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Safety of local anesthetics in cervical nerve root injections: a narrative review

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Abstract

Severe neurological adverse events have been reported after fluoroscopically guided cervical nerve root injections. Particulate corticosteroids inadvertently injected intraarterially and iatrogenic vertebral artery trauma have been implicated in these outcomes. This has raised concern for the potential consequences of including local anesthetic with these injections. As a result, some providers have now discontinued the routine administration of local anesthetic with corticosteroid when performing cervical nerve root injections. At present, there is no consensus regarding whether the use of local anesthetic in this context is safe. Here, the current literature is synthesized into a narrative review aiming to clarify current perspectives of the safety of local anesthetics in cervical nerve root injections.

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Authors and Affiliations

  1. Massachusetts General Hospital, Harvard Medical School Boston MA, Boston, USA

    Zachary E. Stewart

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Zachary E. Stewart was the sole contributor to the conception and design of this review article and responsible for drafting the article or revising it critically for important intellectual content, as well as the final approval of the version to be published and agrees to be accountable for all aspects of the work if questions arise related to its accuracy or integrity.

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Correspondence to Zachary E. Stewart.

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Key points

• Particulate corticosteroids or needle trauma, not local anesthetics, are implicated as the cause of the majority of serious adverse events after cervical nerve root blocks. The incidence of serious adverse events related to the anesthetic in cervical nerve root blocks is unknown and is currently limited to case reports in the literature.

• Non-allergic risks of local anesthetics in cervical nerve root blocks are related to intravascular, subdural, intrathecal, or intraneural injection.

• A volume of 1 mL of 1% lidocaine (10 mg) inadvertently injected in to the vertebrobasilar artery system is at the low end of the theorized thresholds required to incite seizures or other more serious neurologic sequela. Injecting slowly, for instance 5 mg at 30-–90-sintervals, may reduce the risk of adverse events associated with intraarterial anesthetic injection.

• Lidocaine may be preferred to bupivacaine for cervical nerve root blocks due to the shorter time to onset (improved patient comfort during injection), the shorter duration of action (in case of inadvertent subdural or intravascular injection), higher threshold for seizure induction, and potential therapeutic benefits.

• Proper fluoroscopic injection technique, including proper needle positioning and contrast testing with digital subtraction angiography through short extension tubing, may reduce the risk of anesthetic related complications.

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Stewart, Z.E. Safety of local anesthetics in cervical nerve root injections: a narrative review. Skeletal Radiol 52, 1893–1900 (2023). https://doi.org/10.1007/s00256-022-04220-4

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