Cervical Epidural Steroid Injections (CESI) & Other Interventions for the Treatment of Neck Pain & Upper Extremity Pain
Cervical Epidural Steroid Injections (CESI) and Other Interventions for the Treatment of Neck Pain and Upper Extremity Pain
Cervical epidural steroid injections are the only form of conservative treatment for cervical radicular pain (CR) that has supportive data and some consensus opinion[1, 2] of their efficacy. There is evidence for the use of cervical transforaminal epidural steroid injections (CTFESIs) [2-10], and also evidence supporting the use of cervical interlaminar epidural steroid injections (CILESIs) [3, 11-13]. There are theoretical advantages, and known risks, to either approach, however . CTFESIs offer the advantage of injection of local anesthetic and corticosteroid in a directed and concentrated manner to the involved nerve root(s). There have been cases of severe neurological injury or death with this approach, and there has been discussion in the literature regarding the risk vs. benefit of performing CTFESIs. [14, 15] The risks of CTFESI are minimized when a standardized technique, avoidance of excessive sedation, and soluble steroid are used. [16-21] Interlaminar ESIs offer the possible advantage of using particulate steroids, and targeting can be relatively well focused with a paramedian approach and the use of low volumes of injectate, although significant complications are still possible. [3, 22-26] Both approaches are reasonable options.
Additional CESIs can be offered towards the goals of the extinction of symptoms or the restoration of the initial response. It is postulated that the use of repeat injections, when there is a partial response to the prior, may lead to complete relief of pain, and, the best chance of establishing long term improvement of CR symptoms. Likewise, the use of additional injections to treat recurrent pain, following an initial cessation or substantial reduction of pain, may lead to improved long term outcomes.
It is important to ensure that providers of these injections are experienced, safe, and competent, and that they agree to use standardized procedural techniques [3, 16, 19, 21, 22, 27, 28]. The recommended CILESI technique, as noted by Huston, should be modified to utilize a paramedian approach, due to the known incidence of absence of an interlaminar ligament/flavum in the midline, and a 50% chance of unilateral (but uncontrolled) flow of injectate from the midline. A paramedian approach somewhat controls for these variables. This necessitates the use of the “laminar” or ”rooftop” fluoroscopic view to check depth during the procedure.
The concomitant presence of both discogenic and facetogenic pain may be more prevalent in the cervical spine than in the lumbar spine. [27, 29] It is probable that there are not an insubstantial number of patients with CR who will also have pain and disability from concomitant cervical zygapophysial joint generation. Treatment of this cervical Z-joint (CZJ) related pain (or lumbar facet pain) might be indicated to optimize outcomes with CR. This would apply primarily to those cases where the presenting radicular pain has subsided, but there remains sufficient axial pain to effect patients’ reporting of pain, healthcare utilization, and disability. Use of standard techniques for CZJ related intra-articular, medial branch (MB) block, and MB radiofrequency neurotomies is required. [27, 30] CZJ (or LZJ) procedures may be offered according to practice parameters based on parallel (lumbar) guidelines offered by Noridian in their coverage determination for Lumbar Z-Joint procedures (See Noridian Facet Coverage Determination), as well as the work of Lord, Barnsley, and others. [31-34] These guidelines (Noridian) were based on a multi-specialty, multi-society collaborative effort to reach consensus on the proper utilization of these (lumbar) procedures.
Cervical Epidural Steroid (and other) Injections:
- 1 – 2 (see exception below) and up to 5
total cervical ESIs [transforaminal (fluoroscopy, DSA if available, test dose, soluble steroid) and/or interlaminar (fluoroscopy, contrast, particulate steroid)] per first year of treatment, with up to 3 the subsequent year.
- Second ESI 2 weeks after first, if less than 90% sustained relief of pain
- If less than 50% sustained relief with first injection, second ESI should be through opposite route from first (TFESI vs. ILESI)
- Third and subsequent injections may be done if > 50% sustained (> 2 weeks with second or > 6 weeks with third or subsequent injections) relief from earlier procedure(s). Goal of extinction of symptoms or re-instatement of initial response. 4th and subsequent ESIs should be spaced at least 3 months apart.
