Cohen S, larkin t, weitzner a, dolomisiewicz e, wang e, hsu a, anderson-white m, smith m, zhao z

There are few efficacious treatments for mechanical neck pain, with controlled trials suggesting efficacy for muscle relaxants and topical non-steroidal anti-inflammatory drugs. Although studies evaluating topical lidocaine for back pain have been disappointing, the more superficial location of the cervical musculature suggests a possible role for topical local anesthetics.

For the primary outcome, the median reduction in average neck pain score was -1.0 (IQR -2.0, 0.0) for the lidocaine phase vs. -0.5 (IQR -2.0,.0) for placebo treatment (p=0.17). 27.7% of patients experienced a positive outcome during lidocaine treatment vs. 14.9% during the placebo phase (p=0.073). There were no significant differences between treatments for secondary outcomes, though a carryover effect on pain pressure threshold was observed for the lidocaine phase (p=0.015). 27.5% of patients in the lidocaine group and 20.5% in the placebo group experienced minor reactions, the most common of which was pruritis (p=0.036).

The differences favoring lidocaine were small and non-significant, but the trend towards superiority of lidocaine suggests more aggressive phenotyping and applying formulations with greater penetrance may provide clinically meaningful benefit.

Steven P. Cohen, Thomas M. Larkin, Aidan S. Weitzner, Edward Dolomisiewicz, Eric J. Wang, Annie Hsu, Mirinda Anderson-White, Marin S. Smith, Zirong Zhao; Multicenter, Randomized, Placebo-controlled Crossover Trial Evaluating Topical Lidocaine for Mechanical Cervical Pain. Anesthesiology 2024; 140:513–523 doi: https://doi.org/10.1097/ALN.0000000000004857

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