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Peene L, Cohen SP, Brouwer B, James R, Wolff A, Van Boxem K, Van Zundert J. 2. Cervical radicular pain. Pain Pract 2023; 23:800-817. [PMID: 37272250 DOI: 10.1111/papr.13252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Cervical radicular pain is pain perceived in the upper limb, caused by irritation or compression of a cervical spine nerve, the roots of the nerve, or both. METHODS The literature on the diagnosis and treatment of cervical radicular pain was retrieved and summarized. RESULTS The diagnosis is made by combining elements from the patient's history, physical examination, and supplementary tests. The Spurling and shoulder abduction tests are the two most common examinations used to identify cervical radicular pain. MRI without contrast, CT scanning, and in some cases plain radiography can all be appropriate imaging techniques for nontraumatic cervical radiculopathy. MRI is recommended prior to interventional treatments. Exercise with or without other treatments can be beneficial. There is scant evidence for the use of paracetamol, nonsteroidal anti-inflammatory drugs, and neuropathic pain medications such as gabapentin, pregabalin, tricyclic antidepressants, and anticonvulsants for the treatment of radicular pain. Acute and subacute cervical radicular pain may respond well to epidural corticosteroid administration, preferentially using an interlaminar approach. By contrast, for chronic cervical radicular pain, the efficacy of epidural corticosteroid administration is limited. In these patients, pulsed radiofrequency treatment adjacent to the dorsal root ganglion may be considered. CONCLUSIONS There is currently no gold standard for the diagnosis of cervical radicular pain. There is scant evidence for the use of medication. Epidural corticosteroid injection and pulsed radiofrequency adjacent to the dorsal root ganglion may be considered. [Correction added on 12 June 2023, after first online publication: The preceding sentence was corrected.].
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Affiliation(s)
- Laurens Peene
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
| | - Steven P Cohen
- Pain Medicine Division, Department of Anesthesiology, Johns Hopkins School of Medicine, Baltimore, USA
| | - Brigitte Brouwer
- Department of Anesthesiology, Pain Medicine and Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rathmell James
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Leroy D. Vandam Professor of Anesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Andre Wolff
- Department of Anesthesiology, UMCG Pain Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Koen Van Boxem
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
- Department of Anesthesiology, Pain Medicine and Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan Van Zundert
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
- Department of Anesthesiology, Pain Medicine and Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
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Lee JH, Lee JH, Chang MC. Transforaminal Epidural Steroid Injection for Patients with Lumbosacral Disc Herniation in the Absence of Spine Magnetic Resonance Imaging - Is Better Really the Enemy of the Best? J Pain Res 2023; 16:1477-1485. [PMID: 37168846 PMCID: PMC10166140 DOI: 10.2147/jpr.s402405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 05/02/2023] [Indexed: 05/13/2023] Open
Abstract
Purpose This study aimed to evaluate the effect of transforaminal epidural steroid injection (TFESI) in patients with lumbosacral disc herniation by comparing its effect between those diagnosed by clinical evaluation and plain radiography only (X-ray group) and those by additional magnetic resonance imaging (MRI) (MRI group). Additionally, we investigated the accuracy of the preliminary clinical assumption in the X-ray group using confirmative post-injection MRI. Patients and Methods We retrospectively recruited 367 patients with back and radicular pain due to lumbosacral disc herniation from a single pain clinic. Among them, 201 and 166 patients were categorized into the X-ray and MRI groups, respectively. In the X-ray group, the pathological level assumed initially by clinical evaluation and plain radiography concurred with that confirmed later on post-injection MRI in 139 patients (corresponding group); the remaining 62 patients lacked this concurrence (non-corresponding group). The NRS scores and Macnab criteria results were compared between the X-ray and MRI groups as well as the corresponding and non-corresponding groups. Results Both the X-ray and MRI groups showed significant reductions in the NRS scores at 2 and 10 weeks post-injection when compared with the pretreatment scores. However, no significant difference was noted between the groups in terms of the magnitude of clinical improvement assessed by successful reduction in the NRS or Macnab scores. Furthermore, similar results were obtained in the comparison between the corresponding and non-corresponding groups of the X-ray group. Conclusion TFESI guarantees favorable clinical outcomes even in the absence of confirmative MRI in patients with back and radicular pain. The preemptive application of this procedure could be prioritized and justified in patients suspected of lumbosacral disc herniation based on clinical evaluation and plain radiography only without the preceding MRI verification.
