Department of Anesthesiology and Pain Medicine, School of Medicine, Ewha Womans University, Seoul, Korea.</auth-address><titles><title>Cervical transforaminal epidural block using low-dose local anesthetic: a prospective, randomized, double-blind study</title><secondary-title>Pain Med</secondary-title></titles><periodical><full-title>Pain Med</full-title></periodical><pages>61-7</pages><volume>16</volume><number>1</number><keywords><keyword>Analgesia, Epidural/*methods</keyword><keyword>Anesthetics, Local/*administration &amp; dosage/adverse effects</keyword><keyword>Cervical Vertebrae</keyword><keyword>Dexamethasone/administration &amp; dosage</keyword><keyword>Dose-Response Relationship, Drug</keyword><keyword>Double-Blind Method</keyword><keyword>Female</keyword><keyword>Glucocorticoids/administration &amp; dosage</keyword><keyword>Humans</keyword><keyword>Lidocaine/*administration &amp; dosage/adverse effects</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neuralgia/*drug therapy</keyword><keyword>Radiculopathy/drug therapy</keyword><keyword>Cervical</keyword><keyword>Lidocaine</keyword><keyword>Safety</keyword><keyword>Transforaminal Epidural Block</keyword></keywords><dates><year>2015</year><pub-dates><date>Jan</date></pub-dates></dates><isbn>1526-4637 (Electronic)&#xD;1526-2375 (Linking)</isbn><accession-num>25286965</accession-num><urls><related-urls><url> This trial does not provide information of effectiveness of transforaminal corticosteroid injection as such. It was too small to show non-inferiority. The trial results do not change the conclusions of the review.ConclusionsQuality of the evidence Descriptionvery lowThere is evidence of very low quality that transforaminal epidural corticosteroid administration reduces pain for 1 month in patients with cervical radicular painEngel et al. 2014ConsiderationA new search until end February 2018 identified a systematic review ADDIN EN.CITE <EndNote><Cite><Author>House</Author><Year>2018</Year><RecNum>12726</RecNum><DisplayText><style face="superscript">15</style></DisplayText><record><rec-number>12726</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="1521037739">12726</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>House, L. M.</author><author>Barrette, K.</author><author>Mattie, R.</author><author>McCormick, Z. L.</author></authors></contributors><auth-address>Department of Anesthesia and Perioperative Care, University of California San Francisco, 513 Parnassus Avenue, 436, San Francisco, CA 94143, USA.&#xD;Department of Orthopaedic Surgery, Physical Medicine and Rehabilitation, Stanford University, 450 Broadway Street, M/C 6342, Redwood City, CA 94063, USA.&#xD;Department of Anesthesiology, University of California San Francisco, 521 Parnassus Avenue, San Francisco, CA 94143, USA.&#xD;Division of Physical Medicine and Rehabilitation, University of Utah, 30 N 1900 E, Rm 1C441, Salt Lake City, UT 84132, USA. Electronic address: Zachary.mccormick@ucsf.edu.</auth-address><titles><title>Cervical Epidural Steroid Injection: Techniques and Evidence</title><secondary-title>Phys Med Rehabil Clin N Am</secondary-title></titles><periodical><full-title>Phys Med Rehabil Clin N Am</full-title></periodical><pages>1-17</pages><volume>29</volume><number>1</number><edition>2017/11/28</edition><keywords><keyword>Epidural</keyword><keyword>Evidence-based medicine</keyword><keyword>Injections</keyword><keyword>Neck pain</keyword></keywords><dates><year>2018</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>1558-1381 (Electronic)&#xD;1047-9651 (Linking)</isbn><accession-num>29173656</accession-num><urls><related-urls><url>, which in turn included a new RCT.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5NY0Nvcm1pY2s8L0F1dGhvcj48WWVhcj4yMDE3PC9ZZWFy

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ADDIN EN.CITE.DATA 16 This review confirms the previous findings that the RCTs for cervical transforaminal injections are not of such a quality to allow drawing conclusions. The evidence is formed by observational studies and case reports. Serious complications reported in 21 studies including 13 deaths and 31 brain and spinal cord infarctions. Also numerous other serious and persistent central nervous system (CNS) injuriesPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SYXRobWVsbDwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+

