Cervical Interlaminar Epidural Steroid Injection Research Articles

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.

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 < .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

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

The Utility of Determining the Fluoroscopic Contralateral Oblique Angle Measurement During Cervical Interlaminar Epidural Steroid Injections for Use in Repeat Injections.

The Utility of Determining the Fluoroscopic Contralateral Oblique Angle Measurement During Cervical Interlaminar Epidural Steroid Injections for Use in Repeat Injections.

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...

CT Fluoroscopy-Guided Interlaminar Epidural Steroid Injections in the Cervical Spine: Rate of Nontarget Injection Into the Retrodural Space of Okada.

The purpose of this study was to assess the rate of inadvertent injection into the retrodural space of Okada during CT fluoroscopy-guided interlaminar epidural steroid injection in the cervical spine. Images from cases of cervical interlaminar epidural steroid injection under CT fluoroscopic guidance performed at a single institution between November 2009 and November 2015 were obtained and reviewed. For all cases, the following information was recorded: presence or absence of contrast material within the Okada space, cervical anatomic level at which the procedure was performed, laterality of approach, trainee presence, and years of proceduralist experience. Two-tailed chi-square tests were used to assess categoric variables, and t tests were performed to assess for continuous variables predictive of nontarget injection. A total of 974 CT fluoroscopy-guided cervical interlaminar epidural steroid injections were identified in 728 patients. The presence of contrast material in the retrodural space of Okada was identified in 2.9% of cases (28/974). All cases of inadvertent injection were identified and corrected intraprocedurally. The greatest rate of inadvertent injection (4.6% [18/389]) occurred at C5-6. No variables predictive of inadvertent injection into the Okada space were identified. There was a 0.4% (4/974) complication rate, and all complications were minor. We identified a 2.9% rate of unintended injection into the retrodural space of Okada during cervical interlaminar epidural steroid injection. If unrecognized, these nontarget injections can result in treatment failure in a subset of patients who undergo cervical interlaminar epidural steroid injection. Future study is warranted to assess the rate of inadvertent Okada injection under conventional fluoroscopy and to compare the rates of detection between the two imaging-guided modalities.

Serum Triamcinolone Levels following Cervical Interlaminar Epidural Injection.

Background Cervical interlaminar epidural steroid injections (ESIs) are commonly performed procedures to treat painful cervical radiculopathy, but little is known about the systemic absorption and serum levels of steroids following injection. The primary objective of this study was to investigate the pharmacokinetics of fluoroscopy-guided cervical epidural-administered triamcinolone acetonide in a cohort of patients with cervical radicular pain seeking treatment in a pain medicine clinic. Methods The study cohort included eight patients undergoing a fluoroscopically guided C7-T1 interlaminar ESI at a pain medicine specialty clinic. Blood was collected prior to the ESI and on days 1, 2, 4, 6, 8, 14, 21, 28, 35, and 42 following the injection. The sample extract was analyzed by tandem mass spectrometry. Results The terminal elimination half-life of cervical epidural-administered triamcinolone in a noncompartmental analysis was 219 hours. In the noncompartmental analysis, peak triamcinolone concentrations of 5.4 ng/mL were detected within 22.1 hours after administration. Conclusions The pharmacokinetics of cervical epidural-administered triamcinolone is consistent with our previous study of lumbar ESI, demonstrating that the elimination half-life is longer than that which has been reported following intravenous triamcinolone. The elimination half-life was shorter following cervical ESI than that which has been reported following lumbar ESI.

Horner syndrome: A hidden benign complication of cervical epidural injection

Cervical epidural steroid injection is an intervention done for cervical prolapsed intervertebral disc. Cervical epidural steroid injection is done if a patient has not responded to medications and physical therapy. We discuss a case report of the occurrence of Horner's syndrome in the patient with cervical radiculopathy undergoing cervical interlaminar epidural steroid injection which resolved spontaneously without residual side effects.

Effect of Interlaminar Epidural Steroid Injection in Patients with Central Cervical Spinal Stenosis.

