Cervical Epidural Steroid Injection
Performed by Top Pain Management Doctors in San Antonio, Texas
Cervical Epidural Steroid Injectionsare a commonly performed intervention for chronic neck and head pain in the United States (Abdi, et al., 2007). Cervical epidural steroid injections (CESI) are used in the management of chronic pain experienced in the head, neck and upper extremities, particularly when more conservative therapies such as rest, oral pain relievers such as ibuprofen (Advil™) or acetaminophen (Tylenol™), or in some cases opioid narcotics, and physical therapy have failed. Common indications for treatment with CESI’s include:
- Disc problems (i.e. herniation), in which the cartilaginous inter-vertebral discs which act as cushions in between the vertebrae become disrupted and compress or irritate nearby nerve roots causing a radiculopathy, which is pain due to compression/irritation of nerve roots as they leave the spinal cord. In some cases they can also lead to numbness or weakness in the upper extremities
- Spinal stenosis, a degenerative disorder, in which the spinal canal narrows and can subsequently compress or irritate nearby traveling nerve roots causing pain in the neck and upper extremities, often on both sides
- Spondylosis, a disorder in which osteoarthritis develops within facet joints of the spine. As the joint space narrows due to degradation or bony protrusions emerge, nerves can become compressed or irritated when traveling in the spaces between the joints
- In some cases, CESI’s can be used to treat certain types of muscle contraction headache, strain, myofascial pain, reflex sympathetic dystrophy, post-surgical neck pain and certain types of neuralgia, or nerve pain (Williams & Park, 2007).
CSI’s combine steroid medications with a pain relieving anesthetic, which can be injected into the spine to treat certain conditions causing lower back and extremity pain. The steroid targets and reduces inflammation and irritation, while the anesthetic acts to interrupt pain transmission.
The spine consists of a column of bones, known as vertebrae, which are stacked atop one another from the pelvis to the base of the skull, forming a channel to protect the spinal cord (Hansen, 2010). The vertebrae themselves are composed of many structures, beginning with a solid, circular body connected to two transverse processes on either side by thin bony structures termed pedicles. The transverse processes can be thought of bony projections toward each side which serve as points for muscle attachment. These transverse processes are then connected to a centered spinous process, or the back-facing protrusion that can be felt through the skin, by two additional thin, bony structures which are termed the lamina. This design leaves a hollow central clearing in between the processes, lamina, pedicles and vertebral body within which the spinal cord resides.
Each vertebra is separated by cartilaginous, inter-vertebral discs composed of a tough, fibrous outer layer and filled with a soft, gelatinous inner layer. These discs support the vertebrae and allow them to shift across one another, facilitating movement of the spine (Hansen, 2010). Two vertebrae are connected to one another by two facet, or zygapophysial, joints located on either side of the bone. Facet joints connect the superior articular process, or upward-directed portion of one vertebra with the inferior articular process, or downward directed portion of the vertebral bone above it. Facet joints create an opening at the side between two connected vertebrae termed the neural foramen, through which nerve roots exit the spine to peripheral tissues.
There are two anatomical approaches used to administer CESI’s to the spine (Williams & Park, 2007). The interlaminar approach involves injection through the back and directly between the thin laminar portions of two adjacent vertebrae to access the epidural space of the spinal cord. The transforaminal approach involves injection through the neural foramen at the side of two adjacent vertebrae to directly target the epidural space near a nerve root. Regardless of approach, during an ESI procedure, a radiologic technique known as fluoroscopy, a type of real-time x-ray, is used to assist an interventional pain specialist or spinal surgeon in guiding the needle to the proper site for injection. Without fluoroscopic guidance, needle misplacement has been reported to occur up to 40% of the time (Williams & Park, 2007).
One group reported avoiding transforaminal injections due to increasing case reports of injury to the spinal cord and brainstem due to inadvertent injection of medications into nearby arteries supplying blood to the brain (Williams & Park, 2007).
During a CESI procedure, an injection is administered to the epidural space surrounding the spinal cord targeted within the cervical, or neck region. During the procedure, the patient lies prone on their abdomen while the injection site is exposed and sterilized with alcohol and iodine (Williams & Park, 2007). The site is then injected with an anesthetic solution to numb the area and prevent discomfort. The remainder of the procedure depends upon the surgical approach used to inject the medication.
