Cervical Nerve Root Injection Research Articles

Are brake response times altered post CT-guided cervical spine nerve root injections?

To assess if brake response times are altered pre and post CT-guided cervical spine nerve root injections. Brake response times were assessed before and after CT-guided cervical spine nerve root injections in a cohort of patients. The average of 3 brake response times was recorded before and 30 min after injection. Statistical analysis was performed using GraphPad. A paired Student t-test was used to compare the times before and after the injections. Forty patients were included in this study. The mean age was 55 years. There were 17 male and 23 female patients. There was no significant difference in the mean pre and post CT-guided cervical spine nerve root injection brake response times; 0.94 s (range 0.4-1.2 s) and 0.93 s (range 0.5-1.25 s), respectively (P = .77). Brake response time did not significantly differ pre and 30 min post CT-guided cervical spine nerve root injections. To the authors' best knowledge, there are no current studies assessing brake response times post CT-guided cervical spine nerve root injections. While driving safety cannot be proven by a single metric, it is a useful study in demonstrating that this is not inhibited in a cohort of patients.

Ultrasound-guided and CT-guided selective cervical nerve root injection for the treatment of cervical radicular pain: A retrospective clinical study.

To compare the clinical effects and safety of ultrasound (US)-guided selective cervical nerve root injection (SCNI) and computed tomography (CT)-guided SCNI for patients with cervical radicular pain (CRP). Forty-two CT-guided SCNI procedures (26 eligible patients) and forty-two US-guided SCNI procedures (25 eligible patients) performed to treat CRP were identified from the medical record system between October 2017 and July 2021 and enrolled in the study. The numeric rating scale was used to assess pre- and postprocedural pain levels, and the neck disability index was used to assess the level of function. All immediate and delayed clinical complications were also recorded. The cost of each procedure and the radiation dose of the CT procedure were documented. The follow-up data were obtained by telephone calls or outpatient visits. Five patients in the CT group and one patient in the US group were lost to follow-up at 1 year. No procedure-related complications were observed in either group. Significant pain relief and cervical function improvement were achieved after treatment in both the CT-guided SCNI and US-guided SCNI groups; however, there were no significant differences between the two groups. The average cost per CT-guided SCNI procedure was 133.2 USD, which was higher than the cost per US-guided SCNI procedure (42.2 USD). Meanwhile, the necessary radiation dose per patient in the CT group was 0.36 ± 0.08 mGy. US-guided SCNI and CT-guided SCNI have similar efficacy in treating CRP, but US-guided SCNI is radiation free and less costly than the CT-guided procedure.

Safety of local anesthetics in cervical nerve root injections: a narrative review.

Severe neurological adverse events have been reported after fluoroscopically guided cervical nerve root injections. Particulate corticosteroids inadvertently injected intraarterially and iatrogenic vertebral artery trauma have been implicated in these outcomes. This has raised concern for the potential consequences of including local anesthetic with these injections. As a result, some providers have now discontinued the routine administration of local anesthetic with corticosteroid when performing cervical nerve root injections. At present, there is no consensus regarding whether the use of local anesthetic in this context is safe. Here, the current literature is synthesized into a narrative review aiming to clarify current perspectives of the safety of local anesthetics in cervical nerve root injections.

Cervical selective nerve root injection alleviates chronic refractory pain after brachial plexus avulsion: a case report

BackgroundIntractable chronic pain, as well as motor, sensory, and autonomic neuropathy, significantly reduces the quality of life of brachial plexus avulsion (BPA) patients. We report the successful application of cervical selective nerve root injection (CSNRI) in a patient with BPA.Case presentationA 40-year-old man had been diagnosed with complete left BPA due to a motorcycle accident and underwent intercostal nerve transplantation at the age of 18 years and had been experiencing pain ever since. His pain increased after fracture of the left humerus, and he was referred to our pain management clinic. As his exacerbated pain was suspected to be due to peripheral nerve hypersensitivity, we performed repetitive ultrasound-guided CSNRI (3 mL of 1% mepivacaine of each) targeted C5 and 6 intervertebral foramina, and his symptoms gradually improved.ConclusionsRepetitive CSNRI may help diagnose and treat BPA-associated peripheral neuropathic pain, even in patients diagnosed with BPA.

Can we Rotate the Head Safely During Cervical Nerve Root Injection?

