A cervical epidural injection is a safe and effective minimally invasive treatment for neck pain. This type of spinal injection made in the neck region serves two purposes:
(1) it reduces nerve inflammation, calms symptoms, aids healing
(2) it provides important diagnostic information.
The procedure involves injecting a corticosteroid into the epidural space. A corticosteroid is a powerful, slow-releasing, and long-lasting anti-inflammatory medication effective in reducing inflammation. Sometimes a narcotic is also injected to increase pain relief. The epidural space is between the protective membrane (dura mater) covering the spinal cord and the bony spinal canal. After the medication is injected, it flows and coats the nerve roots.
Diagnostically, when the patient’s symptoms are relieved, the injection provides evidence that a particular nerve root is a pain generator.
There are many spinal problems that can cause nerve irritation in the neck. As depicted in the illustration, a herniated disc or bone spurs (osteophytes) can compress fragile spinal nerve roots.
In the cervical spine (the spine around the neck region) there are eight pairs of spinal nerves. Each pair of nerves provides sensation and function to parts of the body. Just as the levels of the cervical spine are abbreviated, the spinal nerve pairs are numbered in a corresponding way. C1 is the area between the skull and first cervical vertebra (also abbreviated C1). C8 exits the spinal canal between the last cervical vertebra (C7) and the first thoracic vertebra (T1).
Each pair of nerve roots exit the spinal column and branch out into the body forming the peripheral (outer) nervous system. These nerves innervate the upper part of the body and enable movement (motor function) and feeling (sensory function). The illustration depicts this pattern called dermatomes. The physician can use the dermatomal pattern to help diagnose the location of spinal problem based on where the patient reports pain or weakness.
Based on symptoms, medical history, physical and neurological examination, and imaging study findings (x-ray, MRI), the physician determines which spinal nerve root(s) may be generating pain and other symptoms.
In advance of the procedure, patients will be asked which medications they take. Certain drugs must be stopped several days before the procedure. In some cases, the physician may ask the patient to cease taking pain and anti-inflammatory medications in order to see how much pain relief can be attributed specifically to the epidural injection.Possible Risks and Complications
Any medical procedure carries with it some inherent risk. Rare but serious complications include bleeding, infection, nerve injury, headache, and allergic reaction to medication. Other risks include an increase in pain, injection site tenderness, and steroid side effects. The physician discusses the risks and benefits of this procedure with the patient.What to Expect: The Procedure and After
The procedure is performed in an operating room, but the patient is awake. The patient, in a hospital gown, is given an intravenous line through which medications are given to keep the patient calm. During the procedure, the patient may be asked questions by the doctor to help guide the procedure. The patient is typically seated in a chair or positioned in a bed in such a way that gives the physician good access to the back of the neck. Next, the skin area is cleaned with a sterile soap. A local anesthetic is injected and given time to numb your skin and spine muscles.
The C-arm of the fluoroscope (named for its characteristic C-shape) is positioned over the patient. A fluoroscope is a type of video x-ray that projects images of the patient’s spine on monitors in the procedure room. The physician uses fluoroscopy as he injects the needle into the neck and injects a small amount of contrast (dye). This dye is injected to confirm that the needle is in the right area. Next, an anesthetic and corticosteroid is injected into the epidural space. Sometimes, pain is temporarily increased during the injection. The patient may be asked about pain. When the injection is complete, a small bandage covers the injection site.
Cervical epidural injections may require one or more injections. The entire procedure lasts about 15-minutes but may take longer if several injections are required. When it is over, the patient is moved to a recovered area and is monitored by a nurse. Upon discharge, the patient is given written instructions for home care.
Some patients experience discomfort after the procedure for two or three days. This is normal and does not necessarily mean the corticosteroid is not taking effect.
The physician’s office typically contacts the patient the day after the procedure for follow up. Patients may be asked to record their pain levels and other symptoms following the procedure because such a pain diary can assist the physician fine-tune future pain treatments.
Cervical epidural injections have provided significant pain relief to many people with moderate to severe chronic neck pain. However, epidural injections are not appropriate for all patients.
A cervical interlaminar epidural steroid injection is a simple procedure for treating neck, upper back, shoulder, and arm pain.