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ADDIN EN.CITE.DATA 13, 17-33The US epidural corticosteroids safe use initiative formulates the following recommendation for the cervical transforaminal epidural injections. PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SYXRobWVsbDwvQXV0aG9yPjxZZWFyPjIwMTU8L1llYXI+

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ADDIN EN.CITE.DATA 12, 13Cervical transforaminal epidural steroid injections should only be performed after injection of contrast medium under real-time fluoroscopy or digital subtraction imaging. Particulate steroids should not be used in cervical transforaminal epidural injections. In the Benelux we actually face the problem that preservative free dexamethasone is not available as pharmaceutical specialty but only as a compounded product. RecommendationsDescriptionStrength of recommendationLevel of evidenceTransforaminal epidural preservative free dexamethasone* could be considered for the treatment of subacute cervical radicular pain, study relatedVery weakVery low* Preservative free dexamethasone is not a pharmaceutical specialty but only as a compounded available in the Benelux(Continuous) Radiofrequency treatment adjacent to the cervical ganglion spinale (DRG)Literature reviewSince the previous guideline, no systematic reviews, randomized controlled trials or observational studies were published. The recommendations of the previous guideline were based on two RCT’s PEVuZE5vdGU+PENpdGU+PEF1dGhvcj52YW4gS2xlZWY8L0F1dGhvcj48WWVhcj4xOTk2PC9ZZWFy

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ADDIN EN.CITE.DATA 34, 35. The first study ADDIN EN.CITE <EndNote><Cite><Author>van Kleef</Author><Year>1996</Year><RecNum>1018</RecNum><DisplayText><style face="superscript">34</style></DisplayText><record><rec-number>1018</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">1018</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>van Kleef, M.</author><author>Liem, L.</author><author>Lousberg, R.</author><author>Barendse, G.</author><author>Kessels, F.</author><author>Sluijter, M.</author></authors></contributors><auth-address>Department of Anaesthesiology, University Hospital of Maastricht, The Netherlands.</auth-address><titles><title>Radiofrequency lesion adjacent to the dorsal root ganglion for cervicobrachial pain: a prospective double blind randomized study</title><secondary-title>Neurosurgery</secondary-title></titles><periodical><full-title>Neurosurgery</full-title></periodical><pages>1127-31; discussion 1131-2</pages><volume>38</volume><number>6</number><keywords><keyword>Adult</keyword><keyword>Brachial Plexus Neuritis/physiopathology/radiography/*surgery</keyword><keyword>Double-Blind Method</keyword><keyword>*Electrosurgery/instrumentation</keyword><keyword>Female</keyword><keyword>Follow-Up Studies</keyword><keyword>Ganglia, Spinal/physiopathology/radiography/*surgery</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Nerve Block</keyword><keyword>Pain Measurement</keyword><keyword>Prospective Studies</keyword></keywords><dates><year>1996</year><pub-dates><date>Jun</date></pub-dates></dates><accession-num>8727142</accession-num><urls><related-urls><url> found radiofrequency treatment adjacent to the cervical ganglion spinale (DRG) to be superior to sham 8 weeks after the intervention.The second study compared RF with an electrode tip temperature of 40°C with RF at 67°C. ADDIN EN.CITE <EndNote><Cite><Author>Slappendel</Author><Year>1997</Year><RecNum>779</RecNum><DisplayText><style face="superscript">35</style></DisplayText><record><rec-number>779</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">779</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Slappendel, R.</author><author>Crul, B. J.</author><author>Braak, G. J.</author><author>Geurts, J. W.</author><author>Booij, L. H.</author><author>Voerman, V. F.</author><author>de Boo, T.</author></authors></contributors><auth-address>Department of Anesthesiology, Sint Maartenskliniek, Nijmegen, The Netherlands.