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Affiliation(s)
- Jung Hwan Lee
- Namdarun Rehabilitation Clinic, Yongin-City, Gyeonggi-Do, South Korea
| | - Jun Ho Lee
- Department of Neurosurgery, Kyung Hee University Medical Center, Seoul, 02447, South Korea
| | - Min Cheol Chang
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Daegu, 705-717, Republic of Korea
- Correspondence: Min Cheol Chang, Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, 317-1, Daemyungdong, Namku, Daegu, 705-717, Republic of Korea, Tel +82-53-620-4862, Email
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Clinical Efficacy of Epidural Injections of Local Anesthetic Alone or Combined with Steroid for Neck Pain: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2022; 2022:8952220. [PMID: 35663039 PMCID: PMC9162875 DOI: 10.1155/2022/8952220] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/09/2022] [Indexed: 11/17/2022]
Abstract
Aims To compare the effectiveness of cervical epidural injections of local anesthetic with vs. without a steroid. Methods Three databases (PubMed, Embase, and Cochrane library) were used to search and assess all clinical randomized controlled trials regarding the clinical efficacy of epidural injections from January 01, 2009, to October 31, 2020. Cochrane review criteria and the Interventional Pain Management Techniques-Quality Appraisal of Reliability and Risk of Bias Assessment instrument were used to evaluate the methodologic quality of the included studies. Qualitative and quantitative analyses were performed according to best evidence synthesis principles and by single-arm meta-analysis, respectively. Results Based on the search criteria, 4 RCTs were qualitatively and quantitatively analyzed in the single-arm meta-analysis. Treatment with lidocaine alone or with the steroid resulted in decreases of 4.46 and 4.29 points, respectively, in pain scores and of 15.8 and 14.46 points, respectively, in functional scores at 6 months. Similar trends were observed at the 1-year follow-up: pain scores decreased by 4.27 and 4.14 points, while functional scores decreased by 15.94 and 14.44 points in patients with neck pain who received lidocaine without or with the steroid, respectively. In the 3 studies that reported 2-year follow-up data, patients with neck pain treated with lidocaine or lidocaine + steroid showed 4.2- and 4.14-point decreases, in pain score and 15.92- and 14.89-point decreases, respectively, in functional scores. Conclusions The studies showed level I (strong) evidence for short- and long-term improvements in pain relief and functionality with cervical epidural injections of local anesthetic alone or with a steroid in the management of neck pain.
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Wang Y, Zhu Y, Wang W, Shi Y, Yang J. New Simple Ultrasound-Guided Transforaminal Injection in Patients With Radiculopathy in the Lower Cervical Spine: A Computed Tomography-Controlled Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:1401-1409. [PMID: 33026685 DOI: 10.1002/jum.15523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/09/2020] [Accepted: 08/29/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To evaluate the feasibility of a new simple ultrasound-guided transforaminal injection in patients with cervical radiculopathy. METHODS Ultrasound scans of the neck in a plastic model and in 5 unaffected participants were first performed to identify the intervertebral foramen. Then ultrasound-guided transforaminal injections were performed in 20 patients with radiculopathy in the lower cervical spine, and computed tomography was used to verify the accuracy. Complications, the visual analog score, and the neck disability index were assessed at 1 and 3 months after the injection. RESULTS Computed tomography confirmed that the needle tip was correctly placed in the intervertebral foramen in 88.5% (23 of 26) of injections. No immediate or short-term complications were observed in all patients. The visual analog score and neck disability index at 1 and 3 months were significantly lower than those before the injection (both P < .0001). CONCLUSIONS Ultrasound may be a feasible and accurate method to guide cervical transforaminal injection.
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Affiliation(s)
- Yuexiang Wang
- Departments of Ultrasound, the first center of Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Yaqiong Zhu
- Departments of Ultrasound, the first center of Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Wei Wang
- Departments Orthopedics, the first center of Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Yizheng Shi
- Anesthesia Operation Center, the first center of Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Jing Yang
- Pain Department, the first center of Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
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Nowicki KW, Gale JR, Agarwal V, Monaco EA. Pneumomyelia Secondary to Interlaminar Cervical Epidural Injection Causing Acute Cord Injury with Transient Quadriparesis. World Neurosurg 2020; 143:434-439. [PMID: 32822950 DOI: 10.1016/j.wneu.2020.08.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 10/23/2022]
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McCormick ZL, Conger A, Sperry BP, Teramoto M, Petersen R, Salazar F, Cunningham S, Michael Henrie A, Bisson E, Kendall R. A Randomized Comparative Trial of Targeted Steroid Injection via Epidural Catheter vs Standard Transforaminal Epidural Injection for the Treatment of Unilateral Cervical Radicular Pain: Six-Month Results. PAIN MEDICINE 2020; 21:2077-2089. [DOI: 10.1093/pm/pnaa242] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Abstract
Objectives
Compare the effectiveness of catheter-directed cervical interlaminar epidural steroid injection (C-CIESI) with triamcinolone to cervical transforaminal steroid injection (CTFESI) with dexamethasone for the treatment of refractory unilateral radicular pain.
