Cervical Epidural Steroid Injections for Symptomatic Disc Herniations

Study Design: A randomized, double-blind, active-controlled trial.Objective: To assess the effectiveness of cervical interlaminar epidural injections of local anesthetic with or without steroids for the management of axial or discogenic pain in patients without disc herniation, radiculitis, or facet joint pain.Summary of Background Data: Cervical discogenic pain without disc herniation is a common cause of suffering and disability in the adult population. Once conservative management has failed and facet joint pain has been excluded, cervical epidural injections may be considered as a management tool. Despite a paucity of evidence, cervical epidural injections are one of the most commonly performed nonsurgical interventions in the management of chronic axial or disc-related neck pain.Methods: One hundred and twenty patients without disc herniation or radiculitis and negative for facet joint pain as determined by means of controlled diagnostic medial branch blocks were randomly assigned to one of the 2 treatment groups. Group I patients received cervical interlaminar epidural injections of local anesthetic (lidocaine 0.5%, 5 mL), whereas Group II patients received 0.5% lidocaine, 4 mL, mixed with 1 mL or 6 mg of nonparticulate betamethasone.The primary outcome measure was ≥ 50% improvement in pain and function. Outcome assessments included numeric rating scale (NRS), Neck Disability Index (NDI), opioid intake, employment, and changes in weight.Results: Significant pain relief and functional improvement (≥ 50%) was present at the end of 2 years in 73% of patients receiving local anesthetic only and 70% receiving local anesthetic with steroids. In the successful group of patients, however, defined as consistent relief with 2 initial injections of at least 3 weeks, significant improvement was illustrated in 78% in the local anesthetic group and 75% in the local anesthetic with steroid group at the end of 2 years. The results reported at the one-year follow-up were sustained at the 2-year follow-up.Conclusions: Cervical interlaminar epidural injections with or without steroids may provide significant improvement in pain and functioning in patients with chronic discogenic or axial pain that is function-limiting and not related to facet joint pain.

Summary of Background Data: The high prevalence of chronic persistent neck pain not only leads to disability but also has a significant economic, societal, and health impact. Among multiple modalities of treatments prescribed in the management of neck and upper extremity pain, surgical, interventional and conservative modalities have been described. Cervical epidural injections are also common modalities of treatments provided in managing neck and upper extremity pain. They are administered by either an interlaminar approach or transforaminal approach. Objectives: To determine the long-term efficacy of cervical interlaminar and transforaminal epidural injections in the treatment of cervical disc herniation, spinal stenosis, discogenic pain without facet joint pain, and post-surgery syndrome. Materials and Methods: The literature search was performed from 1966 to April 2014 utilizing data from PubMed, Cochrane Library, US National Guideline Clearinghouse, previous systematic reviews, and crossreferences. The evidence was assessed based on best evidence synthesis with Level I to Level V. Results: There were 7 manuscripts meeting inclusion criteria. Of these, 4 assessed the role of interlaminar epidural injections for managing disc herniation or radiculitis, and 3 assessed these injections for managing central spinal stenosis, discogenic pain without facet joint pain, and post surgery syndrome. There were 4 high quality manuscripts. A qualitative synthesis of evidence showed there is Level II evidence for each etiology category. The evidence is based on one relevant, high quality trial supporting the efficacy of cervical interlaminar epidural injections for each particular etiology. There were no randomized trials available assessing the efficacy of cervical transforaminal epidural injections. Conclusion: This systematic review with qualitative best evidence synthesis shows Level II evidence for the efficacy of cervical interlaminar epidural injections with local anesthetic with or without steroids, based on at least one high-quality relevant randomized control trial in each category for disc herniation, discogenic pain without facet joint pain, central spinal stenosis, and post-surgery syndrome.

We herein report a case of chemical meningitis that developed after cervical transforaminal steroid injection. A 49-year-old man presented with symptoms of meningitis (severe headache and neck stiffness) after cervical transforaminal steroid injection at the right C5–6 level. The injection solution was a mixture of lidocaine (0.3 mL), hyaluronidase (1 mL), placenta hydrolysate (2 mL), and normal saline (1 mL). The patient developed symptoms of meningitis 2.5 hours after the cervical epidural injection. Cerebrospinal fluid (CSF) analysis was performed 1 day after the injection, and the results showed an elevated white blood cell count at 7106 cells/µL. The patient’s CSF analysis findings and symptoms did not differ from those of bacterial meningitis. However, considering that his symptoms developed 2.5 hours after the epidural injection, we believe that the patient developed chemical meningitis; therefore, he was symptomatically treated with an analgesic. Three days after the cervical transforaminal epidural injection, the patient experienced complete relief from the headache and neck stiffness. A Gram stain of the CSF revealed no organisms. Hence, the diagnosis of chemical meningitis was confirmed. Clinicians should be knowledgeable about the risk of this complication.

