Physical Medicine and Rehabilitation Clinics of North America
Epidural Steroid Injections for Cervical Radiculopathy
Section snippets
General indications
ESIs have been used to treat a variety of spinal disorders. They are primarily and most widely accepted as a treatment of radicular symptoms. Patients with radicular pain that has been unresponsive to noninterventional care for 1 to 2 months including physical therapy, medications, and education are candidates for ESIs. In patients without progressive neurologic deficit or cervical myelopathy, ESIs are considered as a rational part of treatment before surgical intervention. However, the
Complications of ESIs
In general, risks of spine interventions are related to needle placement, the medications used, and patient factors. These include, but are not limited to, tissue trauma, bleeding, infection, nerve/cord injury, spinal block, medication side effects/toxicity, and allergic reaction. Minor procedural complications vasovagal reactions, nausea, transient neurologic symptoms, and increased neck or arm pain. Transient complications with ESIs can occur as a result of side effects of steroids,
Anatomy relevant to cervical ESI
Performing technically sound injections to maximize efficacy and minimize risk requires exact knowledge of the anatomy. The epidural space contains the spinal nerve roots and their dural sleeves, the internal vertebral venous plexus, loose areolar tissue, segmental blood supply, adipose tissue, and lymphatics. The location of the dura is an obvious consideration, and the vascular structures are even more important. The epidural veins form an arcuate pattern, positioned laterally at the level of
ESI approaches, evidence, and efficacy
Techniques available to access the cervical epidural space include the IL and TF approach. The TF route has become more common because it may place the medication more directly at the site of the proposed cause of pain. Prospective studies by Derby and others in the 1990s described improved outcomes using the TF route for radicular pain in the lumbar spine.15, 16 Similar studies comparing the IL and TF routes are not available for the cervical spine, although there is some evidence to suggest
ESI conclusions
Neither TF nor IL ESIs have been studied against a control for the treatment of cervical radicular pain. Retrospective and prospective series overall do suggest favorable results for short-term improvement. Patients with radiculopathy and central stenosis have been shown to have better outcomes after cervical IL ESI, but radiculopathy with disc herniation has also been shown to have better outcomes than osseous central or foraminal stenosis. For cervical TF ESIs, patients with nontraumatic
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