Design
Prospective, randomized, comparative trial.
Methods
Primary outcome: proportion of participants with ≥50% numeric rating scale pain score reduction from baseline “dominant pain” (the greater of arm vs neck) at one month postinjection. Secondary outcomes: ≥30% Neck Disability Index (NDI-5) reduction and Patient Global Impression of Change (PGIC) response indicating “much improved” or “very much improved.”
Results
One hundred twenty participants (55.6% females, 52.3 ± 12.5 years of age, BMI 28.2 ± 6.5 kg/m2), were enrolled. The proportions of participants who experienced ≥50% pain reduction at one, three, and six months were 68.5% (95% CI = 54.9–79.5%), 59.3% (95% CI = 45.7–71.6%), and 60.8% (95% CI = 46.7–73.2%), respectively, in the C-CIESI group compared with 49.1% (95% CI = 36.4–62.0%), 46.4% (95% CI = 33.8–59.6%), and 51.9% (95% CI = 38.4–65.2%), respectively, in the CTFESI group. The between-group difference at one month was significant (P = 0.038). The proportions of participants who experienced a ≥30% NDI-5 score improvement were 64.0% (95% CI = 49.8–76.1%) and 54.9% (95% CI = 41.1–68.0%) in the C-CIESI and CTFESI groups (P = 0.352). Participants reported similar PGIC improvement in both groups: At six months, 53.2% (95% CI 38.9–67.1%) and 54.5% (95% CI = 39.7–68.7%) of the C-CIESI and CTFESI groups reported being “much improved” or “very much improved,” respectively (P = 0.897).
Conclusions
Both C-CIESI with triamcinolone and CTFESI with dexamethasone are effective in reducing pain and disability associated with refractory unilateral cervical radiculopathy in a substantial proportion of participants for at least six months.
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Affiliation(s)
- Zachary L McCormick
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Aaron Conger
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Beau P Sperry
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Masaru Teramoto
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | | | - Fabio Salazar
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Shellie Cunningham
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - A Michael Henrie
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
| | - Erica Bisson
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Richard Kendall
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah
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Segmental Spinal Myoclonus After a Cervical Transforaminal Epidural Steroid Injection. Am J Phys Med Rehabil 2020; 99:e128-e130. [PMID: 32149815 DOI: 10.1097/phm.0000000000001414] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In clinical practice, cervical transforaminal epidural steroid injection is commonly used for alleviating pain. We report a case of segmental spinal myoclonus that developed after cervical transforaminal local anesthetic and steroid injection. A 39-yr-old man presented involuntary movements of the bilateral upper trapezius muscles after cervical transforaminal epidural steroid injection on the right C6 and C7 roots with a 5 mg of dexamethasone injectate mixed with 0.5 ml of 1% lidocaine and 0.5 ml of normal saline at each level. His myoclonus was semirhythmic and continuously persisted at a frequency of approximately 30 episodes per minute. The myoclonus continued even at rest and during sleep. In addition, it was resistive to stimulus, such as touch and voluntary action. Based on the clinical features, the patient was diagnosed as having a segmental spinal myoclonus. Clonazepam 0.25 mg was administered three times daily. The myoclonus gradually improved and resolved completely within 2 wks. Segmental spinal myoclonus is one of rare complications after cervical transforaminal epidural steroid injection. Clinicians should be aware of the likelihood of this potential complication.