To investigate the effect of interlaminar epidural steroid injection (ESI) for management of central cervical spinal stenosis-induced posterior neck pain. This retrospective study recruited 45 patients with posterior neck pain caused by central cervical spinal stenosis. For the ESI procedure, a 21-gauge Touhy needle was inserted into the epidural space between C7 and T1, and 20 mg (40 mg/mL) of dexamethasone with 4 mL of normal saline was injected. The effect of the procedure was evaluated using a numerical rating scale at 1, 2, and 3 months after the procedure. Successful pain relief was defined as reduction in numerical rating scale score of ≥50% compared with before treatment. At 3 months after treatment, patient satisfaction levels were examined; patients who reported very good (score= 7) or good results (score= 6) were considered to be satisfied with the procedure. Posterior neck pain was significantly reduced at follow-up evaluation 1, 2, and 3 months after ESI (P < 0.001, repeated measures 1-factor analysis). At 3 months after the procedure, 58% of the patients achieved a successful response (≥50% pain reduction), and 56% were satisfied with treatment results. Cervical interlaminar ESI appears to be a good treatment method for managing chronic posterior neck pain induced by central cervical spinal stenosis, especially when pain is refractory to oral medication.

Safety and Risk Mitigation for Cervical Transforaminal Epidural Steroid Injections

The purpose of this review is to describe cases of serious neurologic complications due to cervical interlaminar epidural steroid injection, safety techniques to mitigate the risks of these, and briefly cover other more common but less severe complications. The most common complications reported in the largest available cohort of epidural steroid injections include increased pain, steroid side effects, and vasovagal reaction without any cases of serious neurologic complications being captured. The risk of neurologic damage due to aberrant needle location or space occupying lesions is very small, though not zero even if ideal technique is used. Proper utilization of risk mitigation techniques can further reduce the risk of these rare but serious complications.

Safety and Risk Mitigation for Cervical Interlaminar Epidural Steroid Injections

Safety and Risk Mitigation for Cervical Interlaminar Epidural Steroid Injections

Does Cervical Interlaminar Epidural Steroid Injection with Low-Dose Lidocaine Cause Objective Upper Extremity Weakness? A Preliminary Study.

Low-dose local anesthetic is often used in cervical interlaminar epidural steroid injections (CIESI), yet its effect on upper extremity strength has not been studied. The presence of consequent weakness has potential implications for postprocedure safety. This study aimed to determine whether low-dose lidocaine in a C7-T1 CIESI causes objective weakness. Prospective case series. Academic pain center. Adults, cervical radicular pain. Participants underwent CIESI with 1 mL of 1% lidocaine (3 mL total injectate). Elbow flexion (EF), wrist extension (WE), elbow extension (EE), and handgrip strength were measured by dynamometry at baseline, 15 minutes, and 30 minutes postinjection. Changes in strength from baseline and the proportion of participants with a minimum perceptible change in EF, WE, EE, and handgrip strength (≥20%) and 95% confidence intervals (CIs) were calculated. Twenty-seven participants were included. At 15 and 30 minutes postinjection, there was no within-participant difference in EF, WE, EE, and handgrip strength from baseline overall. Nonetheless, five (19%, 95% CI = 4-33) of the participants demonstrated a 20% or greater strength decrease in at least one myotomal distribution. A 20% or greater decrease in strength was present in left EF 4% (95% CI = 0-11%), right EF 7% (95% CI = 0-17%), left WE 4% (95% CI = 0-11%), and right WE 7% (95% CI = 0-17%). The present data suggest that CIESI with an injectate volume of 3 mL that includes 1 mL of 1% lidocaine may result in objective upper extremity weakness that is above the minimum threshold of perception in a subset of patients.

Is There a Relationship Between Body Mass Index and Fluoroscopy Time During Cervical Interlaminar Epidural Steroid Injections?