Objectives: Trans-foraminal epidural injections have been used successfully to aid in the management of cervicobrachialagia. The aim of this study was to assess the cross sectional area of the vertebral artery during transforaminal cervical nerve root injections (TFCNRI) when the head is typically rotated and to compare with the neutral position cross sectional area. We hypothesize that head rotation does not lead to a change of vertebral artery calibre at the neural foramen, thus this technique can be performed relatively safely during TFCNRI. Material and Methods: A pilot study involving a retrospective review of 16 computed tomography guided TFNRI was performed and cross sectional area of vertebral artery with head tilted and head in neutral position was performed. Results: There was no correlation between the degree of head rotation and change in the area of the ipsilateral or contralateral vertebral artery. Conclusion: We suggest that head can safely be rotated to varied degrees while performing TFCNRI.

Cervical Ultrasound Utilization in Selective Cervical Nerve Root Injection for the Treatment of Cervical Radicular Pain: a Review

This paper aims to review the available literature addressing the safety, accuracy, and efficacy of ultrasound-guided injections for cervical radicular pain. Ultrasound-guided injections remain a “partially blind technique” due to the inability to visualize relevant structures and the distribution of injectate. There remains a need for adequately powered studies evaluating the safety, accuracy, and effectiveness of ultrasound-guided steroid injections in the cervical spine. Fluoroscopy remains the best evidence-based image-guidance modality for injections into the cervical epidural space to treat cervical radicular pain. If ultrasound guidance is planned for treatment of cervical radicular pain, the authors recommend concomitant use of fluoroscopy guidance. Given the risk of inaccurate needle placement, physicians should retain fluoroscopic images prior to contrast injection to document the proper vertebral segment and final needle tip position. As epidural flow cannot be fully visualized with ultrasound, it is recommended to use fluoroscopy and, if needed, digital subtraction imaging to confirm the absence of intravascular injection. At a minimum, images should be saved post-contrast injection to document epidural flow.

Paravertebral Collateral Arteries in Patients with Carotid Stenosis: Is There a Safe Space for Transforaminal Cervical Nerve Root Injections?

Image-guided cervical nerve root injections can cause serious complications including spinal cord infarction. This risk may be increased in patients with carotid stenosis who develop collateral arteries. The aim of this study is to describe the prevalence, and anatomical location, of arterial collateral vessels in relation to the optimal needle tip position in cervical nerve root injections. This retrospective study included 25 patients who had > 70% stenosis on a carotid CT angiogram. For each foramen the position of collateral arteries and the most anterior point of the facet joint were recorded, as Cartesian coordinates, by two independent observers. Descriptive statistics were used to analyse and present the results. 14 patients had unilateral and 11 had bilateral stenoses. A total of 85 collaterals were identified at all levels, the most common being C2/3. The median distance from collateral to optimal needle tip placement was 9.6mm (95% CI median: 6.7-12.4, IQR: 5.6-15.6). The minimum distance was 2.9mm. Inter-observer reliability was "substantial" (ICC 0.78, 95% CI 0.71-0.83). Collateral arteries were common in our cohort of patients with carotid artery stenosis and half lay within 10mm of the optimal position for transforaminal cervical nerve root injection.

Safety of CT-guided cervical nerve root corticosteroid injections.

Computed tomography-guided cervical nerve root corticosteroid injections are a commonly performed procedure for cervical radiculopathy. There have been major complications such as spinal cord infarction and posterior circulation stroke reported mostly with X-ray fluoroscopic-guided methods, however, there is relatively little data on the safety of newer CT-guided methods. The purpose of this study was to identify any major complications and evaluate the rate of minor complications from CT-guided cervical nerve root corticosteroid injections performed in a tertiary public hospital. Four hundred and three CT-guided cervical nerve root injection procedures were identified over a period from July 2015 to January 2018 using the radiology information system (RIS) and data collected about the technique and any immediate complications. Patient follow-up and delayed complications were then reviewed, either via outpatient clinic records or telephone consultation. Two hundred and eighty-six procedures were performed by radiology registrars or fellows, and 117 by radiologists, most commonly via an anterolateral approach and injecting 4mg (in 1mL) of dexamethasone. Follow-up data were obtained for all 403 procedures and identified 16 minor complications, but no major neurovascular complications. The overall recorded rate of minor complications with CT-guided nerve root injection was 4.0% with no major neurovascular complications, suggesting that CT-guided transforaminal cervical corticosteroid injection is a safe procedure.