- Avoid total corticosteroid exposure (from all sources – ESI, intra-articular, or p.o.) of > 5 mg/kg (triamcinolone or equivalent) per 6 month period.
- See above for rationale and references
- CZJ (cervical facet) procedures may be included when indicated (may include intra-articular steroid injection and/or medial branch block with subsequent radiofrequency ablation if successful)
- Trigger point injections or dry needling when indicated (maximum 6 sessions)
1. Carragee, E.J.M., FACS, et al., Treatment of Neck Pain: Injections and Surgical Interventions: Results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine, 2008. 33(4S): p. S153-S169 10.1097/BRS.0b013e31816445ea.
2. Bono, e.a. Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders. Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care 2010 [cited 2010; Available from: https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/CervicalRadiculopathy.pdf.
3. Huston, C.W., Cervical epidural steroid injections in the management of cervical radiculitis: interlaminar versus transforaminal. A review. Curr Rev Musculoskelet Med, 2009. 2(1): p. 30-42.
4. Bush, K. and S. Hillier, Outcome of cervical radiculopathy treated with periradicular/epidural corticosteroid injections: a prospective study with independent clinical review. Eur Spine J, 1996. 5(5): p. 319-25.
5. Lin, E.L., et al., Cervical epidural steroid injections for symptomatic disc herniations. J Spinal Disord Tech, 2006. 19(3): p. 183-6.
6. Vallee, J.N., et al., Chronic cervical radiculopathy: lateral-approach periradicular corticosteroid injection. Radiology, 2001. 218(3): p. 886-92.
7. Cyteval, C., et al., Cervical radiculopathy: open study on percutaneous periradicular foraminal steroid infiltration performed under CT control in 30 patients. AJNR Am J Neuroradiol, 2004. 25(3): p. 441-5.
8. Anderberg, L., et al., Transforaminal steroid injections for the treatment of cervical radiculopathy: a prospective and randomised study. Eur Spine J, 2007. 16(3): p. 321-8.
9. Slipman, C.W., et al., Therapeutic selective nerve root block in the nonsurgical treatment of atraumatic cervical spondylotic radicular pain: a retrospective analysis with independent clinical review. Arch Phys Med Rehabil, 2000. 81(6): p. 741-6.
10. Lee, J.W., et al., Cervical transforaminal epidural steroid injection for the management of cervical radiculopathy: a comparative study of particulate versus non-particulate steroids. Skeletal Radiology, 2009. 38(11): p. 1077-1082.
11. Stav, A., et al., Cervical epidural steroid injection for cervicobrachialgia. Acta Anaesthesiol Scand, 1993. 37(6): p. 562-6.
12. Ferrante, F.M., et al., Clinical classification as a predictor of therapeutic outcome after cervical epidural steroid injection. Spine (Phila Pa 1976), 1993. 18(6): p. 730-6.
13. Kwon, J.W., et al., Cervical interlaminar epidural steroid injection for neck pain and cervical radiculopathy: effect and prognostic factors. Skeletal Radiol, 2007. 36(5): p. 431-6.
14. Brouwers, P.J., et al., A cervical anterior spinal artery syndrome after diagnostic blockade of the right C6-nerve root. Pain, 2001. 91(3): p. 397-9.
15. Smuck, M., J.M. Rosenberg, and V. Akuthota, The use of epidural corticosteroids for cervical radiculopathy: an interlaminar versus transforaminal approach. PM R, 2009. 1(2): p. 178-84.
16. Baker, R., et al., Cervical transforaminal injection of corticosteroids into a radicular artery: a possible mechanism for spinal cord injury. Pain, 2003. 103(1-2): p. 211-5.
17. Derby, R., et al., Size and Aggregation of Corticosteroids Used for Epidural Injections. Pain Medicine, 2008. 9(2): p. 227-234.