Cervical epidural steroid injections and spinal cord injuries

Background: Cervical radiculopathy is a common cause of neck and upper-extremity pain, often resulting from degenerative cervical spine conditions. While many patients respond to conservative management, a substantial proportion experience persistent symptoms requiring interventional treatment. Cervical epidural corticosteroid injections have emerged as a widely used option for short-term pain relief in refractory cases. Aim: This article aims to review the indications, anatomical considerations, procedural techniques, complications, and nursing roles associated with cervical epidural corticosteroid injections in the management of cervical radiculopathy. Methods: A narrative review approach was used, integrating anatomical knowledge, clinical indications, injection techniques, imaging guidance, complication profiles, and interprofessional nursing responsibilities. Evidence from clinical studies and established procedural practices was synthesized to provide a comprehensive clinical overview. Results: Cervical epidural injections, particularly via the interlaminar approach, demonstrate effective short-term pain relief for selected patients, with approximately half achieving significant symptom reduction for up to three months. Fluoroscopic guidance enhances procedural accuracy and safety. Although generally safe, these injections are associated with potential complications, especially with transforaminal techniques, underscoring the importance of meticulous patient selection and skilled execution. Nursing involvement is critical in pre-procedural preparation, intra-procedural monitoring, and post-procedural care. Conclusion: Cervical epidural corticosteroid injections represent a valuable interventional modality for cervical radiculopathy when conservative therapies fail. Optimal outcomes depend on appropriate patient selection, precise technique, and coordinated interprofessional care.

Cervical interlaminar epidural injections are usually performed with the loss-of-resistance (LOR) technique. Therefore, no studies have evaluated or compared the hanging drop (HD) technique with the LOR technique in the administration of cervical interlaminar epidural injections (ILESIs). This study aimed to evaluate the success of the HD technique when used with the LOR technique in cervical ILESIs. A prospective, randomized trial. Department of Pain Medicine, Ege Hospital, Baku, Azerbaijan. After obtaining ethical committee approval and initiating a randomization process, we allocated patients diagnosed with cervical herniated nucleus pulposus (CHNP) into LOR- and HD-method groups. The LOR group comprised 38 patients, and the HD group comprised 41 patients. All patients underwent interlaminar epidural steroid injections under C-arm fluoroscopy in contralateral oblique (CLO) safety view with an initial start angle of approximately 60 degrees. For the LOR group, the procedure was considered successful if there was a loss of pressure after slightly crossing the ventral spinolaminar line (VSLL) and the administered contrast material was in the epidural space. The procedure was considered successful if the saline in the needle's hub fell with negative pressure after slightly passing the VSLL and if the contrast administered was seen in the epidural space with fluoroscopy. In the HD group, there was no sensation of a drop in 3 patients, and the procedure was completed with LOR, so these patients were excluded from the study. Complications and pain scores on the VAS (visual analog scale) were questioned at the time of the procedure and at one hour and 3 weeks after the procedure, and successful injection ratios were recorded. The LOR and HD groups were similar in age, gender, body mass index (BMI), and side of ILESI. The successful injection ratio was higher in the right- and left-sided ILESI group than in the median ILESI group (P < 0.01). Therefore, no differences were found between the right and left ILESI groups. Binary logistic regression analysis found that age, gender, and BMI were not associated with successful injection in the HD group, while medial injection was associated with decreased successful injection risk (OR: 0.068, P = 0.034). The successful injection ratio was higher in the LOR group than in the HD group (P < 0.001). The study's limitations include the relatively small number of patients with CHNP and the lack of mention of the level of CHNP. The LOR technique was superior to the HD for cervical ILESIs. More studies with larger sample sizes may provide more precise and detailed information.