Combined fluoroscopic and ultrasound guided cervical nerve root injections.

To assess the technical feasibility, safety and initial clinical efficacy of a combined ultrasound and fluoroscopy imaging approach to cervical nerve root blocks. Fluoroscopic guided cervical transforaminal and selective nerve root injections are often used in the investigation or treatment of radicular symptoms, although rare but serious complications including death have been reported. We report a combined technique developed to increase safety of selective nerve root injections, including the safety and early efficacy of this novel technique in our initial patient cohort. We retrospectively reviewed a consecutive cohort of injections performed in 149 patients by a single consultant radiologist between December 2010 and August 2012. For all patients the outcome was assessed both immediately following the procedure and at sixweeks. Primary outcome was reduction in radicular symptom level. Duration of symptoms were also assessed and all complications were recorded. One hundredand forty nine patients underwent injection at either one or two cervical levels. No patients experienced any complications during the follow-up period, and 72% had an initial positive response to the injection. Of these, 42% were discharged to the care of their General Practitioner, 23% went on to have surgery, 18% were actively monitored in a specialist clinic, 10% were referred to our pain management service and 4% had the injection repeated after symptoms recurred. Using this combined image guided technique cervical nerve root blocks appear both safe and effective in the investigation and management of radicular symptoms from the cervical spine.

Symptomatic, Magnetic Resonance Imaging–Confirmed Cervical Disk Herniation Patients: A Comparative-Effectiveness Prospective Observational Study of 2 Age- and Sex-Matched Cohorts Treated With Either Imaging-Guided Indirect Cervical Nerve Root Injections or Spinal Manipulative Therapy

ObjectiveThe purpose of this study was to compare the outcomes of overall improvement, pain reduction, and treatment costs in matched patients with symptomatic, magnetic resonance imaging–confirmed cervical disk herniations treated with either spinal manipulative therapy (SMT) or imaging-guided cervical nerve root injection blocks (CNRI). MethodsThis prospective cohort comparative-effectiveness study included 104 patients with magnetic resonance imaging–confirmed symptomatic cervical disk herniation. Fifty-two patients treated with CNRI were age and sex matched with 52 patients treated with SMT. Baseline numerical rating scale (NRS) pain data were collected. Three months after treatment, NRS pain levels were recorded and overall “improvement” was assessed using the Patient Global Impression of Change scale. Only responses “much better” or “better” were considered “improved.” The proportion of patients “improved” was calculated for each treatment method and compared using the χ2 test. The NRS and NRS change scores for the 2 groups were compared at baseline and 3 months using the unpaired t test. Acute and subacute/chronic patients in the 2 groups were compared for “improvement” using the χ2 test. Results“Improvement” was reported in 86.5% of SMT patients and 49.0% of CNRI patients (P = .0001). Significantly more CNRI patients were in the subacute/chronic category (77%) compared with SMT patients (46%). A significant difference between the proportion of subacute/chronic CNRI patients (37.5%) and SMT patients (78.3%) reporting “improvement” was noted (P = .002). ConclusionSubacute/chronic patients treated with SMT were significantly more likely to report relevant “improvement” compared with CNRI patients. There was no difference in outcomes when comparing acute patients only.

Correlation of Foraminal Area and Response to Cervical Nerve Root Injections.

Introduction: Patients with age-related degenerative changes in the cervical spine leading to cervical spondylosis may be symptomatic or asymptomatic. Older patients with radicular pain tend to have a better response to epidural steroid injections, but it is often difficult to predict which patients will have a positive response to selective nerve root block (SNRB). We analyzed whether the cervical neuroforaminal area measured on MRI predicts immediate therapeutic responses to SNRB in patients who have cervical radiculopathy.Methods: We retrospectively reviewed all patients who had cervical SNRBs treated at a single tertiary referral center. We recorded patient demographics, the neuroforaminal area of the symptomatic and contralateral sides, Visual Analog Scale (VAS) score pre- and post-injection, history of previous cervical surgery, comorbidities, and history of tobacco use.Results: Sixty-four patients with symptoms of cervical radiculopathy treated with neuroforaminal nerve root injections had appropriate imaging and VAS scores recorded. The average foraminal area of the symptomatic side before treatment was significantly smaller than the contralateral asymptomatic neuroforamen (p<0.0001). Those patients with the smallest neuroforamen had a positive response to SNRB. Diabetes and tobacco use did not influence patient response to treatment.Conclusions: Measurement of neuroforaminal areas on MRI may represent a useful pre-procedural technique to predict which patients with symptoms of cervical radiculopathy secondary to foraminal stenosis are likely to respond to selective nerve root injections. The predictive ability appears to be limited to those patients with severe stenosis and was less useful in those patients with moderate or mild stenosis.

