Cervical Epidural Steroid Injection Research Articles

151. Efficacy of transforaminal steroid injections to prevent surgical treatment for patients with cervical radiculopathy

BACKGROUND CONTEXT The use of epidural spinal injections (ESIs) is a nonoperative method to treat patients dealing with cervical radiculopathy. The efficacy of ESI as a treatment for cervical radiculopathy varies significantly in literature and the possibility of prognostic indicators is controversial. PURPOSE The objective of this study was to determine the efficacy of transforaminal steroid injections in the prevention of surgical treatment for patients with cervical radiculopathy. We also evaluated clinical and demographic factors that may correlate with the success rate of ESI. STUDY DESIGN/SETTING Retrospective study from a single academic center. PATIENT SAMPLE One hundred consecutive patients who received cervical transforaminal epidural steroid injections between February 2009 and March 2014. OUTCOME MEASURES Using clinical and demographic data, we will determine the efficacy of ESIs in the prevention of surgical treatment for patients with cervical radiculopathy. METHODS Clinical and demographic data were collected. Patients were categorized into surgical and nonsurgical treatment groups. Demographic data (gender, BMI, number of injections, number of levels affected, symptom duration, comorbidities) were analyzed in relation to the clinical outcome (surgery or no surgery). The analysis included Chi-square tests for categorical variables and ANOVA tests for continuous variables. RESULTS Study sample, n=100; mean age was 51.5 years (range: 32-82 years), and gender: males=50 and females= 50. The average follow-up was 3.7 years (range: 0-9 years). The average length of time between injection appointments was 3.64 months (range: 0.5-17 months). The average duration of injection treatment for those with multiple appointments was 5.53 months (range: 0.5-34 months). Sixty-three patients (63%) did not require surgery and thirty-seven patients (37%) required surgery following ESIs. The average age was no different between the groups, surgery group (52 years) and nonsurgical group (50 years), p=0.34. The surgery rate was lower in patients with one level of radiculopathy (29%) compared to patients with multilevel radiculopathy (46%), p=0.06. The surgery rate was 57% with patients suffering from acute pain and 34% with patients suffering chronic pain, p=0.08. The average time period between the initial injection and surgery in the surgery group was 5.2 months (1-29 months). No difference was noticed for gender, BMI, comorbidities and the average number of injections between the surgical group and nonsurgical group. CONCLUSIONS The surgery rate was lower in single-level radiculopathy patients who received transforaminal epidural steroid injections. There was a trend toward a higher rate of surgical treatment in patients who had multilevel radiculopathy and were suffering from acute pain. The small study sample and retrospective nature of the study were limitations. FDA DEVICE/DRUG STATUS Epidural spinal injection (Approved for this indication).

Chronic Headache: a Review of Interventional Treatment Strategies in Headache Management.

To provide an overview of current interventional pain management techniques for primary headaches with a focus on peripheral nerve stimulation and nerve blocks. Despite a plethora of treatment modalities, some forms of headaches remain intractable to conservative therapies. Interventional pain modalities have found a niche in treating headaches. Individuals resistant to common regimens, intolerant to pharmaceutical agents, or those with co-morbid factors that cause interactions with their therapies are some instances where interventions could be considered in the therapeutic algorithm. In this review, we will discuss these techniques including peripheral nerve stimulation, third occipital nerve block (TON), lesser occipital nerve block (LON), greater occipital nerve block (GON), sphenopalatine block (SPG), radiofrequency ablation (RFA), and cervical epidural steroid injections (CESI). Physicians have used several interventional techniques to treat primary headaches. While many can be treated pharmacologically, those who continue to suffer from refractory or severe headaches may see tremendous benefit from a range of more invasive treatments which focus on directly inhibiting the painful nerves. While there is a plethora of evidence suggesting these methods are effective and possibly durable interventions, there is still a need for large, prospective, randomized trials to clearly demonstrate their efficacy.

Cross-sectional CT Assessment of the Extent of Injectate Spread at CT Fluoroscopy-guided Cervical Epidural Interlaminar Steroid Injections.

