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Cervical epidural steroid injections
Techniques in Regional Anesthesia and Pain Management (2005) 9, 58-61
Cervical epidural steroid injections Samuel K. Rosenberg, MD, FIPP From Precision Orthopedic Specialties, Inc., Chardon, Ohio. KEYWORDS: Cervical epidural steroid injections; Cervical transforaminal steroid injections
Cervical epidural steroid injections, performed via interlaminar or transforaminal approach, represent a useful interventional pain management procedure indicated in those patients with neck pain, with or without arm pain, commonly seen in cervical herniated discs, cervical spondylosis and cervical spinal stenosis. In properly trained physicians the risks of these procedures should be very low. © 2005 Elsevier Inc. All rights reserved.
Cervical epidural steroid injections can be a very effective therapeutic, nonsurgical intervention for those patients suffering from intractable neck pain that radiates to one or both upper extremities and the interscapular region. Neck pain is less common than back pain, and usually measured together with shoulder pain.1 The prevalence of neck pain, defined as the percentage of patients presenting with pain on the day of interview, ranges between 11.5% and 20% in patients between 20 and 69 years of age.1 The lifetime prevalence was estimated in two population studies: a Canadian study estimated the prevalence of 69%,2 while a Finnish study estimated it at 71%.3 The rate of cervical spondylosis differs between populations. For example, the rate for dentists is at 42% to 50%, miners at 54% to 76%, and meat carriers at 84%.1 Cervical radicular pain affects 1 person out of every 1000 per year. It is mostly caused by cervical herniated discs or foraminal stenosis.4 Whiplash injury, which is considered separately, can also give rise to neck pain. A Canadian study reported gender differences between males at 73 per 100,000 drivers, versus females at 131 per 100,000 drivers.5
Indications Cervical epidural steroid injections are offered more commonly to patients with severe neck and/or arm pain that have not responded to medications such as antiinflammatory Address reprint requests and correspondence: Dr. Samuel K. Rosenberg, Interventional Pain Management Specialist, Precision Orthopedic Specialties, Inc., 150 Seventh Ave., Suite 200, Chardon, OH 44024. E-mail address: [email protected]. 1084-208X/$ -see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1053/j.trap.2005.05.002
medications, steroids, muscle relaxants, mild opioids, and over-the-counter analgesics. The indications for this type of nerve block include: cervical spondylosis, cervical herniated discs, cervical spinal stenosis, and cervical radicular pain with or without radiculopathy. Frequently, patients are in so much pain that they cannot perform physical therapy, and any activity worsens their pain. Patients may present frequently with associated headaches, shoulder and trapezoid muscle pain, interscapular pain, arm pain, hand pain, muscle weakness, and paresthesias. At times patients can drop things. The onset can be acute, subacute, or chronic.
Anatomy The epidural space is subdivided into anterior and posterior compartments. The anterior compartment lies between the vertebral bodies, intervertebral disc, posterior longitudinal ligament, and the thecal sac. The posterior compartment lies between the thecal sac and the ligamentum flavum and laminae. The posterior compartment is triangular in shape and varies in diameter. At the C7 level, it is 1.5 to 2.0 mm, at T2, 4 mm, at L2, 5-6 mm, and at S1, 2 mm.6 The epidural space has adipose tissue, arteries, lymphatic, and venous plexus. The ligamentum flavum is a pair of ligaments that usually fuse in midline during gestation (Figures 1 and 2). The spinal nerve lies at the lower half of the foramen, and the spinal radicular arteries arise from the vertebral artery. The ascending cervical artery accompanies the spinal nerve to the spinal cord.4 It is mandatory to ensure that, during needle placement, the tip of the needle is not in the vertebral artery or the cervical radicular arteries.
Rosenberg
Cervical Epidural Steroid Injections
Figure 1
59
Spaces and compartments of the spinal canal.
Procedure Since the cervical epidural space is very narrow above the C7 region, it is best to enter the epidural space at that level or below it. Entering above the C6 level is not recommended.4 This mandates the use of fluoroscopy, which can correctly identify the entry site. It aids in ensuring that the needle is in the epidural space if contrast material is used, in addition to improving safety. It is best to examine patients before performing this nerve block to assess the amount of neurological deficits. If those neurological deficits include a clear and progressive muscle weakness in the upper extremities, as well as hyperreflexia and a positive Hoffman sign (a positive Hoffman sign occurs after tapping the middle finger while the wrist is
Figure 3 (A) Hoffman Sign, step 1. (B) Hoffman Sign, step 2. Test is positive.