The short- and medium-term effectiveness of CT-guided selective cervical nerve root injection for pain and disability

CT-guided cervical nerve root injection with corticosteroid and/or local anesthetic is a recognized technique in the evaluation and treatment of cervical radiculopathy. There are few prospective studies on the efficacy of the various techniques employed in cervical nerve root injection. We present our results from a 1-year prospective series using a CT-guided anterolateral transforaminal approach for cervical nerve root injection of bupivacaine and dexamethasone. Pain using a numeric rating scale was assessed at pre-injection, 15 min post-injection, 1 month, and 3 months. Disability was assessed using the Oswestry Neck Disability Index (NDI) questionnaire at pre-injection, 1 month post-injection, and 3 months. In total, 50 patients were followed for 3 months. The mean reductions in pain were: 15 min (77 %), 1 month (39 %), and 3 months (33 %). The mean reductions in NDI were: 1 month (26 %) and 3 months (also 26 %). Results were statistically significant. CT-guided selective cervical nerve root injection in the treatment of cervical radicular pain and related disability produces statistically significant reductions in pain and disability to at least 3 months post-procedure.

Outcome Study of Real-time MR-guided Cervical Periradicular Injection Therapy in an Open 1.0 Tesla MRI System

To evaluate the accuracy, safety, and efficacy of cervical nerve root injection therapy using magnetic resonance guidance in an open 1.0 T MRI system. Between September 2009 and April 2012, a total of 21 patients (9 men, 12 women; mean age 47.1 ± 11.1 years) underwent MR-guided cervical periradicular injection for cervical radicular pain in an open 1.0 T system. An interactive proton density-weighted turbo spin echo (PDw TSE) sequence was used for real-time guidance of the MR-compatible 20-gauge injection needle. Clinical outcome was evaluated on a verbal numeric rating scale (VNRS) before injection therapy (baseline) and at 1 week and 1, 3, and 6 months during follow-up. All procedures were technically successful and there were no major complications. The mean preinterventional VNRS score was 7.42 and exhibited a statistically significant decrease (P < 0.001) at all follow-up time points: 3.86 ± 1.53 at 1 week, 3.21 ± 2.19 at 1 month, 2.58 ± 2.54 at 3 months, and 2.76 ± 2.63 at 6 months. At 6 months, 14.3 % of the patients reported complete resolution of radicular pain and 38.1 % each had either significant (4-8 VNRS score points) or mild (1-3 VNRS score points) relief of pain; 9.5 % experienced no pain relief. Magnetic resonance fluoroscopy-guided periradicular cervical spine injection is an accurate, safe, and efficacious treatment option for patients with cervical radicular pain. The technique may be a promising alternative to fluoroscopy- or CT-guided injections of the cervical spine, especially in young patients and in patients requiring repeat injections.

CT-guided cervical nerve root injections: comparing the immediate post-injection anesthetic-related effects of the transforaminal injection with a new indirect technique

To describe an "indirect" cervical nerve root injection technique with a dorsal approach that should carry less inherent risk than the "direct" cervical transforaminal injection approach, and to compare the immediate post-injection results of the two procedures. The indirect and direct cervical nerve root injection procedures are described in detail. Fifty-three consecutive patients receiving the indirect nerve root injections during 2009-2010 were age- and gender-matched to 53 patients who underwent direct transforaminal nerve root injections performed in 2006. Pain level data were collected immediately before and 20-30min after each procedure. The percentages of pain change in the two groups were compared using the unpaired Student'st test. Fifty-two men (mean age 49) and 54 women (mean age 55) were included. The mean percentage of pain reduction for patients receiving indirect nerve root injections was 38.4% and for those undergoing the direct nerve root injections approach it was 43.2%. This was not significantly different (P = 0.455). No immediate or late adverse effects were reported after either injection procedure. The indirect cervical nerve root injection procedure is a potentially safer alternative to direct cervical transforaminal nerve root injections. The short-term pain reduction is similar using the two injection methods.

