Cervical spine ligamentum flavum gaps: MR characterisation and implications for interlaminar epidural injection therapy

Safety of cervical transforaminal epidural steroid injections

Background

In 2014 the FDA issued a drug safety warning that steroids in the epidural space may result in rare but serious neurological adverse events. The FDA identified 131 cases of neurological adverse events and most complications were related to cervical transforaminal epidural injections (TFESIs). These complications occurred before the standard use of non-particulate steroids. Many still consider cervical TFSEIs to be unsafe.

Objectives

The objective of this study was to evaluate the safety of cervical TFESIs with non-particulate steroids.

Methods

A review was done of all cervical TFESIs from 2004 to 2021 at an academic institution when non-particulate steroids became more commonly used by reviewing CPT code 64479 linked to the performing physician. All treating physicians and department directors were queried about catastrophic complications (stroke, spinal cord injury, death or other). A secondary analysis was done on 200 consecutive cervical TFESIs looking at immediate and delayed side-effects documented by the nurse in recovery, day-after phone calls and clinic follow-up notes.

Results

From 2004 to 2021 the CPT code 64479 was used 6967 times, with 6241 cervical TFESIs and 726 thoracic TFESIs. No catastrophic complications occurred. In the subset analysis of 200 consecutive cervical TFESIs, 7 patients (3.5 %, 95 % CI 1.0-6.0) had a transient increase in pain, 18 (9 %, 95 % CI 5.0-13.0) had no change in pain and 171 (85.5 %, 95 % CI 80.6-90.4) had a decrease in pain. The average pain score among all participants dropped 3.7 (95 % 3.0-4.4) points. A 2-point drop was seen in 75.5 % (95 % CI 69.5-81.5) and a 3-point drop was seen in 62.5 % (95 % CI 59.1-65.9). Five of the seven patients with transient increased pain had an increase of ≥ 3 points on numerical rating scale. There was one of each of the following reported: insomnia, glucose >500, transient thumb numbness with pain, and hypertension. Two cases of headaches were reported.

Conclusion

This study supports the safety of cervical TFESIs with non-particulate steroids as recommended by consensus opinions from medical societies.

The Anatomy, Technique, Safety, and Efficacy of Image-Guided Epidural Access

Epidural steroid injections have demonstrable efficacy and safety in treatment of radicular pain syndromes; transforaminal access has greater evidence of efficacy than interlaminar approaches. The interventionalist must understand epidural and foraminal anatomy and imaging to insure delivery of medication to the target, the ventral epidural space at the site of neural compression. This obligates pre-procedural planning. When performed with appropriate risk mitigation strategies, epidural injections by either access are safe. For transforaminal access, the use of dexamethasone as the injectate, and infraneural approaches, provides safety advantages.

2. Cervical radicular pain

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.].

American Society of Regional Anesthesia and Pain Medicine contrast shortage position statement

The medical field has been experiencing numerous drug shortages in recent years. The most recent shortage to impact the field of interventional pain medicine is that of iodinated contrast medium. Pain physicians must adapt to these changes while maintaining quality of care. This position statement offers guidance on adapting to the shortage.