18. Malhotra, G., A. Abbasi, and M. Rhee, Complications of transforaminal cervical epidural steroid injections. Spine (Phila Pa 1976), 2009. 34(7): p. 731-9.
19. Rathmell, J.P., C. Aprill, and N. Bogduk, Cervical transforaminal injection of steroids. Anesthesiology, 2004. 100(6): p. 1595-600.
20. Dreyfuss, P., R. Baker, and N. Bogduk, Comparative effectiveness of cervical transforaminal injections with particulate and nonparticulate corticosteroid preparations for cervical radicular pain. Pain Med, 2006. 7(3): p. 237-42.
21. De Cordoba, J.L. and J. Bernal, Cervical transforaminal blocks should not be attempted by anyone without extensive documented experience in fluoroscopically guided injections. Anesthesiology, 2004. 100(5): p. 1323-4; author reply 1324.
22. Stojanovic, M.P., et al., The role of fluoroscopy in cervical epidural steroid injections: an analysis of contrast dispersal patterns. Spine (Phila Pa 1976), 2002. 27(5): p. 509-14.
23. Abbasi, A., et al., Complications of interlaminar cervical epidural steroid injections: a review of the literature. Spine (Phila Pa 1976), 2007. 32(19): p. 2144-51.
24. Hodges, S.D., et al., Cervical epidural steroid injection with intrinsic spinal cord damage. Two case reports. Spine (Phila Pa 1976), 1998. 23(19): p. 2137-42; discussion 2141-2.
25. Field, J., et al., Neuropathic pain following cervical epidural steroid injection. Anesthesiology, 2000. 93(3): p. 885-8.
26. Siegfried, R.N., Development of complex regional pain syndrome after a cervical epidural steroid injection. Anesthesiology, 1997. 86(6): p. 1394-6.
27. Bogduk, N., ed. International Spine Intervention Society: Practice Guidelines for Spinal Diagnostic and Treatment Procedures. 2004.
28. Schellhas, K.P., et al., Selective cervical nerve root blockade: experience with a safe and reliable technique using an anterolateral approach for needle placement. AJNR Am J Neuroradiol, 2007. 28(10): p. 1909-14.
29. Bogduk, N. and C. Aprill, On the nature of neck pain, discography and cervical zygapophysial joint blocks. Pain, 1993. 54(2): p. 213-7.
30. Fenton, D.S., L.F. Czervionke, and Mayo Foundation for Medical Education and Research., Image-guided spine intervention2003, Philadelphia: Saunders. xvi, 298 p.
31. Lord, S.M., L. Barnsley, and N. Bogduk, The utility of comparative local anesthetic blocks versus placebo-controlled blocks for the diagnosis of cervical zygapophysial joint pain. Clin J Pain, 1995. 11(3): p. 208-13.
32. Lord, S.M., L. Barnsley, and N. Bogduk, Percutaneous radiofrequency neurotomy in the treatment of cervical zygapophysial joint pain: a caution. Neurosurgery, 1995. 36(4): p. 732-9.
33. Lord, S.M., et al., Chronic cervical zygapophysial joint pain after whiplash. A placebo-controlled prevalence study. Spine (Phila Pa 1976), 1996. 21(15): p. 1737-44; discussion 1744-5.
34. Lord, S.M., et al., Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. N Engl J Med, 1996. 335(23): p. 1721-6.
35. Peloso, P., et al., Medicinal and injection therapies for mechanical neck disorders. Cochrane Database Syst Rev, 2005(2): p. CD000319.
36. Goldman, L.B. and N.L. Rosenberg, Myofascial pain syndrome and fibromyalgia. Semin Neurol, 1991. 11(3): p. 274-80.
37. Dommerholt, J. and J. Shah, Myofascial Pain Syndrome, in Bonica’s management of pain, S.M. Fishman, Editor 2010, Lippincott, Williams & Wilkins: Baltimore, MD. p. 450-471