The challenge of obtaining medical imaging in individuals with higher body mass index (BMI) is described, but there is minimal data regarding the relationship between BMI and fluoroscopy time during cervical interlaminar epidural steroid injection (CIESI). To determine the relationship between BMI and fluoroscopy time during CIESI. Retrospective cohort study of patients who underwent fluoroscopically guided CIESI between January 2014 and February 2015 at an academic pain medicine center. Fluoroscopy time data were collected. Comparisons based on analysis of variance were made between patients with normal (<25.0 kg/m 2 ), overweight (25.0-29.9 kg/m 2 ), and obese (≥30.0 kg/m 2 ) BMI. Of 399 procedure encounters, 366 had documented BMI and fluoroscopy time data and were included for analysis. Mean age (± SD) in this cohort was 53 ± 13 years, including 189 females (52%) and 205 first-time injections. Mean fluoroscopy time for all injections was 18 ± 10 seconds. Separated by categorical BMI class, the mean fluoroscopy time was 18 ± 9 seconds for normal weight patients, 17 ± 10 seconds for overweight patients, and 20 ± 11 seconds for obese patients, respectively. Post hoc analysis showed that fluoroscopy time was significantly longer only in obese compared with overweight patients ( P = 0.02). Trainee involvement and first-time vs repeat injection did not significantly alter fluoroscopy time ( P = 0.17 and P = 0.12, respectively). The findings of this study indicate that BMI does not appear to have a clinically significant impact on fluoroscopy time during cervical interlaminar epidural steroid injection procedures. Future study is needed to directly quantify radiation exposure in patients and practitioners, as well as the associated health risk.

Effect of Cervical Interlaminar Epidural Steroid Injection: Analysis According to the Neck Pain Patterns and MRI Findings.

BackgroundIt is widely accepted that cervical interlaminar steroid injection (CIESI) is more effective in treating radicular pain than axial neck pain, but without direct comparison. And the differences of effect after CIESI according to MRI findings are inconsistent. In this retrospective study, we evaluated the therapeutic response of CIESI according to pain sites, durations, MRI findings, and other predictive factors altogether, unlike previous studies, which evaluated them separately.MethodsThe medical records of 128 patients who received fluoroscopy guided CIESI were analyzed. We evaluated the therapeutic response (more than a 50% reduction on the visual analog scale [VAS] by their second visit) after CIESI by (1) pain site; neck pain without radicular pain/radicular pain with or without neck pain, (2) pain duration; acute/chronic (more than 6 month), and (3) findings of MRI; herniated intervertebral disc (HIVD)/spinal stenosis, respectively and altogether.ResultsEighty-eight patients (68%) responded to CIESI, and there were no significant differences in demographic data, initial VAS score, or laboratory findings. And there were no significant differences in the response rate relating to pain site, pain duration, or MRI findings, respectively. In additional analysis, acute radicular pain with HIVD patients showed significantly better response than chronic neck pain with spinal stenosis (P = 0.04).ConclusionsWe cannot find any sole predictive factor of therapeutic response to the CIESI. But the patients having acute radicular pain with HIVD showed the best response, and those having other chronic neck pain showed the worst response to CIESI.

Fluoroscopically Guided Cervical Inter-Laminar Epidural Injections: Correlation Between Degree of Spinal Stenosis and Contrast Dispersal Pattern

Objectives: Cervical inter-laminar injections at C7-T1 have been routinely performed for many years as an effective means of palliating neck pain. The purpose of this study is to measure the extent of contrast spread following C7-T1 cervical inter-laminar epidural steroid injection (CIESI), and to correlate the upper extent of contrast spread with degree of cervical spinal stenosis. Methods: We retrospectively identified 41 consecutive patients over a six months’ time frame fulfilling the following inclusion criteria: (1) Had image guided CIESI at C7-T1, (2) Had PA and oblique epidurogram pre and post procedure, (3) Had procedural notes indicating the amounts injected and (4) Had an antecedent MRI. The epidurograms were reviewed for their extent of injectate spread. MRI studies were evaluated separately and blinded to the epidurograms. For each level the degree of cervical spine narrowing was noted. We correlated the extent of contrast spread with the level of maximal cervical narrowing. Results: Maximal contrast spread was up to the skull base and down to T4-T5; minimal extent was C6-C7 to T2. We found statistically significant correlation (2-tailed Pearson correlation r= 0.867, p<0.001) between the upper-most extent of contrast spread and the lowest level of significant central canal stenosis according to pre-procedure MRI. Conclusion: Following CIESI injectate will spread up as far as the cranio-cervical junction or near the lowest level where there is moderate degenerative central stenosis.