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Hashemi M, Dadkhah P, Taheri M, Ghasemi M, Hosseinpour A, Farjam M. Patient-Reported Outcomes and Satisfaction after Cervical Epidural Steroid Injection for Cervical Radiculopathy. Galen Med J 2019; 8:e1478. [PMID: 34466515 PMCID: PMC8343784 DOI: 10.31661/gmj.v8i0.1478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/10/2019] [Accepted: 03/15/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Cervical radiculopathy caused by disc herniation is a frequent public health issue with economical and socio-professional impacts. The objective of the present study is to evaluate the patient-reported outcomes and satisfaction from cervical epidural steroid injection during a 2-year follow-up. MATERIALS AND METHODS Results based on patients' reports from a previously performed intervention of cervical epidural steroid injection on patients with cervical radiculopathy due to cervical disc herniation are prospectively collected. Outcome measures are Neck Disability Index (NDI), numerical rating scale (NRS) for pain assessment, and 5-scale patient satisfaction questionnaire (PSQ) plus opioid medication for pain relief, additional injections, and progression to surgery. RESULTS Of total 37 cases, 34 were available for follow-up after 2-year postoperatively. The mean preoperative NDI was 21.17 and improved to 17.38, and the mean NRS was 7.7 and improved to 5.00; both were statistically significant. Mean patient satisfaction after 2 years was 3.17 out of 5. 11 cases needed additional injections, and 4 of patients proceeded to surgery. CONCLUSION We showed that transforaminal cervical epidural steroid injection for cervical radiculopathy is an effective non-surgical treatment option, providing significant pain relief and functional improvement during 2-years follow-up along with higher-than-average patient satisfaction in most of our patients.
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Affiliation(s)
- Masoud Hashemi
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Payman Dadkhah
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrdad Taheri
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahshid Ghasemi
- Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Hosseinpour
- Non-Communicable Disease Research Center, Fasa University of Medical Sciences, Fasa, Fars, Iran
| | - Mojtaba Farjam
- Non-Communicable Disease Research Center, Fasa University of Medical Sciences, Fasa, Fars, Iran
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Kim EJ, Chotai S, Schneider BJ, Sivaganesan A, McGirt MJ, Devin CJ. Effect of Depression on Patient-Reported Outcomes Following Cervical Epidural Steroid Injection for Degenerative Spine Disease. PAIN MEDICINE 2019; 19:2371-2376. [PMID: 30357417 DOI: 10.1093/pm/pny196] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Objective To assess the effect depression has on outcomes after cervical epidural steroid injections (CESIs). Design Retrospective review of a prospectively collected database. Setting Single institution tertiary care center. Subjects Fifty-seven patients with cervical spondylosis and cervical radicular pain who were deemed appropriate surgical candidates but elected to undergo CESI first were included. Methods Twenty-one of 57 (37%) patients with depression (defined as Zung Depression Scale >33) were included. Patient-reported outcomes including Neck Disability Index (NDI), numeric rating scale (NRS) for arm pain (AP), NRS for neck pain (NP), and EuroQol-5D (EQ-5D) were collected at baseline and three-month follow-up. Minimal clinically important differences were then calculated to provide dichotomous outcome measures of success. Results Overall, 24 and 28 patients achieved at least 50% improvement in AP and NP, respectively. In terms of disability, 25/57 (43.9%) patients achieved >13.2-point improvement on the NDI overall. In patients with depression, 4/21 (19.0%) and 5/21 (23.8%) achieved at least 50% improvement on the NRS for AP and NP, respectively, compared with 20/36 (55.5%) and 23/36 (63.8%) in patients without depression. This difference was statistically significant for both pain measures (P < 0.002 AP, P < 0.006 NP). Statistically fewer patients, 5/21 (24%), with depression achieved ≥13.2-point improvement on the NDI compared with 20/36 (55%) nondepressed patients (P < 0.01). There was no difference in outcomes between groups on the EQ-5D. Conclusions Patients with cervical spondylosis and comorbid depression who undergo CESI are less likely to achieve successful outcomes in both pain and function compared with nondepressed patients at three months.