For the interlaminar approach, a fluoroscopically guided injection is made through the back in between the thin laminar portions of vertebrae which connect the vertebral body to the spinous process, a site of muscle attachment. This approach allows access to the epidural space such that one injection can spread medication to nerve roots on both sides of the spinal cord. The injected medication then spreads through the epidural space to affected nerves to reduce inflammation and irritation and block pain. The entire procedure generally takes less than 15 minutes, and in most cases patients experience rapid relief of symptoms. For some patients, repeated injections may be required over the course of several weeks (ExitCare, 2012).
Following the procedure, patients are monitored for a short time for any adverse reactions. It is common to have soreness at the injection site for a short time, and some patients experience temporary numbness or weakness in the upper extremities (ExitCare, 2012). Most patients are able to resume normal daily activities shortly after injection.
CESI’s are considered a simple and relatively painless procedure. In a systematic review, researchers found strong evidence for the use of transforaminal CESI’s in the short-term AND long-term treatment of cervical nerve root pain (Abdi & al., 2007). In the same study, evidence was moderate for the short-term improvement, but strong for the long-term improvement of cervical radiculopathy via CESI using the inter-laminar approach.
Complications of CESI are typically of two types; problems with needle placement, or problems associated with the medications administered (Abdi & al., 2007). Complications with medication administration tend to involve the incidental injection of steroids into the blood stream, which can cause systemic side effects such as temporary weight gain, immunocompromise, and high blood sugar. Potential serious complications associated with CESI include:
- Spinal cord trauma
- Dural puncture
- Abscess formation
- Lung collapse
- Nerve damage
- Brain damage
Although these complications can be very devastating, they are also exceedingly rare. In a systematic review of CESI associated complications, researchers found the rate to of complication to be 1.66%, of which almost all were very minor, such as pain at the site of injection, or temporary headache (Abdi & al., 2007). Again, CESI has been proven to be a safe treatment modality in many studies.
Evidence from multiple observational studies suggests that transforaminal or interlaminar CESI’s can provide significant relief lasting 6 months or longer for anywhere from 40-60% of patients (Robinson & Kothari, 2012). In one clinical trial, 72% of patients with neck pain and cervical radiculopathy experienced immediate pain relief following CESI of an intra-laminar approach (Kwon, et al., 2007). Studies have concluded that CESI’s are a safe and effective modality for the treatment of patients experiencing chronic neck pain and associated radiculopathy, however pain relief may vary from person to person, however, as relief lasts longer for some patients than it does for others. In many cases, studies have found pain relief from CESI to be significant enough to prevent patients from needing to consider surgical interventions for chronic pain (Abdi & al., 2007).
- Abdi, S., et al. (2007). Epidural Steroids in the Management of Chronic Spinal Pain: A Systematic Review. Pain Physician , 185-212.
- ExitCare. (2012). Epidural Steroid Injection. Retrieved April 15, 2012, from MD Consult: http://www.mdconsult.com.ezproxy2.library.arizona.edu/das/patient/body/331724931-9/1302729376/10089/60572.html
- Hansen, J. (2010). Back. Retrieved April 7, 2012, from MD Consult. Netter’s Clinical Anatomy.
- Kwon, J., et al. (2007). Cervical interlaminar epidural steroid injection for neck pain and cervical radiculopathy: effect and prognostic factors. Skeletal Radiol , 431-6.
- Robinson, J., & Kothari, M. (2012). Treatment of cervical radiculopathy. Retrieved April 6, 2012, from UpToDate: http://www.uptodate.com.ezproxy1.library.arizona.edu/contents/treatment-of-cervical-radiculopathy?source=search_result&search=cervical+steroid+epidural+injection&selectedTitle=1~150#H12
- Williams, K., & Park, A. (2007). Injection Studies. Retrieved April 8, 2012, from MD Consult. Canale & Beaty: Campbell’s Operative Orthopaedics, 11th ed.: http://www.mdconsult.com.ezproxy1.library.arizona.edu/books/page.do?eid=4-u1.0-B978-0-323-03329-9..50042-8–cesec38&isbn=978-0-323-03329-9&sid=1303352886&uniqId=331965702-9#4-u1.0-B978-0-323-03329-9..50042-8–cesec39