Skip to main content
SpringerLink
Log in

Cervical Epidural Steroid Injections for the Treatment of Cervical Spinal (Neck) Pain

  • Anesthetic Techniques in Pain Management (KA Williams, Section editor)
  • Published:
Current Pain and Headache Reports Aims and scope Submit manuscript

Abstract

Cervical epidural steroid injections (CESI) are an accepted treatment for neck pain with a radicular component, and may be accomplished by using either transforaminal (CTFESI) or interlaminar (CILESI) approaches. CESIs are routinely performed using real-time fluoroscopic-guidance in conjunction with the injection of water soluble, iodine-based contrast media to enhance visualization of intravascular injections. Digital subtraction angiography (DSA) imaging is an adjuvant to fluoroscopic methods for visualizing blood vessels while performing spinal injections. However, as with any neuraxial procedure, various complications associated with CESIs have been reported. Complications are directly associated with the technical procedures of CESIs. Particulate steroids may have a prolonged duration of action but non-particulate steroids are safer for CESIs. Blunt-beveled needles are less likely than sharp-beveled needles to penetrate blood vessels to cause bleeding complications during CTFESI procedures. Small doses of local anesthetics appear to be safe and assist in identifying intravascular injections previously overlooked by conventional techniques.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Thierry-Mieg J. Cervical epidural injections of corticoids in hyperalgic cervico-brachial neuralgias. 1st cervical epidurographical pictures. Rev Rhum Mal Osteoartic. 1961;28:451–3.

    PubMed  CAS  Google Scholar 

  2. Slipman CW, Lipetz JS, Jackson HB, Rogers DP, Vresilovic EJ. Therapeutic selective nerve root block in the nonsurgical treatment of a traumatic cervical spondylotic radicular pain: a retrospective analysis with independent clinical review. Arch Phys Med Rehabil. 2000;81:741–6.

    PubMed  CAS  Google Scholar 

  3. •• Manchikanti L, Boswell MV, Singh V, et al. Comprehensive evidence-based guidelines for interventional techniques in the management of chronic spinal pain. Pain Physician. 2009;12:699–802. A systematic literature review of different interventional techniques used in the treatment of chronic spinal pain, including the cervical (neck) pain.

    PubMed  Google Scholar 

  4. Stout A. Epidural steroid injections for cervical radiculopathy. Phys Med Rehabil Clin N Am. 2011;22:149–59.

    Article  PubMed  Google Scholar 

  5. Kang JD, Georgescu HI, McIntyre-Larkin L, Stefanovic-Racic M, Evans CH. Herniated cervical intervertebral discs spontaneously produce matrix metalloproteinases, nitric oxide, interleukin-6, and prostaglandin E2. Spine. 1995;20:2373–8.

    Article  PubMed  CAS  Google Scholar 

  6. • Lee SH, Kim KT, Kim DH, Lee BJ, Son ES, Kwack YH. Clinical outcomes of cervical radiculopathy following epidural steroid injection: a prospective study with follow-up for more than 2 years. Spine. 2012;37:1041–7. Prospective clinical study analyzing the effects of CILESI and CTFESI in the treatment of cervical radiculopathy with long follow up (more than 2 years).

    Article  PubMed  Google Scholar 

  7. Rathmell JP, Aprill C, Bogduk N. Cervical transforaminal injection of steroids. Anesthesiology. 2004;100:1595–600.

    Article  PubMed  Google Scholar 

  8. Tiso RL, Cutler T, Catania JA, Whalen K. Adverse central nervous system sequelae after selective transforaminal block: the role of corticosteroids. Spine J. 2004;4:468–74.

    Article  PubMed  Google Scholar 

  9. Han KR, Kim C, Park SK, Kim JS. Distance to the adult cervical epidural space. Reg Anesth Pain Med. 2003;28:95–7.

    PubMed  Google Scholar 

  10. • Botwin KP, Castellanos R, Rao S, et al. Complications of fluoroscopically guided interlaminar cervical epidural injections. Arch Phys Med Rehabil. 2003;84:627–33. Retrospective study assessing the incidence of complications of fluoroscopically-guided CILESIs.

