X-ray guidance, called fluoroscopy, is used so the practitioner can visualize the needle going into the cervical epidural space. Contrast dye is injected into the space to make sure the needle is properly positioned in the epidural space near the irritated nerve or nerves. A cortisone steroid solution is injected into the epidural space. The steroid is an anti-inflammatory medication. The goal is to alleviate the local inflammation, which in turn should decrease the associated nerve pain.
A cervical epidural injection is often done with the goal of providing enough pain relief so that the patient can progress with a rehabilitation program. Video: Towel Shoulder Stretch. Video: Crossover Shoulder Stretch. Epidural Steroid Injections. You are here Video. Cervical Epidural Steroid Injection Video. Peer Reviewed. Video Transcript A cervical epidural steroid injection may be performed to relieve pain associated with inflammation around the nerves in the neck.
Steroids also have additional useful properties that make them especially effective, which include an ability to promote the stability of the membranes surrounding the nerves and to hinder the conduction of ions. These processes are associated with reduced pain. A meta-analysis study that focused on reviewing clinical reports regarding the effectiveness and safety of steroid injections, included data that was obtained over a span of ten years.
The results showed strong support for the administration of epidural steroid injections to treat chronic pain. The effects of steroid injections are generally long-term, but the mechanism that is responsible for this effect is still unclear. It has been concluded, however, that repeated injections that are performed over a one-year period can improve the long-term effects of the injections.
In order to understand the injection procedure and where the medication is injected, a brief description of the spinal region will first be explained. The spinal region includes a column of individual bones, called vertebrae, that encase and protect the spinal cord. A vast number of nerves extend out from the spinal cord to the rest of the body. The spinal cord is held in place by a strong membrane. Directly outside of the membrane is a region known as the epidural space, where nerve roots are located.
This is the area in which steroids are injected if nerves become pinched, damaged, or inflamed. Before the injection procedure begins, topical anesthesia is applied to the skin. Next, in order to prevent healthy nerve roots from being exposed to too much medication, the physician will use imaging technology such as fluoroscopy to guide the insertion of the needle and to confirm its correct placement in the epidural space. In addition, contrast dye is typically injected in order to observe where the medication will be administered and to ensure that it will be properly distributed throughout the targets areas.
The administration of steroids and an anesthetic such as Lidocaine directly onto the nerves roots results in dramatic or complete pain relief. The steroid decreases inflammation, while the anesthetic disrupts pain signal transmission.
For example, a cervical herniated disc may impinge on a nerve root, a degenerated disc may cause local inflammation, cervical osteoarthritis or spinal stenosis may reduce the space for the nerves, resulting in inflammation and irritation to the nerves. With a cervical epidural injection, the procedure is performed with the patient laying face down. An area of skin and tissue above the injection site is injected with a local anesthetic to numb the area. Next, a larger needle is inserted. X-ray guidance, called fluoroscopy, is used so the practitioner can visualize the needle going into the cervical epidural space.
Contrast dye is injected into the space to make sure the needle is properly positioned in the epidural space near the irritated nerve or nerves. A cortisone steroid solution is injected into the epidural space. The steroid is an anti-inflammatory medication. The goal is to alleviate the local inflammation, which in turn should decrease the associated nerve pain.
A cervical epidural injection is often done with the goal of providing enough pain relief so that the patient can progress with a rehabilitation program. Video: Towel Shoulder Stretch. Video: Crossover Shoulder Stretch. Epidural Steroid Injections. Non-particulate corticosteroid given the potential for a particulate corticosteroid to thrombus a vessel mixed with local anesthetic and saline is injected with close communication with the patient.
Of note, ultrasound-guided rather than fluoroscopy-guided transforaminal cervical epidural injection is a prospective new imaging modality. A small prospective study demonstrated effective and safe results. This modality has the significant benefit of being able to visualize the vascular structure. Complications occur when the needle comes in contact with the spinal cord, blood vessels, spinal nerves, or contamination.
The mechanism of complications again is unknown, but it has been said to be secondary to emboli and thrombus formation, aortic dissection leading to hemorrhage, arterial vasospasm, as well as a dural puncture. Complications reported with an interlaminar cervical epidural corticosteroid injection include dural puncture, vasovagal reaction, nerve root injury, epidural hematoma, subdural hematoma, transient paresthesias, transient blindness, epidural abscess, cord injury, paralysis, and death.
Complications reported with transforaminal cervical epidural corticosteroid injections include transient increased radicular pain, vasovagal reaction, dural puncture, temporary lightheadedness, transient global amnesia, paralysis, vertebral artery injury, cerebellar infarction, and death. The most common side effects were neck pain 6. The rate of dural puncture incidence was found to be 0. Outcomes of cervical epidural injections typically depend on the mechanism of injury and the degree of pathology.
There is a recurrence of symptoms in up to one-third of patients with compressive cervical radiculopathy following initial treatment. Cervical epidural corticosteroid injections are significant for short-term pain relief. However, limited studies are comparing the effectiveness of various techniques. There is good evidence for cervical epidural injections for pain secondary to cervical disc herniation, central spinal stenosis, and postsurgery syndrome.