</auth-address><titles><title>The efficacy of radiofrequency lesioning of the cervical spinal dorsal root ganglion in a double blinded randomized study: no difference between 40 degrees C and 67 degrees C treatments</title><secondary-title>Pain</secondary-title></titles><periodical><full-title>Pain</full-title></periodical><pages>159-63</pages><volume>73</volume><number>2</number><keywords><keyword>Adult</keyword><keyword>Brachial Plexus Neuritis/*surgery</keyword><keyword>*Catheter Ablation</keyword><keyword>Comparative Study</keyword><keyword>Double-Blind Method</keyword><keyword>Female</keyword><keyword>Ganglia, Spinal/*surgery</keyword><keyword>*Heat</keyword><keyword>Human</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neck/*innervation</keyword><keyword>Pain, Intractable/*surgery</keyword><keyword>Prospective Studies</keyword><keyword>Support, Non-U.S. Gov&apos;t</keyword></keywords><dates><year>1997</year><pub-dates><date>Nov</date></pub-dates></dates><accession-num>9415501</accession-num><urls><related-urls><url> At 6 weeks and at 3 months after treatment there was a significant decrease in the visual analog scale pain score in both groups. There was no significant difference in outcome between the two groups.Because the second study does not compare RF with sham the evaluation is based on the first study.ConclusionQuality of the evidence DescriptionmoderateThere is evidence of moderate quality that radiofrequency treatment adjacent to the cervical cervical ganglion spinale (dorsal root ganglion (DRG)) reduces pain in patients with cervical radicular pain up to 2 months after the intervention. Van Kleef et al. 1996; ConsiderationsContinuous radiofrequency treatment uses neurodestructive electrode tip temperature, which results in nerve damage and can cause deafferentation pain. This is the reason why continuous RF is less frequently used since the development of the less neurodestructive pulsed radiofrequency.RecommendationDescriptionStrength of recommendationLevel of evidenceRadiofrequency treatment adjacent to the cervical ganglion spinale (dorsal root ganglion (DRG)) could be used for the treatment of patients with cervical radicular painWeakModeratePulsed Radiofrequency treatment of DRGLiterature reviewThere were 2 case series with a total of 43 patients.PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5DaG9pPC9BdXRob3I+PFllYXI+MjAxMjwvWWVhcj48UmVj

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ADDIN EN.CITE.DATA 36, 37 These suggested that more than 60% of patients benefited in terms of more than 50% pain relief or treatment success after six months with no serious adverse effects reported. This relief appears to be sustained at 1-year follow-up (12 of 21 patients). ConclusionQuality of the evidence DescriptionModerateThere is evidence of moderate quality that pulsed radiofrequency adjacent to the cervical ganglion spinale (dorsal root ganglion (DRG)) reduces pain in patients with cervical radicular pain up to 6 months Van Zundert et al. 2007ConsiderationA new search until end February 2018 showed no new systematic reviews, RCTs or prospecetive trials relevant to the research question.The newly published case series provide support for the recommendations of previous guidance which recommended pulsed radiofrequency on the basis of a RCT with positive (although not statistically significant) findings at six months ADDIN EN.CITE <EndNote><Cite><Author>Van Zundert</Author><Year>2007</Year><RecNum>1582</RecNum><DisplayText><style face="superscript">38</style></DisplayText><record><rec-number>1582</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="0">1582</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Van Zundert, J.</author><author>Patijn, J.</author><author>Kessels, A.</author><author>Lame, I.</author><author>van Suijlekom, H.</author><author>van Kleef, M.</author></authors></contributors><auth-address>Department of Anesthesiology, Pain Management and Research Centre, University Hospital Maastricht, The Netherlands. janvanzundert@pandora.be</auth-address><titles><title>Pulsed radiofrequency adjacent to the cervical dorsal root ganglion in chronic cervical radicular pain: a double blind sham controlled randomized clinical trial</title><secondary-title>Pain</secondary-title><short-title>cervical radicular</short-title></titles><periodical><full-title>Pain</full-title></periodical><pages>173-82</pages><volume>127</volume><number>1-2</number><keywords><keyword>Adult</keyword><keyword>Chronic