Background Previous studies analyzed contrast agent spread during cervical interlaminar epidural steroid injections (CILESIs) by using planar fluoroscopy and reported wide variance of the rate of spread to the ventral epidural space (VES). Cross-sectional CT allows for direct viewing of contrast agent in the VES, providing improved spread assessment and thereby informing needle placement decisions when targeting pain generators. Purpose To determine the extent of injectate spread at CT fluoroscopy-guided CILESI, with particular attention to the VES and bilateral neuroforamina, by using cross-sectional CT. Materials and Methods This study reviewed 83 consecutive CT fluoroscopy-guided CILESIs at which a postprocedural cervical spine CT was performed (June 2016 to December 2017). All procedures used the same injectate (2 mL corticosteroid, 3 mL contrast agent). Postprocedural CT scans were reviewed for the presence of contrast within the VES, dorsal epidural space, ipsilateral neuroforamen, and contralateral neuroforamen in every cervical interlaminar level. Descriptive data are presented as frequencies or means. McNemar tests or hierarchical logistic models were used to assess associations between covariates and contrast agent spread to particular locations. Results The study cohort included 73 individual patients (59% women; 43 of 73) (mean patient age, 57.6 years ± 11.5 [standard deviation]). Mean number of levels of cranial spread were 0.6 level for VES, 1.9 levels for contralateral neuroforamen, 2.1 levels for ipsilateral neuroforamen, and 3 levels for dorsal epidural space. No VES spread in any level was found with 35% (29 of 83) of injections. VES spread was more likely to occur in the level of needle placement (43%; 36 of 83) than in other interlaminar levels (19.5%; 97 of 498; P < .001). Spread was more likely to occur in the neuroforamen ipsilateral to the needle approach compared with contralateral (P < .001). Conclusion Cervical interlaminar epidural steroid injections have injectate spreads with a mean of less than one level cranially in the ventral epidural space (VES) and approximately two levels in the neuroforamen. VES spread occurs more frequently at the level of needle placement and within the ipsilateral neuroforamen. © RSNA, 2019.

A Contemporary Medicolegal Analysis of Outpatient Interventional Pain Procedures: 2009-2016.

Closed malpractice claim studies allow a review of rare but often severe complications, yielding useful insight into improving patient safety and decreasing practitioner liability. This retrospective observational study of pain medicine malpractice claims utilizes the Controlled Risk Insurance Company Comparative Benchmarking System database, which contains nearly 400,000 malpractice claims drawn from >400 academic and community medical centers. The Controlled Risk Insurance Company Comparative Benchmarking System database was queried for January 1, 2009 through December 31, 2016, for cases with pain medicine as the primary service. Cases involving outpatient interventional pain management were identified. Controlled Risk Insurance Company-coded data fields and the narrative summaries were reviewed by the study authors. A total of 126 closed claims were identified. Forty-one claims resulted in payments to the plaintiffs, with a median payment of $175,000 (range, $2600-$2,950,000). Lumbar interlaminar epidural steroid injections were the most common procedures associated with claims (n = 34), followed by cervical interlaminar epidural steroid injections (n = 31) and trigger point injections (n = 13). The most common alleged injuring events were an improper performance of a procedure (n = 38); alleged nonsterile technique (n = 17); unintentional dural puncture (n = 13); needle misdirected to the spinal cord (n = 11); and needle misdirected to the lung (n = 10). The most common alleged outcomes were worsening pain (n = 26); spinal cord infarct (n = 16); epidural hematoma (n = 9); soft-tissue infection (n = 9); postdural puncture headache (n = 9); and pneumothorax (n = 9). According to the Controlled Risk Insurance Company proprietary contributing factor system, perceived deficits in technical skill were present in 83% of claims. Epidural steroid injections are among the most commonly performed interventional pain procedures and, while a familiar procedure to pain management practitioners, may result in significant neurological injury. Trigger point injections, while generally considered safe, may result in pneumothorax or injury to other deep structures. Ultimately, the efforts to minimize practitioner liability and patient harm, like the claims themselves, will be multifactorial. Best outcomes will likely come from continued robust training in procedural skills, attention paid to published best practice recommendations, documentation that includes an inclusive consent discussion, and thoughtful patient selection. Limitations for this study are that closed claim data do not cover all complications that occur and skew toward more severe complications. In addition, the data from Controlled Risk Insurance Company Comparative Benchmarking System cannot be independently verified.

