Non-Organic (Behavioral) Signs and their Association with Epidural Steroid Injection Treatment Outcomes and Psychiatric Comorbidity in Cervical Radiculopathy: A Multicenter Study —Anesthesiology

Cohen SP, Doshi TL, Dolomisiewicz E, Reece DE, Zhao Z, Anderson- White M, Kasuske A, Wang EJ, Hsu A, Davis SA, Yoo Y, Pasquina PF, Youn Moon J

Neck pain is one of the top five leading causes of disability, with more than one-third being neuropathic in nature. Since 2000, the use of cervical epidural steroid injections has more than tripled, leading to increased scrutinization. The presence of nonorganic (Waddell) signs has been shown to be associated with treatment failure for back pain but has never been validated for neck pain. In a multicenter study, Waddell signs were adapted for cervical pain, with nine signs in five categories validated in a small pilot. Seventy-eight patients with cervical radiculopathy scheduled for epidural steroid injection were then evaluated with these signs for their association with outcome, with a positive outcome defined as a greater-than 2-point decrease in arm pain and a score greater than 5 on a 7-point improvement scale. Seventy-one percent had at least one nonorganic sign and 40% had at least one sign in three categories, with noncorrelative tenderness being most common (51%). Mean number of positive nonorganic categories was higher in individuals with negative outcomes (2.5 ± 1.8; 95% CI, 2.0 to 3.1) versus those with positive outcomes (1.1 ± 1.3; 95% CI, 0.7 to 1.5; P = 0.0002). Positive associations were noted between nonorganic signs and multiple pain (P = 0.011) and multiple psychiatric (P = 0.028) conditions.

Cohen, S. P., Doshi, T. L., Dolomisiewicz, E., Reece, D. E., Zhao, Z., Anderson-Whitle, M., Kasuke, A., Wang, E. J., Hsu, A., Davis, S. A., Yoo, Y., Pasquina, P. F., & Youn Moon, J. Science, Medicine, and the Anesthesiologist. Anesthesiology 2023; 138:A12–A15 doi: https://doi.org/10.1097/ALN.0000000000004586