Disease</keyword><keyword>Double-Blind Method</keyword><keyword>Electric Stimulation Therapy/*methods</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Middle Aged</keyword><keyword>Neck Pain/*therapy</keyword><keyword>Placebo Effect</keyword><keyword>Radiculopathy/*therapy</keyword><keyword>Radio Waves/*therapeutic use</keyword><keyword>Treatment Outcome</keyword></keywords><dates><year>2007</year><pub-dates><date>Jan</date></pub-dates></dates><orig-pub>RCT</orig-pub><accession-num>17055165</accession-num><work-type>PRF</work-type><urls><related-urls><url> </url></related-urls></urls></record></Cite></EndNote>38No neurological complications have been reported after pulsed radiofrequency treatment of the DRG.RecommendationDescriptionStrength of recommendationLevel of evidencePulsed Radiofrequency treatment adjacent to the cervical ganglion spinale (dorsal root ganglion (DRG)) should be used for the treatment of patients with cervical radicular painModerateModerateSpinal cord stimulationLiterature reviewNo systematic reviews or RCTs of spinal cord stimulation for the management of cervical radicular pain were identified.A chart review was reported as an abstract only ADDIN EN.CITE <EndNote><Cite><Author>Zhou L</Author><Year>2013</Year><RecNum>12027</RecNum><DisplayText><style face="superscript">39</style></DisplayText><record><rec-number>12027</rec-number><foreign-keys><key app="EN" db-id="ver2pweeyf0df2ervxhv0xs1v2z9x2zx52sr" timestamp="1470659903">12027</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Zhou L, Lee Y.</author></authors></contributors><titles><title>A retrospective study of 186 cases of spinal cord stimulation therapy.</title><secondary-title>PM and R</secondary-title></titles><periodical><full-title>PM and R</full-title></periodical><pages>S295</pages><volume>9</volume><number>9 Suppl 1</number><dates><year>2013</year></dates><urls></urls></record></Cite></EndNote>39 included 14 patients with Failed Neck Surgery Syndrome and intractable chronic cervical radicular pain were given spinal cord stimulation. After a mean follow up of just over eight years there was significant decrease in pain scores compared to baseline and a perceived improvement of around 66%. Six re-interventions were needed due to lead fracture or lead dislocation. ConclusionsThis study could not be assessed for quality as it was not reported in full. The previous guidance found no literature on this intervention. There is an ongoing need for further investigation into this intervention for cervical radicular pain. Quality of the evidence DescriptionNot gradedThere is no literature available that spinal cord stimulation provides pain relief in patients with cervical radicular pain. ConsiderationsA prospective study found that patients with failed neck surgery; complex regional pain syndrome and neuropathic pain, had a significant improvement in pain at 6 and 12 months. Patients with percutaneous implants reported significantly less disability on ODI compared to those who had paddle implants. 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ADDIN EN.CITE.DATA 40 RecommendationsDescriptionStrength of recommendationLevel of evidenceSpinal cord stimulation for cervical radicular pain could be considered for the treatment of patients with cervical radicular pain.Very weakNot gradedReferences ADDIN EN.REFLIST 1Engel A, King W, MacVicar J, Standards Division of the International Spine Intervention S. The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: a systematic review with comprehensive analysis of the published data. Pain Med. 2014;15:386-402.2Chua NH, Vissers KC, Sluijter ME. Pulsed radiofrequency treatment in interventional pain management: mechanisms and potential indications-a review. Acta Neurochir (Wien). 2011;153:763-771.3Bureau NJ, Moser T, Dagher JH, et al. Transforaminal versus intra-articular facet corticosteroid injections for the treatment of cervical radiculopathy: a randomized, double-blind, controlled study. 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PM and R. 2013;9:S295.40Haider S, Owusu-Sarpong S, Peris Celda M, et al. A Single Center Prospective Observational Study of Outcomes With Tonic Cervical Spinal Cord Stimulation. Neuromodulation. 2017;20:263-268. ................
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