Systemic effects of fluoroscopically guided epidural steroid injection with dexamethasone.

BackgroundEpidural steroid injections (ESIs) have been widely used in managing spinal pain. Dexamethasone has recently emerged as a useful drug in this setting, relative to particulate steroids, although the associated systemic effects have not been fully elucidated. This study aimed to investigate the incidences and types of systemic effects after fluoroscopically guided ESI with dexamethasone.MethodsThis retrospective study included 888 ESIs with dexamethasone (fluoroscopically guided at the cervical and lumbosacral levels) performed on 825 patients during January to June 2017. Data regarding systemic effects were collected via telephone interviews using a standardized questionnaire at 2 weeks after the procedure. Data on patient demographic, clinical, and procedural characteristics were collected and analyzed to identify factors that were associated with systemic effects. All statistical analyses were performed using the chi-squared test.ResultsAmong the 825 patients, 40 patients (4.8%) experienced systemic effects during the 2-week follow-up period. The most common systemic effect was facial flushing (12 patients, 1.5%), which was followed by urticaria (7 patients, 0.8%) and insomnia (7 patients, 0.8%). A history of spine surgery was significantly associated with the occurrence of systemic effects (P = 0.036). Systemic effects were significantly more common for injections at the cervical level than at the lumbar level (P = 0.019).ConclusionsApproximately 4.8% of the patients who underwent ESI with dexamethasone experienced minor and transient systemic effects. These effects were more common in patients who had undergone a previous spine surgery or received a cervical ESI.

DEPTH ASSESSMENT USING CONTRALATERAL OBLIQUE VIEW DURING CERVICAL INTERLAMINAR EPIDURAL STEROID INJECTIONS

Background: Recent literature has demonstrated that the contralateral oblique (CLO) view provides a more reliable angle in determining needle depth when compared to the lateral view during cervical interlaminar injections. Despite the utilization of CLO safety views, contrast patterns, and loss-of-resistance techniques, inherent risk of injury still remains. Additional safety measures must be assessed to provide clinicians with further safeguards to prevent procedural complications. Objective: The purpose of our study is to provide a reliable method of gauging needle depth insertion during cervical interlaminar injections by comparing the distance from the skin to the epidural space when measured on magnetic resonance imaging (MRI) and when measured intraoperatively. Methods: The study sample included 45 patients with cervical radiculopathy or cervical spinal stenosis. The distance from the skin to the epidural space was measured on cervical spine MRI and with the spinal needle intraoperatively. Primary analysis included the correlation between these distances, and whether differences in depth were influenced by injection level, needle tip location, or body mass index (BMI). Results: A significant correlation (r = .975, P &lt; .001) with an average difference of .03 mm (standard deviation, 2.99 mm) was found between MRI and procedural measurements. Neither injection level nor BMI had a significant influence on the difference in depth. Conclusion: When combined with traditional safety techniques, obtaining preprocedural MRI depth measurements can provide a reliable method in predicting the true needle depth to safely enter the epidural space. Because the majority of patients undergoing interlaminar cervical epidural steroid injections will have already obtained MRI, measuring the distance preprocedurally is a simple and practical method for physicians to implement. Key words: Cervical, fluoroscopy, radiculopathy, injection, contra-lateral oblique, contrast, safety, complications, spinal stenosis, radiation, interlaminar

The Effectiveness of Fluoroscopically Guided Cervical Transforaminal Epidural Steroid Injection for the Treatment of Radicular Pain; a Systematic Review and Meta-analysis.

