Cervical Epidural Injections

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SAMPLE EXCERPT
- Full procedure text, video and illustrations available with the full product
PRE-PROCEDURE
INDICATIONS
  • Acute disc injury, with or without radiculopathy
  • Cervical spondylosis with acute disc disruption and radiculopathy
  • Post-laminectomy cervical pain
  • Cervical pain without specific anatomic etiology
    • Cervical strain syndromes with associated myofascial pain
    • Reflex sympathetic dystrophy
    • Post-herpetic neuralgia
    • Acute viral brachial plexitis
    • Muscle contraction headaches
CONTRAINDICATIONS
  • Infection at the injection site
  • Systemic infection
  • Bleeding diathesis
  • Uncontrolled diabetes mellitus
  • Congestive heart failure
EQUIPMENT
  • Pain management table
  • Cervical prone cutout cushion
  • Fluoroscopy unit
  • Isopropyl alcohol
  • Povidone-iodine or chlorhexidine gluconate (Hibiclens)
  • ¼-inch, 27-gauge needle
  • 18-gauge hypodermic needle
  • 3½-inch, 22-gauge spinal needle
  • 3½-inch, 25-gauge spinal needle
  • 3½-inch, 22-gauge Tuohy epidural needle
  • 10-mL syringe (2)
  • 5-mL syringe
  • Preservative-free 1% Xylocaine without epinephrine
  • 8.4% sodium bicarbonate
  • Nonionic contrast dye
  • 6 mg/mL Celestone Soluspan or 50 mg/mL triamcinolone
ANATOMY
  • 7 cervical vertebrae, 8 nerve roots
  • The intervertebral discs
    • Named for the vertebral level immediately cephalad to the disc
    • Inner gelatinous nucleus pulposus, outer annulus fibrosis
    • Secured to vertebral body, cartilaginous endplates, and the anterior and posterior longitudinal ligaments by collagen fibers
  • The dorsal root ganglion
    • Exits the intervertebral foramen at each cervical spine level
    • Forms three branches (the ventral ramus, the sinu-vertebral nerve, and the dorsal ramus)
    • The intervertebral discs are innervated by axons within the dorsal root ganglion

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
TECHNIQUES
  • Post-Procedure: Interlaminar Approach
  • Post-Procedure: Transforaminal Approach

Post-Procedure: Interlaminar Approach

POST-PROCEDURE CARE
  • Monitor recovery for 30-60 minutes.
  • Have patient complete pain scale assessment.
  • Avoid exertional activities day of procedure.
COMPLICATIONS
  • Vasovagal reaction
  • Dural puncture, postdural puncture (positional) headaches
  • Headache without dural puncture
  • Epidural abscess
  • Epidural hematoma
  • Durocutaneous fistula
  • Spinal cord or brain stem injury from intraarterial injection (transforaminal injections)
  • Cushing's syndrome
  • Nonpositional headaches
  • Facial flushing
  • Insomnia
  • Low-grade fever
ANALYSIS OF RESULTS

Both cervical and lumbar epidural injections with corticosteroids have been evaluated in mostly uncontrolled studies with a high rate of success and relatively low complication rate. There have been reports of spinal cord injury from inadvertent intravascular injection using the transforaminal approach.

OUTCOMES AND EVIDENCE
  • Bush and Hillier: 93% of patients with good pain relief from transforaminal injection at 1-12 month follow-up
  • Kwon et al: 72.4% effective pain relief with cervical epidural injection; patients with diagnosed disc protrusion did better than those with stenosis.
  • Lin et al: 63% of patients with disc herniation reported significant pain relief for injection therapy.
  • Cyteval et al: 60% of patients reported "good" pain relief (50% to 74% reduction in pain).
Procedure: Interlaminar Approach

Post-Procedure: Transforaminal Approach

POST-PROCEDURE CARE
  • Monitor recovery for 30-60 minutes.
  • Have patient complete pain scale assessment.
  • Avoid exertional activities day of procedure.
COMPLICATIONS
  • Vasovagal reaction
  • Dural puncture, postdural puncture (positional) headaches
  • Headache without dural puncture
  • Epidural abscess
  • Epidural hematoma
  • Durocutaneous fistula
  • Spinal cord or brain stem injury from intraarterial injection (transforaminal injections)
  • Cushing's syndrome
  • Nonpositional headaches
  • Facial flushing
  • Insomnia
  • Low-grade fever
ANALYSIS OF RESULTS

Both cervical and lumbar epidural injections with corticosteroids have been evaluated in mostly uncontrolled studies with a high rate of success and relatively low complication rate. There have been reports of spinal cord injury from inadvertent intravascular injection using the transforaminal approach.

OUTCOMES AND EVIDENCE
  • Bush and Hillier: 93% of patients with good pain relief from transforaminal injection at 1-12 month follow-up
  • Kwon et al: 72.4% effective pain relief with cervical epidural injection; patients with diagnosed disc protrusion did better than those with stenosis.
  • Lin et al: 63% of patients with disc herniation reported significant pain relief for injection therapy.
  • Cyteval et al: 60% of patients reported "good" pain relief (50% to 74% reduction in pain).
Procedure: Transforaminal Approach
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