The neck pain started out as a dull ache but steadily progressed. It becomes constant and often times keeps you up at night. Turning your head can send an electrical current down your arm. Rest, medications and physical therapy failed to provide much relief. Your doctor referred you to a pain clinic for a Cervical Epidural steroid injection. The injection was performed at an ambulatory surgical center. Unfortunately, the pain is now worse. What is a Cervical Epidural injection? Are there different types of Cervical Epidural injections? What are the indications for a Cervical Epidural steroid injection? What is injected during a Cervical Epidural steroid injection? What are the 5 major reasons for increased pain after a Cervical Epidural steroid injection? How to avoid increased pain after Cervical Epidural steroid injection? Let’s dig in.
What Is a Cervical Epidural Injection?
An Epidural steroid injection is a medical procedure in which steroids and a local anesthetic are injected into the epidural space. The goal of the injection is to provide pain relief and reduce inflammation. Most individuals are familiar with labor Epidirual injections which are used to ease the discomfort associated with childbirth. A labor Epidural is performed in the low back. In contrast, a Cervical Epidural is performed in the neck for a number of pain conditions.
What is the Epidural space? It is potential space between the dura and the spinal ligaments. The Dura is a thick connective tissue that surrounds the brain and spinal cord. The Epdirual space contains fat, veins, arteries, spinal nerve roots, and lymphatics. It starts at the base of the skull and extends down to the tailbone.
Confused? Think of the bicycle tire tube that you purchase from the store. It comes tightly folded in a box. There is no air in the tube when you purchase it. The space within the tube is a potential space as it easily expands when you inflate it with a pump. So too with the Epidural space. It fills up with medicine when a needle is accurately placed into it.
Are There Different Types of Cervical Epidural Injections?
There are two different types of Cervical Epidurals: Interlaminar vs Transforaminal. The differences are based upon their approach to the cervical spine.
An Interlaminar Epidural is performed on the backside of the spine. Patients are typically lying face down on a procedure table. The injection is best performed with x-ray guidance and contrast. The Lamina is a thin bone on the backside of the vertebrae. It provides important protection to the fragile spinal cord. An Interlaminar Epidural injection is the injection of medicine into the epidural space by directing a needle between the Lamina of two adjacent vertebrae bodies.
A Transforaminal Cervical Epidural injection is a much different procedure as it is performed on the front portion of the neck. The Foramen is the boney doorway through which the spinal nerve exits. There are right and left Foramen at each level of the spine. For example, at the C5/6 level, the C6 nerve exits through the Foramen and travels down the neck into the shoulder and upper arm providing important information. The prefix “Trans” means around. Hence a Transforaminal Cervical Epidural injection is an injection of medicine into the epidural space and nerve by placing a needle near the targeted Foramen and exiting nerve.
What Are the Indications for a Cervical Epidural?
There are a number of indications for Cervical Epidural steroid injections (1). This is not a first-line treatment and should only be performed if symptoms have not responded to conservative care. Common indications include:
- Cervical Degenerative Disc Disease
- Cervical Disc Herniation
- Radiating arm down arm (Cervical Radiculopathy)
- Cervical headaches
- Post neck surgery pain
- Mild Cervical Stenosis (narrowing)
- Mild Scoliosis causing nerve root irritaion or compression
What Is Injected During a Cervical Epidural Steroid Injection?
Local anesthetic and steroids are injected during a Cervical Epidural steroid injection. Steroids are powerful anti-inflammatory agents that can reduce pain and swelling. They also have significant negative side effects which include damaging cartilage, increase risk of infection after knee surgery (2), increased risk of infection, delayed healing, compromises glucose balance and increase risk for bone fracture.
There are many different types of steroids used. Common names include Hydrocortisone, Betamethasone, Dexamethason and Methylprednisolone.
5 Major Reasons for Increased Pain After Cervical Epidural Steroid Injection
Nerve Irritation
The epidural space has spinal nerve roots. If the Cervical Epidural injection if performed incorrectly an exiting nerve root can be irritated or injured leading to an increase in pain (3). The pain can be severe with lancinating pain radiating down the arm.
Vascular Injection
The epidural space has both veins and arteries both of which can be injected. This is NOT the desired outcome but rather is a complication that can lead to significant complications including stroke and pain. Inadvertent injection into the Radicular artery is a documented complication of Cervical Epidural steroid injections (4).
Severe Underlying Condition
The underlying condition may be so severe that a single Cervical Epidural may not be sufficient to treat the pain and dysfunction. It is for this reason that some providers recommend second Cervical steroid injection if the first procedure failed to provide significant or sustained relief. Not all cervical conditions can be successfully treated with a Cervical steroid injection
Dural Puncture
The Dura is one of the protective layers around the spinal cord. If the epidural is not performed correctly the Dura can be punctured leading to severe and positional headaches. This is often referred to as a Dural leak and can be treated with another epidural that contains blood. The latter is oftentimes referred to as a blood patch. The goal is to patch the hole in the Dura and in so doing stop the spinal fluid leak and symptoms.
Failed Injection
Simply put not all injections are performed correctly. Yes I know it is hard to believe but it absolutely true. Some Cervical Epidural injections are not successfully placed into the epidural space The consequence is that the injected medicines does not get to its intended target and therefore are not able to treat the underlying condition. For patients, this often times means increased pain after Cervical Epidural steroid injection. Why? There is trauma to the skin and underlying tissue by the needles used when performing a Cervical Epidural.
If the steroid did not get into the epidural space where did it go? In most cases, the steroid is incorrectly injected into the neck muscles or ligaments. Steroids injected into muscles and ligaments can cause significant pain, swelling and can weaken the ligament strength.