relaxed, and the first and second fingers move toward each other (Figure 3A and B); this sign is often present in myelopathic patients where the pathology arises from the cervical spine), an immediate referral to a spine surgeon is in order. The nerve block is not recommended. To help determine the probable source for the pain, it is best to obtain and view an MRI of the cervical spine. If the canal is too narrow (⬍10 mm) at the entry site (commonly C7-T1), it may warrant entry at the level below. One may not even recommend this type of nerve block. Some physicians have recommended not performing these types of procedures if the epidural space measures ⬍1 mm at the entry-level site.6 Pain specialists have abandoned the performance of these procedures without the use of fluoroscopy. Up to 25% of the so-called “blind injections” performed by experienced hands are not in the epidural space.6 Only with the injection of contrast material is it possible to verify that the needle is not intravascular, and that the needle is in the epidural space.7 It can also help determine whether the needle is intrathecal. There are two approaches to the cervical epidural space: the interlaminar and the transforaminal approach. Only trained and experienced physicians capable of identifying a needle moving at 1 mm at a time should attempt these procedures. Some physicians have recommended doing these types of injections after completing at least 1000 lumbar injections. These injections can be done under local anesthesia or intravenous sedation.
Interlaminar approach Figure 2 arteries.
Ascending cervical, vertebral, and spinal radicular
The positioning of the patient for the interlaminar epidural injection is prone, with a blanket or two under the
60
Techniques in Regional Anesthesia and Pain Management, Vol 9, No 2, April 2005
chest to accentuate neck flexion. The jaw needs to be out of the way, and the patient monitored with a pulse oximeter and a blood pressure cuff. Recognizing the first rib identifies the C7-T1 interspace. The needle marker should be placed at the middle of the laminae of T1 on the affected site. A 25-gauge needle numbs the skin with 0.5 to 1.0 mL of local anesthetic. Then a 17- to 20-gauge Tuohey needle is inserted into the laminae to establish depth. Once bone is reached, another 0.5 mL of local anesthetic is injected. After that, the Tuohey needle is advanced slightly toward the painful side, and following the loss of resistance to saline technique into the midline. The epidural space is reached anywhere between 0.5 and 2 cm from the area where the needle reached the laminae. Commonly one feels a “change” in resistance, but not necessarily a “loss” of resistance. Nonionic contrast material (Omnipaque, Isovue M200) should then be injected under live fluoroscopy to ensure correct placement of the needle. The spread of the contrast material reveals nerve roots. It can also reveal the spread of the solution intrathecally or in blood vessels (either arteries or veins). If the physician encounters a spread that is not completely understood, such as a “blob,” or an intravascular uptake is identified, then the procedure should be aborted or the needle repositioned. Rapid clearance of the nonionic contrast material can signify a solution that is either intraarterial or subarachnoid. The total volume of 4 to 6 mL is injected after the injection of the contrast material. This can include 1 to 2 mL of steroid (Betamethasone 6 mg/mL, Triamcinolone 25-40 mg/mL, preservative-free preparations, such as Dexamethasone 4 mg/mL or Betamethasone 4 mg/mL), along with 1 mL of Bupivacaine 0.25%, and the remainder as a preservative, normal saline 2 to 4 mL. The patient needs to be monitored for at least 30 to 45 minutes after the injection.
Figure 5 Oblique view of intervertebral foramina in transforaminal approach.
Commonly the patients experience pain relief a few days to a week after the procedure.
Transforaminal approach
Figure 4 Patient in anterior oblique position for transforaminal approach.
For the transforaminal approach, the patient needs to be in the anterior oblique position about 20 to 30°, with the painful side up (Figures 4 and 5). The foramen chosen depends on what the MRI and physical examination show. It is this physician’s practice to mark the large blood vessels of the neck ahead of time to ensure that the needle insertion is far away from those structures. Once the foramen is clearly visualized, a 25-gauge needle is used to provide local anesthetic to the skin with less than 0.5 mL of Lidocaine. Then a 25-gauge styletted needle is inserted into the posterior part of the foramen. This is best ensured if initially the needle is directed toward the superior articulating process. Once bone is contacted, the needle is carefully advanced, maintaining its posterior position. A minimal bend on the tip of the needle can help accomplish this. The needle should only advance to the target area in an AP view, to ensure that the tip is away from the uncinate process and therefore the spinal canal. Nonionic contrast material (Omnipaque, Isovue M200) is injected during real-time fluoroscopy visualization (Figure 6). This is not only to ensure the passage of the contrast material from the nerve root into the
Rosenberg
Cervical Epidural Steroid Injections
61 after the injection, bleeding, those side effects of local anesthetics and steroids, vasovagal reactions, and rarely, nerve damage and paralysis. Patients should not be on nonsteroidal antiinflammatory medications, as well as Warfarin (3-5 days before the procedure) and Clopidogrel (7-10 days before the procedure), to avoid bleeding complications. All of the above are very rare if proper guidelines are used.