    PubMed  Google Scholar 

  11. Goodman B, Petalcorin JS, Mallempati S. Optimizing patient positioning and fluoroscopic imaging for the performance of cervical interlaminar epidural steroid injections. Pm R. 2010;2:783–6.

    Article  PubMed  Google Scholar 

  12. Lirk P, Kolbitsch C, Putz G, et al. Cervical and high thoracic ligamentum flavum frequently fails to fuse in the midline. Anesthesiology. 2003;99:1387–90.

    Article  PubMed  Google Scholar 

  13. Goel A, Pollan JJ. Contrast flow characteristics in the cervical epidural space: an analysis of cervical epidurograms. Spine. 2006;31:1576–9.

    Article  PubMed  Google Scholar 

  14. Wolter T, Knoeller S, Berlis A, Hader C. CT-guided cervical selective nerve root block with a dorsal approach. AJNR: Am J Neuroradiol. 2010;31:1831–6.

    Article  PubMed  CAS  Google Scholar 

  15. Wald JT, Maus TP, Geske JR, et al. Safety and efficacy of CT-guided transforaminal cervical epidural steroid injections using a posterior approach. AJNR Am J Neuroradiol. 2012;33:415–9.

    Article  PubMed  CAS  Google Scholar 

  16. Anderberg L, Annertz M, Brandt L, Saveland H. Selective diagnostic cervical nerve root block–correlation with clinical symptoms and MRI-pathology. Acta Neurochir. 2004;146:559–65.

    Article  CAS  Google Scholar 

  17. Manchikanti L. The growth of interventional pain management in the new millennium: a critical analysis of utilization in the Medicare population. Pain Physician. 2004;7:465–82.

    PubMed  Google Scholar 

  18. • Jee H, Lee JH, Kim J, Park KD, Lee WY, Park Y. Ultrasound-guided selective nerve root block vs fluoroscopy-guided transforaminal block for the treatment of radicular pain in the lower cervical spine: a randomized, blinded, controlled study. Skeletal Radiol. 2013;42:69–78. Prospective clinical study comparing short-term effect and advantages of ultrasound-guided SCNRBs and fluoroscopically-guided CTFESIs.

  19. Siegenthaler A, Mlekusch S, Trelle S, Schliessbach J, Curatolo M, Eichenberger U. Accuracy of ultrasound-guided nerve blocks of the cervical zygapophysial joints. Anesthesiology. 2012;117:347–52.

    Article  PubMed  Google Scholar 

  20. Tofuku K, Koga H, Komiya S. Subdural spread of injected local anesthetic in a selective transforaminal cervical nerve root block: a case report. J Med Case Rep. 2012;6:142.

    Article  PubMed  Google Scholar 

  21. Galiano K, Obwegeser AA, Walch C, Schatzer R, Ploner F, Gruber H. Ultrasound-guided vs computed tomography-controlled facet joint injections in the lumbar spine: a prospective randomized clinical trial. Reg Anesth Pain Med. 2007;32:317–22.

    PubMed  Google Scholar 

  22. Huston CW. Cervical epidural steroid injections in the management of cervical radiculitis: interlaminar vs transforaminal. A review. Curr Rev Musculoskelet Med. 2009;2:30–42.

    Article  PubMed  Google Scholar 

  23. Manchikanti L, Malla Y, Wargo BW, Cash KA, Pampati V, Fellows B. Complications of fluoroscopically directed facet joint nerve blocks: a prospective evaluation of 7500 episodes with 43,000 nerve blocks. Pain Physician. 2012;15:E143–50.

    PubMed  Google Scholar 

  24. Muro K, O'Shaughnessy B, Ganju A. Infarction of the cervical spinal cord following multilevel transforaminal epidural steroid injection: case report and review of the literature. J Spinal Cord Med. 2007;30:385–8.