Method to Reduce the False-Positive Rate of Loss of Resistance in the Cervical Epidural Region.

Background. The cervical epidural space can be detected by the loss of resistance (LOR) technique which is commonly performed using air. However, this technique using air has been associated with a high false-positive LOR rate during cervical interlaminar epidural steroid injections (CIESIs). Objective. We investigated whether the detection of LOR with contrast medium might reduce the false-positive LOR rate on the first attempt. Methods. We obtained data retrospectively. A total of 79 patients were divided into two groups according to the LOR technique. Groups 1 and 2 patients underwent CIESI with the LOR technique using air or contrast medium. During the procedure, the injection technique (median or paramedian approach), final depth, LOR technique (air or contrast), total number of LOR attempts, and any side effects were recorded. Results. The mean values for the total number of LOR attempts were 1.38 ± 0.65 (Group 1) and 1.07 ± 0.25 (Group 2). The false-positive rate on the first attempt was 29.4% and 6.6% in Groups 1 and 2, respectively (P = 0.012). Conclusions. The use of contrast medium for LOR technique is associated with a lower rate of false-positivity compared with the use of air.

Multicenter Survey of Attitudes and Perceptions of Pain Medicine Fellows Toward the Use of Lateral Versus Contralateral-Oblique Fluoroscopic View for Interlaminar Cervical Epidural Injection

For interlaminar cervical epidural steroid injections (CESI) the lateral fluoroscopic view (LAT) is often considered to improve needle localization. However, the contralateral-oblique view (CLO) is a useful alternative with potential advantages to improve identification of cervical anatomy and needle depth assessment. The authors explored the attitudes and perceptions of pain medicine fellows currently training in two ACGME-accredited pain medicine fellowship programs regarding the use of these two types of fluoroscopic views. The survey was conducted online following a request by e-mail. Of a total of 20 fellows who were contacted, there were 17 respondents who had experience with both techniques, and they were included for analysis. The response rate for participation was 95%. Whereas 70.6% respondents reported they were very certain about the assessment of anatomy with the CLO view, only 17.6% felt very certain with the LAT view. Compared with learning to perform interlaminar CESI using the LAT view only, the majority of fellows thought that using the CLO technique was easier to learn (P < 0.01) and offered better visualization of contrast dye spread pattern to confirm the cervical epidural space (P = 0.013). All respondents perceived that the likelihood of interlaminar CESI complications would be lower with CLO technique. Overall, 82.4% of respondents considered CLO visualization as a preferred technique for interlaminar CESI. Respondents stated that the likelihood of using the CLO technique as an independent physician was significantly higher than using only the LAT technique (P < 0.001), particularly for patients who are obese and have short necks. For interlaminar CESI, using the CLO is perceived to provide better definition of anatomy and yet is easier to learn. Trainees may become more confident in performing interlaminar CESI with the CLO. We encourage all fellowship programs to include the CLO technique for interlaminar CESI as part of the training.

Epidural steroid injections in the management of cervical disc herniations with radiculopathy

Objectives: To evaluate the efficacy and safety of cervical epidural steroid injection (CESI) in the management of cervical disc herniations with radiculopathy.Method: We conducted a prospective interventional study with a 1-year follow-up comprising 33 consecutive patients presenting symptoms of cervicobrachial pain; positive neurological signs; corresponding cervical disc herniation/protrusion as verified by magnetic resonance imaging (MRI); insufficient improvement on prior conservative therapy; and no claims for financial compensation. Symptoms and clinical findings were registered in validated questionnaires before the procedure. Blind midline interlaminar CESI at the level of disc herniation was administered utilizing the loss of resistance (LOR) technique. Outcome was assessed during the first 3 months by telephone interview or clinical examination and final outcome measures were obtained at 1 year using validated questionnaires.Results: The study included 20 men (60%) and 13 women (40%); median age was 51 (range 30–63) years. Median duration of neck and arm pain was 72 (7–450) and 64 (5–443) days, respectively. On average, patients received 1.7 CESIs (range 1–3). Sixteen patients (49%) had only one injection. All 33 patients were potentially surgical candidates. Only two (6%) needed surgical intervention during follow-up. There was significant improvement in pain intensity and functional outcome. Intake of analgesics was significantly reduced. Eighty-two per cent would say ‘yes’ to receiving the same treatment again. No serious adverse events were observed.Conclusions: CESI appears to be a safe and efficient part of the treatment of patients with symptomatic cervical disc herniations and may be considered before patients are referred to surgery.

