Medicinal and injection therapies for mechanical neck disorders
Abstract
Background
Controversy persists regarding medicinal therapies and injections.
Objectives
To determine the effects of medication and injections on primary outcomes (e.g. pain) for adults with mechanical neck disorders and whiplash.
Search methods
We searched CENTRAL, MANTIS, CINAHL from their start to May 2006; MEDLINE and EMBASE to December 2006. We scrutinised reference lists for other trials.
Selection criteria
We included randomised controlled trials with adults with neck disorders, with or without associated headache or radicular findings. We considered medicinal and injection therapies, regardless of route of administration.
Data collection and analysis
Two authors independently selected articles, abstracted data and assessed methodological quality. When clinical heterogeneity was absent, we combined studies using random‐effects models.
Main results
We found 36 trials that examined the effects of oral NSAIDs, psychotropic agents, steroid injections, and anaesthetic agents. Trials had a mean of 3.1 on the Jadad Scale for methodological quality; 70% were high quality.
For acute whiplash, administering intravenous methylprednisolone within eight hours of injury reduced pain at one week (SMD ‐0.90, 95% CI ‐1.57 to ‐0.24), and sick leave but not pain at six months compared to placebo in one trial. For chronic neck disorders at short‐term follow‐up, intramuscular injection of lidocaine was superior to placebo (SMD ‐1.36, 95% CI ‐1.93 to ‐0.80); NNT 3, treatment advantage 45% and dry needling, but similar to ultrasound in one trial each. In chronic neck disorders with radicular findings, epidural methylprednisolone and lidocaine reduced neck pain and improved function more than when given by intramuscular route at one‐year follow‐up, in one trial.
In subacute and chronic neck disorders, muscle relaxants, analgesics and NSAIDs had limited evidence and unclear benefits.
In participants with chronic neck disorders with or without radicular findings or headache, there was moderate evidence from five high quality trials that Botulinum toxin A intramuscular injections had similar effects to saline in improving pain (pooled SMD: ‐0.39, 95%CI ‐1.25 to 0.47), disability or global perceived effect.
Authors' conclusions
The major limitations are the lack of replication of the findings and sufficiently large trials. There is moderate evidence for the benefit of intravenous methylprednisolone given within eight hours of acute whiplash, from a single trial. Lidocaine injection into myofascial trigger points appears effective in two trials. There is moderate evidence that Botulinum toxin A is not superior to saline injection for chronic MND. Muscle relaxants, analgesics and NSAIDs had limited evidence and unclear benefits.
Plain language summary
Medicinal and Injection Therapies for mechanical neck disorders
Neck disorders are common, disabling and costly. Over 25% of the population will experience neck pain at some time in their lives. The disorders examined in this review are mechanical neck disorders that are not related to an underlying systemic problem. They may be a result of whiplash, degenerative changes, headaches developing because of neck problems, and symptoms such as pain, numbness and weakness that radiate down the arm, stemming from the neck.
Medication (drugs), given by mouth or injections are commonly used to treat neck pain. In this review, we included 36 trials that studied the effects of drugs on neck pain. Most of the trials used strong research methods, which reduced the potential for bias in the results. However, there were not many drugs that were studied in multiple trials, which made it difficult to pool results from different trials. For this reason, we were only able to draw conclusions on a few medications.
The main drugs studied were:
‐ oral (non‐steroidal) anti‐inflammatories (NSAIDs) and analgesics;
‐ psychotropics (drugs that act by their effects on the brain and spinal cord);
‐ corticosteroid injections (anti‐inflammatory drugs);
‐ local anaesthetics (local freezing); and
‐ Botulinum toxin A injection (Botox A, a drug that acts on muscle spasm).
Corticosteroid injections given within eight hours of the injury appear to reduce the pain of acute whiplash. Local anaesthetics appear to reduce chronic neck pain. An epidural injection of a corticosteroid plus local anaesthetic seems to reduce pain and improve function for patients with chronic neck pain with associated arm symptoms. However, there are not enough studies on any one drug to allow a high degree of confidence in these results. Muscle relaxants, analgesics and NSAIDs have unclear benefits. There is moderate evidence showing that, on average, Botulinum toxin A is no better than saline injections at lessening pain and disability.
There was no information given in the trials about possible side effects of the different drugs, but some individuals may experience stomach problems from NSAIDs and drowsiness, dizziness and other side effects from some of the others. Therefore, individuals with neck pain should discuss the pros and cons with their physicians before using them.