    PubMed  Google Scholar 

  25. Wallace MA, Fukui MB, Williams RL, Ku A, Baghai P. Complications of cervical selective nerve root blocks performed with fluoroscopic guidance. Am J Roentgenol. 2007;188:1218–21.

    Article  Google Scholar 

  26. •• Scanlon GC, Moeller-Bertram T, Romanowsky SM, Wallace MS. Cervical transforaminal epidural steroid injections: more dangerous than we think? Spine. 2007;32:1249–56. Study based on pain physicians survey about serious neurological complications following CTFESIs.

    Article  PubMed  Google Scholar 

  27. Baker R, Dreyfuss P, Mercer S, Bogduk N. Cervical transforaminal injection of corticosteroids into a radicular artery: a possible mechanism for spinal cord injury. Pain. 2003;103:211–5.

    Article  PubMed  Google Scholar 

  28. Lee JY, Nassr A, Ponnappan RK. Epidural hematoma causing paraplegia after a fluoroscopically guided cervical nerve-root injection. A case report. J Bone Joint Surg Am. 2007;89:2037–9.

    Article  PubMed  Google Scholar 

  29. Popescu A, Lai D, Lu A, Gardner K. Stroke following epidural injections-case report and review of literature. J Neuroimaging. 2011. doi:10.1111/j.1552-6569.2011.00615.x [Epub ahead of print].

  30. Stauber B, Ma L, Nazari R. Cardiopulmonary arrest following cervical epidural injection. Pain Physician. 2012;15:147–52.

    PubMed  Google Scholar 

  31. Rozin L, Rozin R, Koehler SA, et al. Death during transforaminal epidural steroid nerve root block (C7) due to perforation of the left vertebral artery. Am J Forensic Med Pathol. 2003;24:351–5.

    Article  PubMed  Google Scholar 

  32. • Furman MB, Giovanniello MT, O'Brien EM. Incidence of intravascular penetration in transforaminal cervical epidural steroid injections. Spine. 2003;28:21–5. Prospective observational clinical study evaluating the incidence of intravascular contrast injection during fluoroscopically-guided CTFESIs.

    Article  PubMed  Google Scholar 

  33. Malhotra G, Abbasi A, Rhee M. Complications of transforaminal cervical epidural steroid injections. Spine. 2009;34:731–9.

    Article  PubMed  Google Scholar 

  34. •• Kim do W, Han KR, Kim C, Chae YJ. Intravascular flow patterns in transforaminal epidural injections: a comparative study of the cervical and lumbar vertebral segments. Anesth Analg. 2009;109:233–9. Prospective observational study comparing cervical and lumbar transforaminal epidural steroid injections and showing the incidence much higher than previously reported.

    Article  PubMed  Google Scholar 

  35. Derby R, Lee SH, Date ES, Lee JH, Lee CH. Size and aggregation of corticosteroids used for epidural injections. Pain Med. 2008;9:227–34.

    Article  PubMed  Google Scholar 

  36. Huntoon MA. Anatomy of the cervical intervertebral foramina: vulnerable arteries and ischemic neurologic injuries after transforaminal epidural injections. Pain. 2005;117:104–11.

    Article  PubMed  Google Scholar 

  37. Hoang JK, Apostol MA, Kranz PG, et al. CT fluoroscopy-assisted cervical transforaminal steroid injection: tips, traps, and use of contrast material. Am J Roentgenol. 2010;195:888–94.

    Article  Google Scholar 

  38. Verrills P, Nowesenitz G, Barnard A. Penetration of a cervical radicular artery during a transforaminal epidural injection. Pain Med. 2010;11:229–31.

    Article  PubMed  Google Scholar 

  39. Kranz PG, Raduazo P, Gray L, Kilani RK, Hoang JK. CT fluoroscopy-guided cervical interlaminar steroid injections: safety, technique, and radiation dose parameters. Am J Neuroradiol. 2012;33:1221–4.