Determine the effectiveness of fluoroscopically guided cervical transforaminal epidural steroid injection (CTFESI) for the treatment of radicular pain. Systematic review and meta-analysis. Persons aged ≥18 years with cervical radicular pain due to disc herniation or degenerative spondylosis. Sham, placebo procedure, or active standard of care treatment, excluding alternative versions of epidural steroid injection. The primary outcome measure was patient-reported improvement in pain of at least 50% from baseline, assessed four or more weeks after the treatment intervention. Secondary outcomes included validated functional assessment tools and avoidance of spinal surgery. Randomized or nonrandomized comparative studies and nonrandomized studies without internal control were included. Three reviewers independently assessed publications in the Medline, PubMed, and Cochrane databases up to July 2018. The Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system was used to evaluate risk of bias and overall quality of evidence. A meta-analysis was conducted for comparative measures of effect and for within-group response rates if applicable. There were no studies with an internal comparison group (control group) meeting the review's definition of comparison group. Therefore, comparative measures of effect were not calculated. In cohort studies, pooled response rates were 48% (95% confidence interval [CI] = 34-61%) at one month and 55% (95% CI = 45-64%) at three months. Approximately 50% of patients experience ≥50% pain reduction at short- and intermediate-term follow-up after CTFESI. However, the literature is very low quality according the GRADE criteria, primarily due to a lack of studies with placebo/sham or active standard of care control comparison groups.

Painless cervical motor radiculopathy relieved by cervical epidural steroid injection - A case report -

Painless cervical motor radiculopathy relieved by cervical epidural steroid injection - A case report -

Cervical Epidural Steroid Injection: Parasagittal versus Midline Approach in Patients with Unilateral Cervical Radicular Pain; A Randomized Clinical Trial.

Objective:To compare parasagittal interlaminar cervical epidural steroid injection (PSIL-CESI) and the classic midline interlaminar cervical epidural steroid injection (MIL-CESI) in terms of pain relief and functional improvement in patients with unilateral upper extremity radicular pain.Methods:This was a randomized clinical trial being conducted in a single pain center in Tehran. Twenty-six patients were allocated into two groups of 13, undergoing either PSIL-CESI or MIL-CESI. After confirmation of radiocontrast spread in the epidural space by fluoroscopic guidance, dexamethasone 8 mg and bupivacaine 0.125% in a volume of 5 ml were delivered to the epidural space. Evaluation of functional state and pain intensity before and 1 month after the procedure was accomplished using the neck disability index (NDI) and the numeric rating scale (NRS) respectively.Results:Demographic and baseline characteristics of the cases showed no significant statistical difference. Improvements in the NDI and the NRS were observed in both groups; meanwhile, improvements were more pronounced in the PSIL-CESI group as compared to the MIL-CESI group (P<0.001). With the PSIL approach the ventral spread of radiocontrast was significantly higher (38%) than with the MIL approach (0.7%) (P<0.001). All patients in PSIL group showed radiocontrast spread ipsilateral to the painful side and all patients in the MIL group showed a midline distribution of radiocontrast.Conclusion:PSIL-CESI provides superior pain relief and improvement of functional disability in patients with unilateral upper extremity radicular pain in comparison to the classic MIL-CESI.Clinical trial registry: IRCT20180524039816N1

Rare Case of Ischaemic Stroke Following Cervical Transforaminal Injection.

We report a case of brainstem infarction following a C5–C6 cervical transforaminal injection, a rare and serious neurological complication of this procedure. Cervical transforaminal steroid injection is a common therapy for patients with persistent cervical radiculopathy not relieved by conservative treatment, and is effective in 65–70% of cases. Unfortunately, this procedure may lead to serious complications such as neurological damage. These complications are rare but potentially fatal, as reported in our case. Complications could be due to three mechanisms: the technique itself, the cervical vascular anatomy and the properties of the product (corticoids). The neurological complications can be diagnosed through brain MRI. This case report focuses on the importance of a risk/benefit evaluation when performing this medical procedure.LEARNING POINTSPhysicians should be better informed about severe complications following cervical transforaminal epidural steroid injections and their strict indications.Severe adverse events are rare but they can be disastrous.Non-particulate corticosteroid should be used.