The dura is a protective covering of the spinal cord and its nerves. The space surrounding the dura is called the epidural space. In the neck it is called the cervical epidural space.
The cervical area of the spine has seven bones, called the vertebrae. Soft discs found between these vertebrae cushion them, hold them together, and control motion. If a disc tears, chemicals inside may leak out. This can inflame nerve roots or the dura, and cause pain. A large disc tear may cause a disc to bulge, inflaming the nerve roots or the dura and cause pain. Bone spurs called osteophytes, can also press against nerve roots and cause pain.
If you have pain in your neck or upper back when you move your head, you may have cervical disc and dural inflammation. If paint travels to your arm when you move your head, you may have nerve root inflammation. Common tests such as MRIs can show disc bulges and nerve root compression, But may not show a torn or leaking disc. A cervical epidural injection can help to determine if disc problems, dural, or nerve root inflammation are causing your pain.
During a cervical epidural steroid injection, an anesthetic and a steroid are injected into the epidural space to reduce inflammation. The easiest way is from the back of the spine. This is called an interlaminar injection.
The doctor who will perform the injection will review your medical records and imaging studies to plan for the best location for these injections. Patients who are taking aspirin or blood thinners may need to stop taking the several days before epidural steroid injection, doctor will provide specific instructions. Discuss any medications with your doctors, including the one who prescribed them and the doctor who will perform the injection. The injection is usually performed in an outpatient procedures suite that has access to fluoroscopy. You will need make arrangements to have someone drive you to and from the office or outpatient center the day of the injection.
Before your injection, you will be asked to sign consent forms, list medications you are taking, and list any allergies to medications. Procedure may last 15-30 minutes followed by a recovery period. Patients remain awake for these procedures. Sedatives can be given to help lessen anxiety. The patient will be lying face down on the table, will receive a local anesthetic, which will numb the skin before the injection is given. If IV sedation is used, your blood pressure, heart rate and breathing will be monitored during the procedure. With the aid of a fluoroscope (a special X-ray), the doctor will direct a hollow needle through the skin and muscles of your neck into the cervical epidural space. Fluoroscopy allows the doctor to watch the needle in real-time on the fluoroscope monitor to make sure that the needle goes into correct location. Contrast agent is injected into the epidural space to confirm correct needle position and desired medication spread. Some discomfort may occur, but patients typically feel more pressure than pain. After the needles are confirmed to be in correct position, the doctor will inject long acting corticosteroid medication into your cervical epidural space. The needle is then removed.
Most patients can walk immediately after the procedure. After being monitored for a short time, you can usually leave the office or suite. Someone must drive you home. Typically patients will resume full activity the next day. If soreness around the injection site is present the following day, it may be relieved by using ice and taking mild pain medications such as Tylenol. The doctor’s office may want to follow up with you 7 to 14 days after the procedure to assess you response to this injection. You may be provided a diary to record you response to this procedure. You may notice a slight increase in pain after the numbing medicine wears off and before the corticosteroid medication starts to take effect. If discs are the source of pain, you may begin to notice pain improvement in two to five days after the injection. If after three injections you experience no or a little pain relief, then it is unlikely that you will benefit from more injections. Additional diagnostic tests may be needed to accurately diagnose your pain.
The potential risks associated with inserting the needle include bleeding, infection, allergic reaction, headache, and nerve damage (rare), corticosteroid medication induced side effects such as weight gain, water retention, flushing (hot flashes), mood swings or insomnia, and elevated blood sugar levels in diabetics. These usually resolve within 3 days. Patients who are being treated for chronic conditions (e.g. heart disease, diabetes, rheumatoid arthritis, or those who cannot temporarily discontinue anti-clotting medication) should consult their personal physician for a risk assessment. With few risks, epidural steriod injections are considered an appropriate nonsurgical treatment for some patients.
The length of time that you can expect pain relief depends on the amount of inflammation you have. Sometimes an injection can bring several months of pain relief, and then further treatment is needed. Other times, a single injection can bring long-term pain relief. If your pain is caused by injury to more than one area, only some of your symptoms will be helped by a single injection.