Transforaminal (TF) approach is preferred by physician to interlaminar (IL) approach because it can deliver injectates directly around nerve root and dorsal root ganglion, which is regarded as main pain sources. Axial neck pain is originated from sinuvertebral nerve located in ventral epidural spaces, which has been described to be related to central or paramedian disc herniation. It is very questionable that TF injection is also more effective than IL injection in the patients with axial neck or interscapular pain. This study was to evaluate clinical efficacy of cervical epidural injection in patients with axial pain due to cervical disc herniation and to compare the clinical outcomes between TF and IL approaches. Fifty-six and 52 patients who underwent IL and TF epidural injections, respectively, for axial neck/interscapular pain due to central or paramedian cervical disc herniation were included. Numeric Rating Scale (NRS) and Neck Disability Index (NDI) were compared between both groups at 2 and 8 weeks after treatment. Successful pain relief was defined if a 50% or more reduction of NRS score was achieved in comparison with pretreatment one. Successful functional improvement was defined if at least a 40% reduction of NDI was obtained. Overall, 79 (73.1%) and 57 (52.8%) among 108 patients showed successful pain relief at 2 and 8 weeks, respectively. Seventy-six (70.4%) and 52 (48.1%) had successful functional improvement at 2 and 8 weeks, respectively. The IL and TF groups showed no significant difference in proportion of successful results of NRS 2 weeks (73.2% vs 67.3%) and 8 weeks (48.2% vs 48.1%). Also, no significant difference was obtained in proportion of successful NDI between 2 groups at 2 weeks (75.0% vs 71.2%) and 8 weeks (53.6% vs 51.9%). Cervical epidural injection showed favorable results in 2 weeks and moderate results in 8 weeks in patients with axial pain due to cervical disc herniation. IL and TF showed no significant difference in clinical efficacy. Considering TF was relevant to more serious side effects, IL was more recommendable in these patients.

We investigated cervical epidural steroid injection effects on Current Perception Threshold (CPT) measures in a patient with neuropathic pain using the NeurometerAE CPT/C device (Neurotron, Inc Baltimore MD, USA). CPT measures pre injection revealed a significant hypoesthesia in A�¥ and C fibers with normal A�≤ fiber function. CPT testing 24 hours after a cervical epidural injection at the C7-T1 interspace using methylprednisolone and lignocaine revealed normal measures indicating a reversal of

To the editor: We read with great interest the article by Simopoulos et al. (1), who reported an unusual complication of cervical epidural steroid injection. We would like to add a few more pointers toward the safe performance of this technique. A history of vasovagal syncope with previous needle punctures should have precluded the use of the sitting position (2). The choice of technique for identification of the epidural space is usually based on the pain management specialist’s previous training and personal experience rather than scientific data. However, the loss of resistance to saline for identification of the epidural space has significant advantages (<0.5% failure rate) over the hanging drop technique (up to 2% failure rate) (3). If there is any doubt about the position of the needle because of patient movement, it should be removed and the epidural should be resited. Finally, performance under radiological guidance with confirmation of needle placement by injection of radio-contrast will be the “gold standard” to make sure that the injectate is reaching the correct target. J. Kurian, MD, MRCP, FFARCSI V. Raghavan, MD, FRCA R. Raobaikady, MD, FRCA

Background: Epidural block failures can occur due to a misleading loss of resistance (LOR) signal. Objective: This study was designed to evaluate the false LOR rate and to determine whether the Epidrum, which is an LOR device for identifying the epidural space, improves the ability to find the epidural space during cervical epidural injection compared the LOR technique. Study Design: A randomized, single-blind trial. Setting: Single academic medical center. Methods: A total of 150 patients undergoing cervical interlaminar epidural injections at C7-T1 were randomized to receive either the LOR technique with a syringe (group C) or the Epidrum guidance (group E). Fluoroscopic images were used to confirm the accuracy of the needle placement within the epidural space. The rate of misleading epidural signals and adverse effects were recorded and analyzed. Results: The false LOR rate was 74.7% for group C, 62.7% for group E, and 68.7% overall. The incidence of false LOR was not significantly different between the 2 groups. Also, the success rate and the rate of true epidural signals were similar between the 2 groups. Limitations: The Epidrum cannot be used to confirm whether the needle has entered the vascular space without fluoroscopy. Conclusions: In this study, we did not find any difference in accuracy between the Epidrum and the LOR technique with a syringe for detecting the cervical epidural space. The overall higher false LOR rate suggests that the combined use of fluoroscopy and LOR technique with a syringe or the Epidrum is necessary to increase the rate of finding the true cervical epidural space. Clinical Trials registration: KCT0001333 Key words: Cervical epidural injection, epidural space, Epidrum, false positive, false negative, loss of resistance