A Prospective Comparison of CT-Epidurogram Between Th1-Transforaminal Epidural Injection and Th1/2-Parasagittal Interlaminar Epidural Injection for Cervical Upper Limb Pain

Background: Cervical epidural injections for treating neck and upper limb pain are performed by 2 methods: transforaminal and interlaminar. Many serious complications caused by inadvertent intravascular injection have been reported with the use of cervical transforaminal epidural steroid injection through the anterior-lateral approach. Despite international practical guidelines that have been proposed, cervical transforaminal epidural injection is still less recommended than cervical interlaminar epidural injection. Objectives: The objective of this study is to introduce Th1-transforaminal epidural injection (Th1- TFEI) through the posterior-lateral approach, compare the injectate spread in Th1-TFEI with that of Th1/2-parasaggital interlaminar epidural injection (Th1/2-pILEI), and clarify the clinical characteristics of Th1-TFEI. Study Design: This research involved a prospective study of 30 patients receiving both Th1-TFEI and Th1/2-pILEI. Methods: Thirty patients with unilateral upper limb pain were enrolled for this prospective study. Th1-TFEI and Th1/2-pILEI were administered on each case in random order under fluoroscopy, and computed tomographic (CT) epidurograms were compared. Changes in circulatory dynamics, presence of Horner’s syndrome, changes in the Numerical Rating Scale (NRS-11), and adverse events were investigated. Results: Patients included 15 men and 15 women and included 24 cases of cervical spine disease and 6 cases with other upper limb pain. The Th1-TFEI group had significantly higher rates of “Th1 root filling” (100%), “ventral spread” (70.0%), and “lateral limitation” (26.7%) compared to the Th1/2-pILEI group. In the Th1-TFEI group, cephalad spread averaged 2.97 vertebral bodies, reaching approximately up to C6. The Th1/2-pILEI group had an average of 4.76 vertebral bodies, approximately up to C4. The 2 groups showed significant differences in cephalad spread. Horner’s syndrome appeared in the Th1-TFEI group at a rate of 56.7%, significantly higher than that in the Th1/2-pILEI group at 17.2%. The presence of Horner’s syndrome showed significant correlations with “ventral spread” and “spread up to C6.” There were no significant differences in NRS-11 improvement and changes in circulatory dynamics between the groups. There were no major complications. Limitations: The components of injectate were standardized; however, the needle gauge numbers were varied. In addition, interpretation of the CT-epidurogram was not blinded. The sample size was small; therefore, multivariate analysis was not possible. Conclusions: CT-epidurogram comparison revealed that Th1/2-pILEI was not localized on the injection side, and there was better dorsal spread – although ventral spread was small. Contrarily, Th1-TFEI was localized on the injection side, and better ventral spread was shown while cephalad spread was limited. We expected the addition of a sympathetic block effect suggested by the Horner’s syndrome as well as the merits of the ventral spread. However, short-term clinical effects were equal to those of Th1/2 pILEI. In future research, we need to standardize the diseases to include and to increase the number of cases to enable evaluation of clinical effectiveness.Key words: Epidural, cervical, transforaminal, interlaminar, fluoroscopy, CT-epidurogram, dorsal, ventral, cephalad, Horner’s syndrome

Dispersal Pattern of Injectate After Cervical Epidural Steroid Injection Evaluated With Magnetic Resonance Imaging

Study Design:Prospective, nonrandomized, clinical study.Objective:Epidural steroid injections (ESIs) are an important diagnostic and treatment modality for spine pathology. The success of these injections has been attributed to the anatomic location reached by the injectate. This study evaluates injectate dispersal patterns after cervical interlaminar ESI using magnetic resonance imaging (MRI).Methods:Patients between the ages of 18 and 85 years with cervical radiculopathy were identified. After obtaining consent for study participation, a gadolinium-enhanced cervical ESI was administered via an interlaminar approach under fluoroscopic guidance. Study participants underwent a cervical spine MRI within 15 minutes of administering the injection. Craniocaudal dispersal and the presence or absence of circumferential dispersal was assessed.Results:The injectate dispersed a mean of 8.11 cm in the cranial direction, 6.63 cm in the caudal direction, and 360° circumferentially. No adverse events related to the ESI were reported.Conclusions:Fluoroscopy-guided cervical interlaminar ESI resulted in nearly uniform circumferential dispersal within the epidural space with multilevel migration in the cranial and caudal directions. MRI is a safe and accurate tool to evaluate spinal injectate dispersal.