Incidence of Inadvertent Intravascular Injection during CT Fluoroscopy-Guided Epidural Steroid Injections.

Inadvertent intravascular injection during epidural steroid injection can result in complications and has been investigated previously with conventional fluoroscopy, but not CT fluoroscopy. The purpose of this study was to determine the incidence of intravascular injections recognized during CT fluoroscopy-guided epidural steroid injection. We retrospectively reviewed 575 consecutive CT fluoroscopy-guided epidural steroid injections. Procedures were assessed to determine the incidence of intravascular injection. Cases positive for intravascular injection were classified on the basis of anatomic location, distance from the needle tip, washout pattern, and presence of combined epidural and vascular injection. Cases were also graded as either venous or arterial by using a 5-point scale. Intravascular injection was observed in 26% of cervical transforaminal epidural steroid injections (7/27), 9% of cervical interlaminar epidural steroid injections (4/47), 8% of lumbar transforaminal epidural steroid injections (22/275), and 2% of lumbar interlaminar epidural steroid injections (4/222). Vessels were most commonly identified close to the needle, but in 30% of cases, they were visualized in the anterior paraspinal soft tissues remote from the needle. Washout was most commonly delayed (86%), though rapid washout occurred in 14% of cases. Simultaneous epidural and vascular injections occurred in 32% of cases. Most visualized vessels were venous, but 2 cases were classified as probably arterial. Intravascular injections can be detected with CT fluoroscopy. The incidence in our study was similar to that in previous reports using conventional fluoroscopy. Technical factors such as the "double-tap" on CT fluoroscopy following contrast injection, assessment for discordance between injected and visualized contrast volume, and maintenance of an appropriate FOV facilitate the detection of such events.

Evaluation of Anxiety in Procedure-Naive Patients During Cervical and Lumbar Epidural Steroid Injection Procedures

The lack of studies that identify patient and procedural risk factors for increased levels of anxiety during spine injections represents a major barrier to the development of safe tailored sedation practices. We measured and compared anxiety in procedure-naive patients undergoing a cervical or lumbar interlaminar epidural steroid injection to identify predictors of patient movement and vasovagal responses in the periprocedural period. This prospective observational cohort study was conducted with injection-naive patients presenting for a routine cervical or lumbar epidural steroid injection. The primary outcome measure was the Spielberger State Trait Anxiety Inventory (STAI) score. Participants also reported anxiety using the Numeric Rating Scale in the periprocedural period. The Wilcoxon rank sum test was used to compare STAI scores; Numeric Rating Scale values were compared using Friedman test. Post hoc tests were corrected for 12 comparisons using the Bonferroni method. We found no group differences in age, gender, marital status, Visual Analog Scale pain score, duration of pain symptoms, or utilization of health care resources for pain symptom management. The mean STAI score was 43 ± 8 in the cervical group (n = 140) and 44 ± 9 in the lumbar group (n = 140) (P = 0.35), a low level of anxiety. There were no between-group differences in anxiety at any point during the periprocedural period. A vasovagal response was identified in 10% of the cervical group and in 3% of the lumbar group (P = 0.04). No group differences in anxiety were seen between cervical and lumbar groups. Anxiety levels were not associated with patient movement or vasovagal symptoms. Our results suggest that the practice of routine prevention or treatment of injection-related anxiety in the procedure-naive general population with a duration of pain less than 6 months and without a history of an anxiety disorder should be reevaluated.