Cervical Spine: Case Presentation, Complications, and Their Prevention

Abstract

Objective. A number of case presentations of catastrophic outcomes after cervical epidural injections have occurred after both interlaminar and transforaminal injection techniques. Practitioners in pain medicine need guidance to avoid these complications Design. A systematic search of the MEDLINE database, electronically available pain journals, and recent pain and spine meeting abstracts was searched for articles relevant to cervical spine interventional procedure complications. Results. A representative case of cervical radicular pain is presented to illustrate key differences of radicular pain presenting in the cervical area from those in the lumbar area Although cervical interlaminar epidural complications more likely involve direct neurological trauma to the spinal cord or spinal nerve, the mechanism for injury after transforaminal epidural corticosteroid injections is less clear. Many investigators hypothesize that particulate steroids may be the primary cause, in that these particles may occlude segmental medullary feeding arteries that reinforce the longitudinal anterior spinal artery supply to the spinal cord. Anatomical nomenclature of spinal cord blood supply and variants of normal are presented. Conclusions. Specific examples of potential injury avoidance strategies are discussed, including: 1) the use of nonparticulate steroid preparations; 2) needle bevel/size and other technical considerations; 3) preprocedural planning and sedation considerations; 4) test dosing with local anesthetics; and 5) imaging considerations, including the use of digital subtraction to better define angiographic patterns. Recommendations for the conduct of cervical epidural injection procedures are discussed.