Cervical epidural hematoma following interlaminar epidural steroid injection via the contralateral oblique view in patient taking omega-3 fatty acids

Background and objectivesWe sought to describe a case of an epidural hematoma after a cervical interlaminar epidural steroid injection (ILESI) performed using contralateral oblique view. We also discuss factors that...

Is Cervical Epidural Steroid Injection Safe and Efficacious for the Treatment of Cervical Radiculopathy?

Is Cervical Epidural Steroid Injection Safe and Efficacious for the Treatment of Cervical Radiculopathy?

A Two-Year Cost Analysis of Maximum Nonoperative Treatments in Patients with Cervical Stenosis that Ultimately Required Surgery

The aim of this study is to characterize the use and associated costs of maximal nonoperative therapy (MNT) received within 2-years before anterior cervical discectomy and fusion (ACDF) surgery in patients with symptomatic cervical stenosis. An insurance database, including private/commercially insured and Medicare Advantage beneficiaries, was queried for patients undergoing 1-level, 2-level, or 3-level ACDF procedures between 2007 and 2016. Research records were searchable by International Classification of Diseases diagnosis and procedure, Current Procedural Terminology, and generic drug codes. The use of MNTs within 2 years before index ACDF surgery was assessed by cost billed to patients, prescriptions written, and number of units billed. Of 220,902 (7.16%) eligible patients, 15,825 underwent index surgery. Patient breakdown of the use of MNT modalities was as follows: 5731 (36.2%) used nonsteroidal antiinflammatory drugs; 9827 (62.1%) used opioids; 7383 (46.7%) used muscle relaxants; 3609 (22.8%) received cervical epidural steroid injection; 5504 (34.8%) attended physical therapy/occupational therapy; 1663 (10.5%) received chiropractor treatments; and 200 (1.3%) presented to the emergency department. During the 2-year preoperative period, there were 51,675 prescriptions for diagnostic cervical imaging. The total direct cost associated with all MNTs before ACDF was $16,056,556. Cervical spine imaging comprised the largest portion of the total MNT cost ($8,677,110; 54.0%), followed by cervical epidural steroid injection ($3,315,913; 20.7%) and opioids ($2,228,221; 13.9%). Opiates were the most frequently prescribed therapy (71,602 prescriptions). Opioids are the most frequently prescribed and most used therapy in the preoperative period for cervical stenosis. Further studies and improved guidelines are necessary to determine which patients may benefit from ACDF earlier in the course of nonoperative therapies.

Increased neuropathic pain following cervical epidural steroid injection

To draw attention to an uncommon complication that could arise from routinely performed procedure in pain practice like cervical epidural steroid injection. We report a case of 47-year-old female whose neuropathic pain was increased after cervical epidural steroid injection. Cervical epidural injection with methylprednisolone and lignocaine produced transient paresthesia during injection followed by a dull ache with pronounced allodynia in fingers. Next day, the patient reported severe pain in left forearm and hand with burning and sensitivity to light touch and swelling of the dorsum of the hand. On examination, there was marked allodynia, warmth, erythema, and swelling of the left hand. Sensory examination showed decreased sensation to pinprick. Patient was prescribed a tapering dose of oral steroids, pregabalin, and analgesic-muscle relaxant combination. Symptoms gradually resolved on weekly follow-ups for 4 weeks and no further intervention was needed. Increased neuropathic pain after cervical epidural steroid injection may result from either a direct nerve root irritation caused by the steroid solution or nerve root injury. Direct nerve root irritation by steroid injection is most probable cause in midline approach.

Is Cervical Epidural Steroid Injection Safe and Efficacious for the Treatment of Cervical Radiculopathy?

Is Cervical Epidural Steroid Injection Safe and Efficacious for the Treatment of Cervical Radiculopathy?

Needle Entry Angle to Prevent Carotid Sheath Injury for Fluoroscopy-Guided Cervical Transforaminal Epidural Steroid Injection.