Acute retinal necrosis is a rare, sight-threatening condition typically found in immunocompromised patients and is most commonly caused by varicella zoster virus. Due to the poor prognosis and rapid progression of the disease course, prompt antiviral management is paramount. A case report of acute retinal necrosis in a patient with herpes virus infection following a cervical epidural corticosteroid injection. Extensive laboratory work and frequent follow-ups are necessary for management. This case report outlines the clinical signs of acute retinal necrosis and discusses the appropriate referrals and treatment needed to improve prognosis. A 63-year-old man presented to our eye clinic with symptoms of pain and light sensitivity. Examination revealed anterior uveitis, vitritis, optic disc edema, macular edema, vasculitis, and retinitis of the left eye. The serum antibody test results showed abnormal ranges for varicella zoster virus and herpes simplex virus type 1, and the patient was diagnosed with acute retinal necrosis. Treatment prescribed by a retina specialist included oral valacyclovir and later oral prednisolone, for which the patient responded well before developing the common complication of retinal detachment. The progressive nature of acute retinal necrosis is usually debilitating to vision, even when managed properly. Because prognosis is often poor, it is important to make proper diagnoses combined with a complete review of the patient's medical history and immune status to prevent further vision loss.

Background: Cervical epidural injections for treating neck and upper limb pain are performed by 2 methods: transforaminal and interlaminar. Many serious complications caused by inadvertent intravascular injection have been reported with the use of cervical transforaminal epidural steroid injection through the anterior-lateral approach. Despite international practical guidelines that have been proposed, cervical transforaminal epidural injection is still less recommended than cervical interlaminar epidural injection. Objectives: The objective of this study is to introduce Th1-transforaminal epidural injection (Th1- TFEI) through the posterior-lateral approach, compare the injectate spread in Th1-TFEI with that of Th1/2-parasaggital interlaminar epidural injection (Th1/2-pILEI), and clarify the clinical characteristics of Th1-TFEI. Study Design: This research involved a prospective study of 30 patients receiving both Th1-TFEI and Th1/2-pILEI. Methods: Thirty patients with unilateral upper limb pain were enrolled for this prospective study. Th1-TFEI and Th1/2-pILEI were administered on each case in random order under fluoroscopy, and computed tomographic (CT) epidurograms were compared. Changes in circulatory dynamics, presence of Horner’s syndrome, changes in the Numerical Rating Scale (NRS-11), and adverse events were investigated. Results: Patients included 15 men and 15 women and included 24 cases of cervical spine disease and 6 cases with other upper limb pain. The Th1-TFEI group had significantly higher rates of “Th1 root filling” (100%), “ventral spread” (70.0%), and “lateral limitation” (26.7%) compared to the Th1/2-pILEI group. In the Th1-TFEI group, cephalad spread averaged 2.97 vertebral bodies, reaching approximately up to C6. The Th1/2-pILEI group had an average of 4.76 vertebral bodies, approximately up to C4. The 2 groups showed significant differences in cephalad spread. Horner’s syndrome appeared in the Th1-TFEI group at a rate of 56.7%, significantly higher than that in the Th1/2-pILEI group at 17.2%. The presence of Horner’s syndrome showed significant correlations with “ventral spread” and “spread up to C6.” There were no significant differences in NRS-11 improvement and changes in circulatory dynamics between the groups. There were no major complications. Limitations: The components of injectate were standardized; however, the needle gauge numbers were varied. In addition, interpretation of the CT-epidurogram was not blinded. The sample size was small; therefore, multivariate analysis was not possible. Conclusions: CT-epidurogram comparison revealed that Th1/2-pILEI was not localized on the injection side, and there was better dorsal spread – although ventral spread was small. Contrarily, Th1-TFEI was localized on the injection side, and better ventral spread was shown while cephalad spread was limited. We expected the addition of a sympathetic block effect suggested by the Horner’s syndrome as well as the merits of the ventral spread. However, short-term clinical effects were equal to those of Th1/2 pILEI. In future research, we need to standardize the diseases to include and to increase the number of cases to enable evaluation of clinical effectiveness.Key words: Epidural, cervical, transforaminal, interlaminar, fluoroscopy, CT-epidurogram, dorsal, ventral, cephalad, Horner’s syndrome

