Image-Guided Cervical Injections with Most Updated Techniques and Society Recommendations

Abstract

Cervical injections can be safely performed with the use of conventional fluoroscopy while adhering to stringent guidelines. Cervical transforaminal injections are an effective treatment option for cervical radicular pain and have been shown to reduce the rate of surgery. It is recommended that dexamethasone be used for all cervical transforaminal steroid injections due to the theoretic reduction in risk of spinal cord injury , stroke, or death. Although radiation exposure theoretically increases 2 to 4 times when using DSA compared with conventional fluoroscopy, we strongly encourage its use in cervical transforaminal epidural steroid injections due to the statistically significant decrease in detecting intravascular flow and potentially preventing catastrophic complications. Cervical interlaminar epidural steroid injections are typically conducted at the C6-7 and C7-T1 levels and are not recommended above the C6-7 level due to the increasing risk of dural puncture or direct spinal cord injury when performed at higher levels. Most complications associated with cervical interlaminar epidural steroid injections are minor and self-limited and include dural puncture headache, increased neck pain, stiffness, intracranial hypotension , and vasovagal reactions. Major complications include spinal cord injury, epidural abscess , and epidural/subdural hematoma. Over sedation should be avoided while performing cervical interlaminar epidural steroid injections as excess sedation could result in patients being unable to respond to pain or paresthesias caused by spinal cord irritation. Cervical facet joints are the primary source of pain in 26% to 70% of patients with chronic neck pain. The C2-3 facet joint is commonly associated with cervicogenic headaches as the C2-3 facet joint is also innervated by the third occipital nerve. Cervical medial branch block volumes should be less than or equal to 0.3 mL and intraarticular facet joint injection volumes should not exceed 1 mL including the contrast to prevent capsule rupture and/or aberrant injectate spread to maximize the specificity of the block. Before cervical RFA, sensory and motor stimulation should be conducted to decrease the potential risk of ablating unintended spinal nerves . We support a more stringent threshold of diagnostic response (80% or greater) on two diagnostic median branch blocks to consider cervical median branch radiofrequency ablation to optimize outcomes.