There is weaker evidence for the transforaminal approach and a higher side effect profile. For short-term pain relief less than six weeks , a cervical epidural, there is moderate evidence in its use but sparse long-term data. Similar evidence studies have been done for both interlaminar and transformational injections. Interestingly corticosteroid injections did not have any significant reduction of pain at three weeks follow-up for the same study. Seventy-fiver percent pain relief occurred in 40 percent of patients.
While no pain relief occurred in 32 percent of patients. Cervical epidural injections are a minor outpatient procedure, the risk of the procedure is relatively low, but there have been associated cases with serious complications that worsen patient morbidity. Patients with at least four to six weeks of stable radicular pain secondary to nerve compressive of the cervical vertebrae can benefit from a cervical epidural corticosteroid injection.
Before the procedure, it is imperative to identify the risk factors and perform a thorough assessment of the patient. An interprofessional team approach is the best way to care for patients with cervical radiculopathy and minimize the complications of this procedure. Before and after the epidural injection, the patient should have the following done:. Coordination of the interprofessional team provides improved outcomes and higher patient satisfaction.
Patients resume full activity the next day after a cervical epidural injection. Patients may complain of soreness at the injection site following the procedure. Pain is often relieved by using ice and taking over the counter analgesics such as acetaminophen. Side effects of the injection are typically discussed following the procedure by the provider and or their nursing staff. A total of three doses recommended up to one to four weeks apart, following an initial injection.
Transient paralysis has been reported following an injection. However, numbness or weakness of muscles usually resolves within eight hours of onset. Occasionally, a patient may need to be monitored for more than 30 minutes after the epidural. Physical therapy and home exercise programs are recommended following this procedure.
Patients have a few weeks to a few month windows following the procedure to help strengthen the pain in their neck while benefiting from the analgesic effects of the corticosteroid. Patients are typically monitored after the procedure minutes.
Occasionally, in refractory cases, patients need to be driven home. A population-based study from Rochester, Minnesota, through Brain : a journal of neurology. Prospective, multicenter study with independent clinical review. Engel A,King W,MacVicar J, The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: a systematic review with comprehensive analysis of the published data. Pain medicine Malden, Mass.
Persson L,Anderberg L, Repetitive transforaminal steroid injections in cervical radiculopathy: a prospective outcome study including patients. Evidence-based spine-care journal. A review. European journal of neurology. Pain physician. Hogan QH, Epidural anatomy examined by cryomicrotome section. Influence of age, vertebral level, and disease. Regional anesthesia. Huntoon MA, Anatomy of the cervical intervertebral foramina: vulnerable arteries and ischemic neurologic injuries after transforaminal epidural injections.
Physical medicine and rehabilitation clinics of North America. Wagner AL, CT fluoroscopic-guided cervical nerve root blocks. American journal of neuroradiology. American journal of roentgenology. Current pain and headache reports. International journal of medical sciences. Journal of pain research. Archives of neurology. The American journal of forensic medicine and pathology. An analysis of injections. The Journal of bone and joint surgery.
American volume. Archives of physical medicine and rehabilitation. Siegfried RN, Development of complex regional pain syndrome after a cervical epidural steroid injection. Mangar D,Thomas PS, Epidural steroid injections in the treatment of cervical and lumbar pain syndromes.
Cervical Epidural Injection. Continuing Education Activity Cervical epidural corticosteroids can provide significant benefits in patients experiencing chronic neck pain secondary to cervical radiculopathy. Introduction Many patients with symptoms of cervical radiculopathy can benefit from a cervical epidural injection. Contraindications Absolute contraindication to an epidural corticosteroid injection includes active infections.
Equipment Equipment needed for a cervical epidural corticosteroid injection includes topical anesthesia such as lidocaine, a low resistant syringe, and a needle i. Personnel A cervical epidural injection is an outpatient procedure often done by pain management physicians. Preparation A cervical epidural injection is recommended to be performed at an ambulatory surgical center with fluoroscopy capabilities.
Complications Complications occur when the needle comes in contact with the spinal cord, blood vessels, spinal nerves, or contamination. Clinical Significance Outcomes of cervical epidural injections typically depend on the mechanism of injury and the degree of pathology.
Enhancing Healthcare Team Outcomes Cervical Epidural Injections Cervical epidural injections are a minor outpatient procedure, the risk of the procedure is relatively low, but there have been associated cases with serious complications that worsen patient morbidity. Before and after the epidural injection, the patient should have the following done: Evaluation by their primary care physician.
The patient should have failed conservative management of cervical radiculopathy before being a candidate for an epidural injection. Complete advanced imaging, including X-ray, CT, or MRI, is confirming the underlying pathology causing cervical radiculopathy by a radiologist. In cases of nonequivalent imaging, nerve conduction studies or electromyography EMG can be done by a neurologist or physical medicine specialist.
Be consulted by the pharmacist for the use of blood thinners before the procedure. In cases of worsening or severe symptoms, a neurosurgeon should be consulted for surgical decompression of the spinal cord rather than a minimally invasive epidural injection.
The various specialist performs cervical epidural injection depending on the severity and duration of the patient's neck pain. A referral by the primary care physician can be placed to either anesthesia, a pain medicine specialist, physical medicine, and rehabilitation, or neurology interventional. Specially trained nurses in radiology, neuroscience, and rehabilitation are essential for the care of these patients. A fluoroscopy technician should be present for the procedure.