ObjectiveTo suggest rotation angles of fluoroscopy that can bypass the carotid sheath according to vertebral levels for cervical transforaminal epidural steroid injection (TFESI).MethodsPatients who underwent cervical spine magnetic resonance imaging (MRI) from January 2009 to October 2017 were analyzed. In axial sections of cervical spine MRI, three angles to the vertical line (α, angle not to insult carotid sheath; β, angle for the conventional TFESI; γ, angle not to penetrate carotid artery) were measured.ResultsAlpha (α) angles tended to increase for upper cervical levels (53.3° in C6-7, 65.2° in C5-6, 75.3° in C4-5, 82.3° in C3-4). Beta (β) angles for conventional TFESI showed a constant value of 45° to 47° (47.5° in C6-7, 47.4° in C5-6, 45.7° in C4-5, 45.0° in C3-4). Gamma (γ) angles increased at higher cervical levels as did α angles (25.2° in C6-7, 33.6° in C5-6, 43.0° in C4-5, 56.2° in C3-4).ConclusionThe risk of causing injury by penetrating major vessels in the carotid sheath tends to increase at upper cervical levels. Therefore, prior to cervical TFESI, measuring the angle is necessary to avoid carotid vessels in the axial section of CT or MRI, thus contributing to a safer procedure.

The effectiveness of ultrasound-guided cervical transforaminal epidural steroid injections in cervical radiculopathy: a prospective pilot study.

BackgroundCervical transforaminal epidural steroid injection (CTFESI) is used to provide pain relief and restore function in patients with cervical radiculopathy. Traditionally, it is performed under the guidance of fluoroscopy or computed tomography. Here, we introduce a novel technique – ultrasound-guided CTFESI – with which operators can easily distinguish the close soft tissue (nerve, vessels) around the cervical foramina to avoid intravascular injection during the procedure.ObjectiveTo present the immediate and long-term effectiveness of ultrasound-guided CTFESI in patients with cervical radiculopathy in an academic pain-management center with prospective clinic experiments.MethodsFifteen patients with cervical radiculopathy who were resistant to conservative therapies and ultrasound-guided selective cervical spinal nerve-root injections, were treated with ultrasound-guided CTFESI. During the injection procedures, the needle tips were reconfirmed by real-time fluoroscopy. Pain numeric rating-scale and neck-disability-index scores were assessed from onset to six months after the procedures.ResultsDuring the procedures, based on real-time fluoroscopic confirmation, the injection solution outlined the spinal nerve root and spread into the epidural space in most cases (14 of 15). All patients reported pain relief within 10 minutes after the injection. The majority of patients (eleven of 15) experienced pain relief and neck-disability index-score improvement throughout the 6-month study period. No patient experienced any complication.ConclusionWe suggest that ultrasound-guided CTFESI is an effective, safe, and simple procedure free of radiation or magnetization and provides sustained pain relief in patients with cervical radiculopathy who have failed previous conservation therapies.

Diagnosis and Spontaneous Resolution of an Epidural Hematoma in a Patient Presenting after Cervical Epidural Steroid Injection

While not a cure for the underlying spinal pathology, cervical epidural steroid injections (CESI) are an important minimally invasive treatment for neck pain with radiculopathy. Although CESIs are considered safe, cervical epidural hematoma (CEH) is a major complication and has previously been reported. Patients, who develop CEH, present with acute neck pain and upper extremity radiculopathy. A prolonged time to treatment may lead to worsened neurological outcome. Diagnostic magnetic resonance imaging and surgical decompression is the mainstay of treatment. This report presents a patient with a history of chronic neck pain and repeat cervical injections, who presented with increased neck pain and upper extremity weakness after undergoing a CESI. Initial radiographic findings were complicated and inconclusive of a definitive epidural hematoma. With conservative management, the patient showed signs of clinical improvement and ultimately had spontaneous resolution of his CEH. Though CEH are frequently rapidly progressing and most often surgically decompressed, some acutely presenting cases may be approached conservatively. Though MRI is an important diagnostic tool for CEH, interpretation of radiographic findings, following a recent CESI, may be challenging due to distortion of the epidural space anatomy. Patients with a history of multiple cervical epidural injections may have an increased risk for the development of CEH. Key words: Cervical epidural steroid injection, cervical epidural hematoma, spontaneous resolution, conservative management, magnetic resonance imaging, complication