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Affiliation(s)
- Elliott J Kim
- Departments of Orthopaedic Surgery.,Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Silky Chotai
- Departments of Orthopaedic Surgery.,Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Byron J Schneider
- Departments of Orthopaedic Surgery.,Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ahilan Sivaganesan
- Departments of Orthopaedic Surgery.,Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew J McGirt
- Department of Neurological Surgery, Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA
| | - Clint J Devin
- Departments of Orthopaedic Surgery.,Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Altafulla J, Yilmaz E, Lachkar S, Iwanaga J, Peacock J, Litvack Z, Tubbs RS. Neck movement during cervical transforaminal epidural injections and the position of the vertebral artery: an anatomical study. Acta Radiol Open 2019; 8:2058460119834688. [PMID: 30886742 PMCID: PMC6415478 DOI: 10.1177/2058460119834688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/09/2019] [Indexed: 11/15/2022] Open
Abstract
BackgroundCervical transforaminal epidural steroid injections (CTFESIs) are sometimes performed in patients with cervical radiculopathy secondary to nerve-root compression. Neck movements for patient positioning may include rotation, flexion, and extension. As physicians performing such procedures do not move the neck for fear of injuring the vertebral artery, we performed fluoroscopy and cadaveric dissection to analyze any movement of the vertebral artery during head movement and its relation to the foramina in the setting of CTFESI.PurposeTo determine cervical rotational positioning for optimized vertebral artery location in the setting of cervical transforaminal epidural steroid injections.Material and MethodsFour sides from two Caucasian whole cadavers (all fresh-frozen) were used. Using a guide wire and digital subtraction fluoroscopy, we evaluated the vertebral artery mimicking a CTFESI, then we removed the transverse processes and evaluated the vertebral artery by direct observation.ResultsAfter performing such maneuvers, no displacement of the vertebral artery was seen throughout its course from the C6 to the C2 intervertebral foramina. To our knowledge, this is the first anatomical observation of its kind that evaluates the position of the vertebral artery inside the foramina during movement of the neck.ConclusionSpecial caution should be given to the medial border of the intervertebral foramina when adjusting the target site and needle penetration for the injection. This is especially true for C6-C4 levels, whereas for the remaining upper vertebrae, the attention should be focused on the anterior aspect of the foramen. Since our study was centered on the vertebral artery, we do not discard the need for contrast injection and real-time digital subtraction fluoroscopy while performing the transforaminal epidural injection in order to prevent other vascular injuries.
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Affiliation(s)
- Juan Altafulla
- Seattle Science Foundation, Seattle, WA, USA
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
- Juan Altafulla, Seattle Science Foundation, 550 17th Avenue, Seattle, WA 98122, USA.
| | - Emre Yilmaz
- Seattle Science Foundation, Seattle, WA, USA
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
| | | | - Joe Iwanaga
- Seattle Science Foundation, Seattle, WA, USA
| | - Jacob Peacock
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
| | - Zachary Litvack
- Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
| | - R Shane Tubbs
- Seattle Science Foundation, Seattle, WA, USA
- Department of Anatomical Sciences, St. George’s University, St. George’s, Grenada
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Choi J, Ha DH, Kwon S, Jung Y, Yu J, Kim M, Min K. Needle Entry Angle to Prevent Carotid Sheath Injury for Fluoroscopy-Guided Cervical Transforaminal Epidural Steroid Injection. Ann Rehabil Med 2018; 42:814-821. [PMID: 30613074 PMCID: PMC6325316 DOI: 10.5535/arm.2018.42.6.814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 07/26/2018] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To suggest rotation angles of fluoroscopy that can bypass the carotid sheath according to vertebral levels for cervical transforaminal epidural steroid injection (TFESI). METHODS Patients who underwent cervical spine magnetic resonance imaging (MRI) from January 2009 to October 2017 were analyzed. In axial sections of cervical spine MRI, three angles to the vertical line (α, angle not to insult carotid sheath; β, angle for the conventional TFESI; γ, angle not to penetrate carotid artery) were measured. RESULTS Alpha (α) angles tended to increase for upper cervical levels (53.3° in C6-7, 65.2° in C5-6, 75.3° in C4-5, 82.3° in C3-4). Beta (β) angles for conventional TFESI showed a constant value of 45° to 47° (47.5° in C6-7, 47.4° in C5-6, 45.7° in C4-5, 45.0° in C3-4). Gamma (γ) angles increased at higher cervical levels as did α angles (25.2° in C6-7, 33.6° in C5-6, 43.0° in C4-5, 56.2° in C3-4). CONCLUSION The risk of causing injury by penetrating major vessels in the carotid sheath tends to increase at upper cervical levels. Therefore, prior to cervical TFESI, measuring the angle is necessary to avoid carotid vessels in the axial section of CT or MRI, thus contributing to a safer procedure.