    Article  PubMed  CAS  Google Scholar 

  40. Khan S, Pioro EP. Cervical epidural injection complicated by syrinx formation: a case report. Spine. 2010;35:E614–6.

    PubMed  Google Scholar 

  41. Kim H, Lee SH, Kim MH. Multislice CT fluoroscopy-assisted cervical transforaminal injection of steroids: technical note. J Spinal Disord Tech. 2007;20:456–61.

    Article  PubMed  Google Scholar 

  42. Narouze SN. Ultrasound-guided interventional procedures in pain management: evidence-based medicine. Reg Anesth Pain Med. 2010;35:S55–8.

    Article  PubMed  Google Scholar 

  43. • McLean JP, Sigler JD, Plastaras CT, Garvan CW, Rittenberg JD. The rate of detection of intravascular injection in cervical transforaminal epidural steroid injections with and without digital subtraction angiography. Pm R. 2009;1:636–42. Retrospective analysis comparing the detection rate of intravascular injections with and without DSA, showing that it improves the detection rate of intravascular injection during CTFESIs.

    Article  PubMed  Google Scholar 

  44. Karasek M, Bogduk N. Temporary neurologic deficit after cervical transforaminal injection of local anesthetic. Pain Med. 2004;5:202–5.

    Article  PubMed  Google Scholar 

  45. Smuck M, Maxwell MD, Kennedy D, Rittenberg JD, Lansberg MG, Plastaras CT. Utility of the anesthetic test dose to avoid catastrophic injury during cervical transforaminal epidural injections. Spine J. 2010;10:857–64.

    Article  PubMed  Google Scholar 

  46. Chung SG. Convulsion caused by a lidocaine test in cervical transforaminal epidural steroid injection. Pm R. 2011;3:674–7.

    Article  PubMed  Google Scholar 

  47. Heavner JE, Racz GB, Jenigiri B, Lehman T, Day MR. Sharp vs blunt needle: a comparative study of penetration of internal structures and bleeding in dogs. Pain Pract. 2003;3:226–31.

    Article  PubMed  Google Scholar 

  48. Smuck M, Leung D. Inadvertent injection of a cervical radicular artery using an atraumatic pencil-point needle. Spine. 2011;36:E220–3.

    Article  PubMed  Google Scholar 

  49. Candido KD, Ghaly RF, Mackerley S, Knezevic NN. A Whitacre-type spinal needle does not prevent intravascular injection during cervical nerve root injections. South Med J. 2010;103:679–82.

    Article  PubMed  Google Scholar 

  50. Heavner JE, Racz GB. Using procedure-specific needles: what is blunt? South Med J. 2010;103:604.

    Article  PubMed  Google Scholar 

Download references

Disclosure

No potential conflicts of interest relevant to this article were reported.

Author information

Authors and Affiliations

  1. Department of Anesthesiology, Advocate Illinois Masonic Medical Center, 836 W. Wellington Ave. Suite 4815, Chicago, IL, 60657, USA

    Kenneth D. Candido & Nebojsa ‘Nick’ Knezevic

  2. Department of Anesthesiology, University of Illinois, Chicago, IL, 60612, USA

    Kenneth D. Candido & Nebojsa ‘Nick’ Knezevic

Authors
  1. Kenneth D. Candido
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nebojsa ‘Nick’ Knezevic
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Kenneth D. Candido.

Additional information

This article is part of the Topical Collection on Anesthetic Techniques in Pain Management

Rights and permissions

Reprints and permissions

About this article

Cite this article

Candido, K.D., Knezevic, N. Cervical Epidural Steroid Injections for the Treatment of Cervical Spinal (Neck) Pain. Curr Pain Headache Rep 17, 314 (2013). https://doi.org/10.1007/s11916-012-0314-7

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11916-012-0314-7

Keywords

Search

Navigation