How to Avoid Increased Pain After Cervical Epidural Steroid Injection
Pain can be debilitating keeping us sidelined from our passions. Nobody wants their pain to escalate. Four ways to avoid increase pain after steroid injection include
Experience and Board Certification
Experience, education, and training are critical. Your best option is a board-certified physician whose exclusive focus is pain management and advanced pain procedures. You do not want someone who performs Botox on Tuesdays, ascetic fillers on Wednesday, and pain injections on Thursday. Check reviews and DORA (Department of Regulatory Agencies).
Correct Diagnosis
Not all neck conditions can be successfully treated with a Cervical Epidural injection. Neck pain is not a diagnosis but rather is a symptom. Ensure that you have the correct diagnosis. Know what is causing your ongoing neck symptoms and whether a Cervical Epidural steroid injection is appropriate. Ask which type of Cervical Epidural steroid is best for your condition.
Proper Guidance
Cervical Epidural steroid injections should always be performed under x-ray guidance. Why? To ensure that the needle is accurately placed into the correct place. Incorrect placement can result in nerve irritation or injury, puncture of the dura, injection into a blood vessel, or damage to the muscles and ligaments. Blind injections, those injections performed without x-ray guidance are below the standard of care. Never agree to Cervical Epidural injection without an x-ray! Ultrasound is a powerful imaging tool for tendon, ligament, and peripheral joints injections. Ultrasound is not an appropriate imaging option for Cervical Epidural steroids as it can not confirm the accurate placement of the needle into the epidural space.
Use of Constrast
Contrast is a dye that is used during x-ray guided injections. It is essential. The injected contrast outlines the targeted nerves and Epidural space confirming that the medicine to be injected will get to its intended target. Without the use of contrast during an x-ray guided procedure there is no way to know if the targeted structures were injected. Often times the medicine is injected into the muscle, subcutaneous fat, or ligaments which in addition to providing no therapeutic benefit can cause an increase the pain after the Cervical Epidural steroid injection. A recent study demonstrated that greater than 50% of Cervical Epidural injections performed without x-ray and contrast failed to reach the Epidural space (5).
At the Centeno-Schultz Clinic we see patients from many different parts of North America. Many patients are seeking second opinions. Some patients have undergone multiple injections without success. To ensure a correct diagnosis we ask for and review x-ray images of their previous injections. The results of often are very disappointing as the injections performed at other clinics were performed without guidance or no contrast was used. If contrast was not utilized during the injection there is no way to confirm accurate placement of the needle and the injected medicine. Without this information, an appropriate diagnosis cannot be made. This can be heartbreaking to the patient and their families who are sincerely looking for a diagnosis and treatment options. Choose right: insist on x-ray guided injections with contrast. Ask for the images at the completion of your procedure. Keep them as part of your medical records.
In Conclusion
An Epidural steroid injection is a medical procedure in which steroids and local anesthetics are injected into the epidural space.
The goal of Epidural steroid injection is to reduce pain and inflammation.
The epidural space is a potential space that contains fat, veins, arteries, spinal nerve roots, and lymphatics.
There are two different types of Cervical Epidural steroid injections: Interlaminar and Transforaminal.
Common indications for a Cervical Epidural steroid injection include Cervical Degenerative Disc Disease, Cervical Disc Herniation, radiating arm pain, Cervical headaches, and post-surgery neck pain.
Local anesthetic and steroid is injected during a Cervical Epidural steroid injection.
The 5 major reasons for increased pain after Cervical Epidural steroid injection are:
- Nerve irritation
- Vascular Injection
- Severe Underlying Condition
- Dural Puncture
- Failed injection
The best ways to avoid increased pain after Cervical Epidural steroid injection are:
Partner with Board Certified Expert
Ensure a Correct Diagnosis
Insist on X-ray Guidance and the Use of Contrast
At the Centeno-Schultz Clinic, we are experts in the treatment of neck pain. If you or your family members suffer from ongoing neck and or radiating arm pain, please consider an in-office or virtual evaluation. A board-certified, fellowship-trained physician will review your history, imaging and discuss non-surgical treatment options.
1.Forsythe B, Forlenza EM, Agarwalla A, Cohn MR, Lavoie-Gagne O, Lu Y, Mascarenhas R. Corticosteroid Injections One Month Before Arthroscopic Meniscectomy Increase the Risk of Surgical Site Infection. Arthroscopy. 2021 Mar 31:S0749-8063(21)00289-9. doi: 10.1016/j.arthro.2021.02.047. Epub ahead of print. PMID: 33812029.
2.Forsythe B, Forlenza EM, Agarwalla A, Cohn MR, Lavoie-Gagne O, Lu Y, Mascarenhas R. Corticosteroid Injections One Month Before Arthroscopic Meniscectomy Increase the Risk of Surgical Site Infection. Arthroscopy. 2021 Mar 31:S0749-8063(21)00289-9. doi: 10.1016/j.arthro.2021.02.047. Epub ahead of print. PMID: 33812029.
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4.Derby R, Lee SH, Kim BJ, Chen Y, Seo KS. Complications following cervical epidural steroid injections by expert interventionalists in 2003. Pain Physician. 2004 Oct;7(4):445-9. PMID: 16858486.
5.Stojanovic MP, Vu TN, Caneris O, Slezak J, Cohen SP, Sang CN. The role of fluoroscopy in cervical epidural steroid injections: an analysis of contrast dispersal patterns. Spine (Phila Pa 1976). 2002 Mar 1;27(5):509-14. doi: 10.1097/00007632-200203010-00011. PMID: 11880836. [Google Scholar]