A Whitacre-Type Spinal Needle Does Not Prevent Intravascular Injection During Cervical Nerve Root Injections

We present a case of intravascular injection in a 41-year-old female during cervical selective nerve root injection using a 22-gauge 3.5-inch Whitacre-type pencil-point subarachnoid needle with a curve placed at the distal tip positioned using continual live fluoroscopic guidance. After negative aspiration for blood and cerebrospinal fluid and no elicited paresthesias during the procedure, 1 mL of contrast was injected. Initial imaging at C6 captured the outline of the nerve root along with a significant amount of transient vascular runoff. This case report demonstrates that Whitacre-type spinal needles do not prevent vascular injection, and that aspiration of the needle is not a reliable sign of intravascular injection.

Ultrasound-Guided Cervical Selective Nerve Root Block

Reports of intravascular injection during cervical transforaminal injections, even after confirmation by contrast fluoroscopy, have led some to question the procedure's safety. As ultrasound allows for visualization of soft tissues, nerves, and vessels, thus potentially improving precision and safety, we evaluated its feasibility in cervical nerve root injections. This is a prospective series of 10 patients who received cervical nerve root injections using ultrasound as the primary imaging tool, with fluoroscopic confirmation. Our radiologic target point was the posterior aspect of the intervertebral foramen just anterior to the superior articular process in the oblique view and at the midsagittal plane of the articular pillars in the anteroposterior (AP) view. The needle was exactly at the target point in 5 patients in the oblique view and in 3 patients in the AP views. The needle was within 3 mm in all patients in the lateral oblique view and in 8 patients in the AP view. In the remaining 2 patients, the needle was within 5 mm from the radiologic target. In 4 patients, we were able to identify vessels at the anterior aspect of the foramen, whereas 2 patients had critical vessels at the posterior aspect of the foramen, and in 1 patient, this artery continued medially into the foramen, most likely forming or joining a segmental feeder artery. In both cases, the vessels might well have been in the pathway of a needle correctly positioned under fluoroscopic control. Our case series shows the feasibility of using ultrasound imaging to guide selective cervical nerve root injections. It may facilitate identifying critical vessels at unexpected locations relative to the intervertebral foramen and avoiding injury to such vessels, which is the leading cause of the reported complications from cervical nerve root injections. A randomized controlled trial to compare the effectiveness and safety of ultrasound imaging against other imaging techniques seems warranted.

Ultrasound-guided cervical transforaminal injection and selective nerve root block

Traditionally, cervical transforaminal injections have been performed under fluoroscopic guidance. Real-time fluoroscopy with contrast injection is necessary to minimize intra-arterial injections. But even with strict guidelines, multiple instances of inadvertent intra-arterial injections with resultant spinal cord injury have been reported. This has led some practitioners to question the use of this procedure and whether the benefits outweigh the risks. The use of ultrasound (US) imaging to facilitate nerve blocks has increased recently. US allows visualization of soft tissues, as well as nerves and vessels, and also permits visualization of the injectate around the nerve. Unlike fluoroscopy and computed tomography, US does not expose the patients or personnel to radiation, and the image can be performed continuously while the injectate can be visualized in real time, thereby increasing the precision of injection. US imaging can be used to obtain well-defined images of the cervical neural foramina with real-time visualization of the spinal nerves and vessels and may improve the safety of the technique. It may facilitate identifying anomalous critical vessels at unexpected locations relative to the intervertebral foramen and avoiding injury to such vessels, which is the leading cause of the reported complications from cervical nerve root injections.

Ultrasound Guided Nerve Root Injection in Patients with Cervical Spondylytic Radicular Pain

Selective cervical nerve root injection using a mixture of corticosteroid and lignocaine is a treatment option for managing cervical radiculopathic pain. The procedure is usually performed under image guided fluoroscopy or Computerized Tomograhy. Ultrasound-guided cervical nerve root block does not expose the patients and personnel to radiation. During injection, the fluid is mostly visualized in a real-time fashion. This retrospective study reviewed the effectiveness of ultrasound in guiding cervical peri-radicular injection for pain relief in patients with recalcitrant cervical radiculopathy. There were no complications reported in this series.