Conclusion Cervical epidural steroid injections represent a very useful and efficacious pain management intervention that can help patients with severe neck pain, arm pain, and headaches associated with them. The incidence of major complications is minimal if proper training and careful selection of patients is followed.
References
Figure 6 Fluoroscopic visualization of epidural space using nonionic contrast material.
epidural space, but also to ensure that NO uptake is seen within blood vessels, including the vertebral artery or radicular arteries. Then 1 mL of steroid along with 1 mL of either contrast material or local anesthetic is injected. Some physicians do it under real-time fluoroscopy. The patient should be monitored for about an hour. The potential risks of cervical epidural steroid injections include: spinal headache, infection, pain with injection and
1. Nachemson A, Waddell G, Norlund AI: Epidemiology of neck and low back pain, in Nachemson A, Jonsson E (eds): Neck and Back Pain. Philadelphia, PA, Lippincott, Williams and Wilkins, 2000, pp 165-187 2. Cote P, Cassidy JD, Carroll L: The Saskatchewan health and back pain survey: The prevalence of neck pain and related disability in Saskatchewan adults. Spine 23:1689-1698, 1998 3. Makelle M, Heliovaara M, Sievers K, et al: Prevalence, determinants and consequences of chronic neck pain in Finland. Am J Epidemiol 134:1356-1367, 1991 4. Rathmell JP, Aprill C, Bogduk N: Cervical transforaminal injection of steroids. Anesthesiology 100:1595-1600, 2004 5. Suissa S, Harder S, Velleux M: The Quebec whiplash-associated disorders cohort study: section 2. Spine 20:12S-58S, 1995 6. Sitzman BT: Epidural injections, in Fenton DS, Czervionke LF (eds): Image-Guided Spine Intervention. Philadelphia, PA, Saunders, 2003, pp 99-126 7. Reinfrew DL, Moore TE, Kathol MH, et al: Correct placement of epidural steroid injections: fluoroscopic guidance and contrast administration. AJNR 12:11003-11007, 1991
Cervical epidural steroid injections Samuel K. Rosenberg, MD, FIPP From Precision Orthopedic Specialties, Inc., Chardon, Ohio. KEYWORDS: Cervical epidural steroid injections; Cervical transforaminal steroid injections
Cervical epidural steroid injections, performed via interlaminar or transforaminal approach, represent a useful interventional pain management procedure indicated in those patients with neck pain, with or without arm pain, commonly seen in cervical herniated discs, cervical spondylosis and cervical spinal stenosis. In properly trained physicians the risks of these procedures should be very low. © 2005 Elsevier Inc. All rights reserved.
Cervical epidural steroid injections can be a very effective therapeutic, nonsurgical intervention for those patients suffering from intractable neck pain that radiates to one or both upper extremities and the interscapular region. Neck pain is less common than back pain, and usually measured together with shoulder pain.1 The prevalence of neck pain, defined as the percentage of patients presenting with pain on the day of interview, ranges between 11.5% and 20% in patients between 20 and 69 years of age.1 The lifetime prevalence was estimated in two population studies: a Canadian study estimated the prevalence of 69%,2 while a Finnish study estimated it at 71%.3 The rate of cervical spondylosis differs between populations. For example, the rate for dentists is at 42% to 50%, miners at 54% to 76%, and meat carriers at 84%.1 Cervical radicular pain affects 1 person out of every 1000 per year. It is mostly caused by cervical herniated discs or foraminal stenosis.4 Whiplash injury, which is considered separately, can also give rise to neck pain. A Canadian study reported gender differences between males at 73 per 100,000 drivers, versus females at 131 per 100,000 drivers.5
Indications Cervical epidural steroid injections are offered more commonly to patients with severe neck and/or arm pain that have not responded to medications such as antiinflammatory Address reprint requests and correspondence: Dr. Samuel K. Rosenberg, Interventional Pain Management Specialist, Precision Orthopedic Specialties, Inc., 150 Seventh Ave., Suite 200, Chardon, OH 44024. E-mail address: [email protected]. 1084-208X/$ -see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1053/j.trap.2005.05.002
medications, steroids, muscle relaxants, mild opioids, and over-the-counter analgesics. The indications for this type of nerve block include: cervical spondylosis, cervical herniated discs, cervical spinal stenosis, and cervical radicular pain with or without radiculopathy. Frequently, patients are in so much pain that they cannot perform physical therapy, and any activity worsens their pain. Patients may present frequently with associated headaches, shoulder and trapezoid muscle pain, interscapular pain, arm pain, hand pain, muscle weakness, and paresthesias. At times patients can drop things. The onset can be acute, subacute, or chronic.