Background: Cervical interlaminar epidural injections are performed frequently in managing chronic neck and upper extremity pain, although less commonly than lumbar interlaminar epidural injections. Recently, the US Food and Drug Administration warnings and safeguards to prevent neurologic complications. These were developed by the Multi-Society Pain Workgroup have taken center stage for all types of epidural injections, including cervical interlaminar epidural injections. The recommendations of safeguards to prevent neurologic complications after epidural steroid injections include that cervical interlaminar epidural injections must be performed utilizing fluoroscopy with anteroposterior, lateral, or oblique views with injection of contrast medium and that entry be limited to the C7-T1 epidural space or occasionally the C6-C7 with requirements for magnetic resonance imaging assessment of the epidural space. Objectives: To assess the incidence of dural puncture associated with fluoroscopically directed cervical interlaminar epidural injections. Study Design: A retrospective assessment of patients undergoing cervical interlaminar epidural injections from January 2012 through February 2015. Setting: A private interventional pain management practice; a specialty referral center in the United States. Methods: The data were collected for 4,396 consecutive cervical interlaminar epidural injections performed from January 2012 through February 2015. The procedures were all performed under fluoroscopic visualization under posteroanterior view with contrast medium injection with lateral view confirmation when indicated. The procedures were performed by one of 2 physicians; the dural puncture and subsequent postoperative complications with level of epidural entry were determined. Outcomes Assessment: The outcome was assessment of dural puncture. Results: A review of multiple manuscripts showed that defects in the ligamentum flavum may extend to as much as 100% of the population. However, it also has been shown that among the levels with a gap, the location of a gap in the caudal third of the ligamentum flavum was more frequent than in the middle or cephalic portion of the ligamentum flavum. Among the 4,396 epidural injections performed at C7-T1, C6-C7, and C5-C6, 1,227 were performed at C7-T1; 1,835 were performed at C6-C7; and 1,334 were performed at C5-C6. Dural punctures were observed in 1.8% (24 procedures) at the C5-C6 level entry; 0.87% (16 procedures) at the C6-C7 level entry; and 1.71% (21 procedures) at the C7-T1 level. There was no significant difference among the entry levels. No complications or spinal cord damage or postdural puncture headache were observed. Limitations: The limitations of this report include that it is an assessment by only 2 well experienced physicians, even though it included a relatively large number of patients Conclusion: This study illustrates that dural puncture is equally prevalent, though very rare, irrespective of the needle entry level into the epidural space, with an overall dural puncture rate of 1.4%, with 1.8% at the C5-C6 level, 0.87% at the C6-C7 level, and 1.71% at the C7-T1 level. Based on the present literature, it appears that performing the procedure by inserting the needle into the cephalic portion of the intervertebral space rather than the caudal portion may be safer. Key words: Cervical interlaminar epidural injection, dural puncture, steroids, neck pain, upper extremity pain.

Chronic neck pain with or without upper extremity pain or headaches is relatively common in the adult population secondary to disc herniation, discogenic pain, spinal stenosis, spondylosis, and post-surgery syndrome. Treatments for chronic neck pain, recalcitrant to conservative management resulting in disability, include surgical management as well as interventional techniques with epidural injections utilizing either an interlaminar approach or transforaminal approach. Even though there have been multiple systematic reviews and randomized clinical trials of efficacy of cervical interlaminar epidural injections, the literature is sparse in reference to cervical transforaminal epidural injections. In addition, cervical transforaminal epidural injections have been associated with an inordinate risk.

This study aimed to determine whether the distribution of radicular pain has predictive value in identifying patients who would benefit from transforaminal cervical epidural steroid injections. Retrospective cohort study of subjects with cervical radiculopathy who underwent cervical epidural steroid injections from February 2005 to January 2006. Data from subjects were divided into groups based on pain distribution, imaging-based diagnosis of cervical disk herniation or stenosis, and their response to treatment. χ tests were used to assess the relationships between distribution and benefit. Of the 117 charts reviewed, complete data were available for 94 subjects. Forty-eight subjects had cervical disk herniations and, of these, 52% had pain above the elbow with 60% benefit, and 48% had pain below the elbow with 61% benefit. Forty-six subjects had cervical stenosis and, of these, 57% had pain above the elbow with 62% benefit, and 43% had pain below the elbow with 80% benefit. Benefit was defined as 70% or greater reduction in pain. χ testing demonstrated no statistically significant difference in beneficial response to cervical epidural steroid injections based on pain distributions. The likelihood of subjects to report a positive benefit from cervical epidural steroid injections as a treatment of their cervical radicular pain was independent of the distribution of their pain. Although our results did not show pain distribution to have a predictive value, additional research is needed in identifying predictive factors to improve outcomes and reduce cost.