Epidural Hematoma Causing Paraplegia After a Fluoroscopically Guided Cervical Nerve-Root Injection

Extraforaminal cervical nerve-root blocks, administered under image guidance, are extremely useful for both the diagnosis and treatment of cervical radiculopathy. In terms of safety, Ma et al., in their analysis of fluoroscopically guided cervical nerve blocks, found no instances of paralysis in their 1036 patients after injection1. Although devastating neurological complications after cervical transforaminal nerve block are rare, there have been anecdotal case reports of spinal cord infarction2-4, injection into surrounding vascular structures5,6, epidural abscess7, and cerebellar and/or brain-stem herniation and infarction8,9. An expanding epidural hematoma is a rare complication that can cause major neurological morbidity. Repeated injections, preexisting coagulopathy, and the use of anticoagulation or antiplatelet medications are known risk factors for the development of an epidural hematoma in the lumbar spine after an injection10-13. Injection-related epidural hematomas in the cervical spine have rarely been reported11,14. Consequently, the risk factors for the development of cervical epidural hematoma following transforaminal nerve-root injection are not clearly defined. We present the case of a patient with dense paralysis as a result of a slowly expanding cervical epidural hematoma that developed after a series of image-guided transforaminal cervical nerve-root injections. The only potential risk factor identified in this patient was the administration of multiple injections. Our patient was informed that data regarding this case would be submitted for publication. An otherwise healthy, thirty-eight-year-old woman was involved in a motor-vehicle accident that resulted in a right upper-extremity radiculopathy. She was initially evaluated and treated by an orthopaedic surgeon who recommended physical therapy and cervical epidural injections. After a short course of physical therapy, the patient underwent a series of three fluoroscopically guided right transforaminal epidural injections at the C7-T1 level. …

Complications and side effects of cervical and lumbosacral selective nerve root injections

Huston CW, Slipman CW, Garvin C. Complications and side effects of cervical and lumbosacral selective nerve root injections. Objective To determine the incidence of complications and side effects of cervical and lumbosacral selective nerve root injections (SNRIs). Design Prospective, nonrandomized controlled trial of consecutive patients with independent interviews for immediate, 1-week, and 3-month follow-ups. Setting Tertiary, academic spine center. Participants Of 160 patients eligible for SNRI, 151 underwent 306 SNRIs (study group). Sixty patients who had not undergone any intervention served as the control group. Interventions Diagnostic and therapeutic fluoroscopically guided cervical and lumbosacral SNRIs. Lidocaine (Xylocaine) was used in the diagnostic injections and a mixture of lidocaine and betamethasone was used in the therapeutic injections. Main outcome measures Complications and side effects experienced during the procedure were recorded by the interventionalist. Side effects and complications experienced immediately, 1 week, and 3 months after injection were determined through independent interviews using a questionnaire format. The control group was independently interviewed using the same questionnaire. Results There were no major complications, such as death, paralysis, spinal nerve injury, infection, or allergic reaction, during the study. Ninety-one percent of subjects had no side effects during the procedure. A positive response on interview was reported by 39.4% of the study subjects immediately after the procedure. Lumbosacral SNRI side effects were as follows: increased pain at the injection site (17.1%); increased radicular pain (8.8%); lightheadedness (6.5%); increased spine pain (5.1%); nausea (3.7%); nonspecific headache (1.4%); and vomiting (0.5%). Immediate side effects from cervical SNRI were as follows: increased pain at injection site (22.7%); increased radicular pain (18.2%); lightheadedness (13.6%); increased spine pain (9.1%); nonspecific headache (4.5%); and nausea (3.4%). At the 1-week interview, comparison of the study and control groups showed statistical significance for the following: pain at injection site, cervical ( P=.001) and lumbar ( P=.005); nonspecific headache, cervical ( P=.019); and nonspinal headache, cervical ( P=.002). At 3 months, 2 subjects complained of increased neck pain and 1 reported heartburn and fluid retention. Two lumbar SNRI subjects were lost to follow-up. Conclusions There were no major complications with cervical and lumbosacral SNRIs, although various minor side effects occurred.