Anatomy The epidural space is subdivided into anterior and posterior compartments. The anterior compartment lies between the vertebral bodies, intervertebral disc, posterior longitudinal ligament, and the thecal sac. The posterior compartment lies between the thecal sac and the ligamentum flavum and laminae. The posterior compartment is triangular in shape and varies in diameter. At the C7 level, it is 1.5 to 2.0 mm, at T2, 4 mm, at L2, 5-6 mm, and at S1, 2 mm.6 The epidural space has adipose tissue, arteries, lymphatic, and venous plexus. The ligamentum flavum is a pair of ligaments that usually fuse in midline during gestation (Figures 1 and 2). The spinal nerve lies at the lower half of the foramen, and the spinal radicular arteries arise from the vertebral artery. The ascending cervical artery accompanies the spinal nerve to the spinal cord.4 It is mandatory to ensure that, during needle placement, the tip of the needle is not in the vertebral artery or the cervical radicular arteries.
Rosenberg
Cervical Epidural Steroid Injections
Figure 1
59
Spaces and compartments of the spinal canal.
Procedure Since the cervical epidural space is very narrow above the C7 region, it is best to enter the epidural space at that level or below it. Entering above the C6 level is not recommended.4 This mandates the use of fluoroscopy, which can correctly identify the entry site. It aids in ensuring that the needle is in the epidural space if contrast material is used, in addition to improving safety. It is best to examine patients before performing this nerve block to assess the amount of neurological deficits. If those neurological deficits include a clear and progressive muscle weakness in the upper extremities, as well as hyperreflexia and a positive Hoffman sign (a positive Hoffman sign occurs after tapping the middle finger while the wrist is
Figure 3 (A) Hoffman Sign, step 1. (B) Hoffman Sign, step 2. Test is positive.
relaxed, and the first and second fingers move toward each other (Figure 3A and B); this sign is often present in myelopathic patients where the pathology arises from the cervical spine), an immediate referral to a spine surgeon is in order. The nerve block is not recommended. To help determine the probable source for the pain, it is best to obtain and view an MRI of the cervical spine. If the canal is too narrow (⬍10 mm) at the entry site (commonly C7-T1), it may warrant entry at the level below. One may not even recommend this type of nerve block. Some physicians have recommended not performing these types of procedures if the epidural space measures ⬍1 mm at the entry-level site.6 Pain specialists have abandoned the performance of these procedures without the use of fluoroscopy. Up to 25% of the so-called “blind injections” performed by experienced hands are not in the epidural space.6 Only with the injection of contrast material is it possible to verify that the needle is not intravascular, and that the needle is in the epidural space.7 It can also help determine whether the needle is intrathecal. There are two approaches to the cervical epidural space: the interlaminar and the transforaminal approach. Only trained and experienced physicians capable of identifying a needle moving at 1 mm at a time should attempt these procedures. Some physicians have recommended doing these types of injections after completing at least 1000 lumbar injections. These injections can be done under local anesthesia or intravenous sedation.
Interlaminar approach Figure 2 arteries.
Ascending cervical, vertebral, and spinal radicular
The positioning of the patient for the interlaminar epidural injection is prone, with a blanket or two under the
60
Techniques in Regional Anesthesia and Pain Management, Vol 9, No 2, April 2005
chest to accentuate neck flexion. The jaw needs to be out of the way, and the patient monitored with a pulse oximeter and a blood pressure cuff. Recognizing the first rib identifies the C7-T1 interspace. The needle marker should be placed at the middle of the laminae of T1 on the affected site. A 25-gauge needle numbs the skin with 0.5 to 1.0 mL of local anesthetic. Then a 17- to 20-gauge Tuohey needle is inserted into the laminae to establish depth. Once bone is reached, another 0.5 mL of local anesthetic is injected. After that, the Tuohey needle is advanced slightly toward the painful side, and following the loss of resistance to saline technique into the midline. The epidural space is reached anywhere between 0.5 and 2 cm from the area where the needle reached the laminae. Commonly one feels a “change” in resistance, but not necessarily a “loss” of resistance. Nonionic contrast material (Omnipaque, Isovue M200) should then be injected under live fluoroscopy to ensure correct placement of the needle. The spread of the contrast material reveals nerve roots. It can also reveal the spread of the solution intrathecally or in blood vessels (either arteries or veins). If the physician encounters a spread that is not completely understood, such as a “blob,” or an intravascular uptake is identified, then the procedure should be aborted or the needle repositioned. Rapid clearance of the nonionic contrast material can signify a solution that is either intraarterial or subarachnoid. The total volume of 4 to 6 mL is injected after the injection of the contrast material. This can include 1 to 2 mL of steroid (Betamethasone 6 mg/mL, Triamcinolone 25-40 mg/mL, preservative-free preparations, such as Dexamethasone 4 mg/mL or Betamethasone 4 mg/mL), along with 1 mL of Bupivacaine 0.25%, and the remainder as a preservative, normal saline 2 to 4 mL. The patient needs to be monitored for at least 30 to 45 minutes after the injection.