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Affiliation(s)
- Jaewoo Choi
- Department of Rehabilitation Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Doo Hoe Ha
- Department of Radiology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Shinyoung Kwon
- Department of Rehabilitation Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Youngsu Jung
- Department of Rehabilitation Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Junghoon Yu
- Department of Rehabilitation Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - MinYoung Kim
- Department of Rehabilitation Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Kyunghoon Min
- Department of Rehabilitation Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
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Abstract
RATIONALE Despite undergoing transforaminal epidural steroid injection (TFESI), many patients complain of persisting cervical radicular pain. For the management of chronic cervical radicular pain, clinicians are widely applying pulsed radiofrequency (PRF) stimulation to dorsal root ganglions (DRGs). To enhance the effect of PRF stimulation, we conducted bipolar PRF stimulation in 2 patients with chronic cervical radicular pain that was refractory to monopolar PRF and repeated TFESIs. PATIENT CONCERNS Patients 1 and 2 presented with a numeric rating scale (NRS) score of 7 and 6 for chronic cervical radicular pain, respectively, despite undergoing monopolar PRF and 2 TFESIs. DIAGNOSES On cervical magnetic resonance imaging, foraminal stenosis at the right C6-7 and right central to right foraminal disc protrusion on C6-7 were observed in patients 1 and 2, respectively. Two patients showed a positive response on diagnostic right C7 selective nerve root block with 0.5 mL of 1% lidocaine. INTERVENTIONS Bipolar PRF stimulation was performed under C-arm fluoroscopy. Two parallel RF cannulas (less than 1 cm apart) were used for DRG stimulation. The PRF treatment was administered at 5 Hz and a 5-ms pulsed width for 360 seconds at 45 V with the constraint that the electrode tip temperature did not exceed 42°C. OUTCOMES At the 2-week and 1-month follow-up, after undergoing bipolar PRF, the pain of patient 1 was completely relieved, and at 2, 3, and 6 months, the pain was scored as NRS 2. In patient 2, at the 2-week follow-up after undergoing bipolar PRF, pain severity was reduced from NRS 6 to 2. The effect of bipolar PRF on patient 2 lasted for at least 6 months. No adverse effects were observed in either patient. LESSONS Application of bipolar PRF to DRGs seems to be an effective and safe technique for treating refractory chronic cervical radicular pain.
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Lee JH, Lee SH. Can repeat injection provide clinical benefit in patients with cervical disc herniation and stenosis when the first epidural injection results only in partial response? Medicine (Baltimore) 2016; 95:e4131. [PMID: 27442637 PMCID: PMC5265754 DOI: 10.1097/md.0000000000004131] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Epidural steroid injection (ESI) is known to be an effective treatment for neck or radicular pain due to herniated intervertebral disc (HIVD) and spinal stenosis (SS). Although repeat ESI has generally been indicated to provide more pain relief in partial responders after single ESI, there has been little evidence supporting the usefulness of this procedure. The purpose of this study, therefore, was to determine whether repeat ESI at a prescribed interval of 2 to 3 weeks after the first injection would provide greater clinical benefit in patients with partial pain reduction than intermittent ESI performed only when pain was aggravated. One hundred eighty-four patients who underwent transforaminal ESI (TFESI) for treatment of axial neck and radicular arm pain due to HIVD or SS and could be followed up for 1 year were enrolled. We divided the patients into 2 groups. Group A (N = 108) comprised partial responders (numeric rating scale (NRS) ≥ 3 after the first injection) who underwent repeat injection at a prescribed interval of 2 to 3 weeks after the first injection. Group B (N = 76) comprised partial responders who did not receive repeat injection at the prescribed interval, but received intermittent injections only for aggravation of pain. Various clinical data were assessed, including total number of injections during 1 year, NRS duration of <3 during 1 year (NRS < 3 duration), and time interval until pain was increased to require additional injections after repeat injection in Group A, or after first injection in Group B (time to reinjection). Groups A and B were compared in terms of total population, HIVD, and SS. In the whole population, HIVD subgroup, and SS subgroup, patients in Group A required significantly fewer injections to obtain satisfactory pain relief during the 1-year follow-up period. Group A showed a significantly longer time to reinjection and longer NRS < 3 than Group B did. Repeat TFESI conducted at 2- to 3-week intervals after the first injection in partial responders contributed to greater clinical benefit compared with intermittent TFESI performed only upon pain aggravation, with fewer TFESI sessions.
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Affiliation(s)
- Jung Hwan Lee
- Department of Physical Medicine and Rehabilitation
- Correspondence: Jung Hwan Lee, Department of Physical Medicine and Rehabilitation, Wooridul Spine Hospital, 46-17 Chungdam-Dong, Gangnam-Gu, Seoul, Korea (e-mail: )
| | - Sang-Ho Lee
- Department of Neurosurgery, Wooridul Spine Hospital, Seoul, Korea
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