Cervical Epidural Injections

• 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

• Infection at the injection site
• Systemic infection
• Bleeding diathesis
• Uncontrolled diabetes mellitus
• Congestive heart failure

• 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

• 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

• 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).

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).