Figure 5 Oblique view of intervertebral foramina in transforaminal approach.
Commonly the patients experience pain relief a few days to a week after the procedure.
Transforaminal approach
Figure 4 Patient in anterior oblique position for transforaminal approach.
For the transforaminal approach, the patient needs to be in the anterior oblique position about 20 to 30°, with the painful side up (Figures 4 and 5). The foramen chosen depends on what the MRI and physical examination show. It is this physician’s practice to mark the large blood vessels of the neck ahead of time to ensure that the needle insertion is far away from those structures. Once the foramen is clearly visualized, a 25-gauge needle is used to provide local anesthetic to the skin with less than 0.5 mL of Lidocaine. Then a 25-gauge styletted needle is inserted into the posterior part of the foramen. This is best ensured if initially the needle is directed toward the superior articulating process. Once bone is contacted, the needle is carefully advanced, maintaining its posterior position. A minimal bend on the tip of the needle can help accomplish this. The needle should only advance to the target area in an AP view, to ensure that the tip is away from the uncinate process and therefore the spinal canal. Nonionic contrast material (Omnipaque, Isovue M200) is injected during real-time fluoroscopy visualization (Figure 6). This is not only to ensure the passage of the contrast material from the nerve root into the
Rosenberg
Cervical Epidural Steroid Injections
61 after the injection, bleeding, those side effects of local anesthetics and steroids, vasovagal reactions, and rarely, nerve damage and paralysis. Patients should not be on nonsteroidal antiinflammatory medications, as well as Warfarin (3-5 days before the procedure) and Clopidogrel (7-10 days before the procedure), to avoid bleeding complications. All of the above are very rare if proper guidelines are used.
Conclusion Cervical epidural steroid injections represent a very useful and efficacious pain management intervention that can help patients with severe neck pain, arm pain, and headaches associated with them. The incidence of major complications is minimal if proper training and careful selection of patients is followed.
References
Figure 6 Fluoroscopic visualization of epidural space using nonionic contrast material.
epidural space, but also to ensure that NO uptake is seen within blood vessels, including the vertebral artery or radicular arteries. Then 1 mL of steroid along with 1 mL of either contrast material or local anesthetic is injected. Some physicians do it under real-time fluoroscopy. The patient should be monitored for about an hour. The potential risks of cervical epidural steroid injections include: spinal headache, infection, pain with injection and
1. Nachemson A, Waddell G, Norlund AI: Epidemiology of neck and low back pain, in Nachemson A, Jonsson E (eds): Neck and Back Pain. Philadelphia, PA, Lippincott, Williams and Wilkins, 2000, pp 165-187 2. Cote P, Cassidy JD, Carroll L: The Saskatchewan health and back pain survey: The prevalence of neck pain and related disability in Saskatchewan adults. Spine 23:1689-1698, 1998 3. Makelle M, Heliovaara M, Sievers K, et al: Prevalence, determinants and consequences of chronic neck pain in Finland. Am J Epidemiol 134:1356-1367, 1991 4. Rathmell JP, Aprill C, Bogduk N: Cervical transforaminal injection of steroids. Anesthesiology 100:1595-1600, 2004 5. Suissa S, Harder S, Velleux M: The Quebec whiplash-associated disorders cohort study: section 2. Spine 20:12S-58S, 1995 6. Sitzman BT: Epidural injections, in Fenton DS, Czervionke LF (eds): Image-Guided Spine Intervention. Philadelphia, PA, Saunders, 2003, pp 99-126 7. Reinfrew DL, Moore TE, Kathol MH, et al: Correct placement of epidural steroid injections: fluoroscopic guidance and contrast administration. AJNR 12:11003-11007, 1991