Cervical Epidural Steroid Injections (CESI) and Other Interventions for the Treatment of Neck and Upper Extremity Pain

Cervical epidural steroid injections (CESI) are the only form of conservative treatment for cervical radicular pain (CR) that has supportive data and some consensus opinion(Carragee, Hurwitz et al. 2008; Bono 2010) of their efficacy. There is evidence for the use of cervical transforaminal epidural steroid injections (CTFESIs) (Bush and Hillier 1996; Slipman, Lipetz et al. 2000; Vallee, Feydy et al. 2001; Cyteval, Thomas et al. 2004; Lin, Lieu et al. 2006; Anderberg, Annertz et al. 2007; Huston 2009; Lee, Park et al. 2009; Bono 2010), and also evidence supporting the use of cervical interlaminar epidural steroid injections (CILESIs) (Ferrante, Wilson et al. 1993; Stav, Ovadia et al. 1993; Kwon, Lee et al. 2007; Huston 2009). There are theoretical advantages, and known risks, to either approach, however (Huston 2009). CTFESIs offer the advantage of injection of local anesthetic and corticosteroid in a directed and concentrated manner to the involved nerve root(s). There have been cases of severe neurological injury or death with this approach, and there has been discussion in the literature regarding the risk vs. benefit of performing CTFESIs. (Brouwers, Kottink et al. 2001; Smuck, Rosenberg et al. 2009) The risks of CTFESI are minimized when a standardized technique, avoidance of excessive sedation, and soluble steroid are used. (Baker, Dreyfuss et al. 2003; De Cordoba and Bernal 2004; Rathmell, Aprill et al. 2004; Dreyfuss, Baker et al. 2006; Derby, Lee et al. 2008; Malhotra, Abbasi et al. 2009) Interlaminar ESIs offer the possible advantage of using particulate steroids, and targeting can be relatively well focused with a paramedian approach and the use of low volumes of injectate, although significant complications are still possible. (Siegfried 1997; Hodges, Castleberg et al. 1998; Field, Rathmell et al. 2000; Stojanovic, Vu et al. 2002; Abbasi, Malhotra et al. 2007; Huston 2009) Both approaches are reasonable options.

Additional CESIs can be offered towards the goals of the extinction of symptoms or the restoration of the initial response. It is postulated that the use of repeat injections, when there is a partial response to the prior, may lead to complete relief of pain, and, the best chance of establishing long term improvement of CR symptoms. Likewise, the use of additional injections to treat recurrent pain, following an initial cessation or substantial reduction of pain, may lead to improved long term outcomes.

It is important to ensure that providers of these injections are experienced, safe, and competent, and that they agree to use standardized procedural techniques (Stojanovic, Vu et al. 2002; Baker, Dreyfuss et al. 2003; Bogduk 2004; De Cordoba and Bernal 2004; Rathmell, Aprill et al. 2004; Schellhas, Pollei et al. 2007; Huston 2009). The recommended CILESI technique, as noted by Huston, should be modified to utilize a paramedian approach, due to the known incidence of absence of an interlaminar ligament/flavum in the midline, and a 50% chance of unilateral (but uncontrolled) flow of injectate from the midline. A paramedian approach somewhat controls for these variables. This necessitates the use of the “laminar” or ”rooftop” fluoroscopic view to check depth during the procedure.

The concomitant presence of both discogenic and facetogenic pain may be more prevalent in the cervical spine than in the lumbar spine. (Bogduk and Aprill 1993; Bogduk 2004) It is probable that there are not an insubstantial number of patients with CR who will also have pain and disability from concomitant cervical zygapophysial joint generation. Treatment of this cervical Z-joint (CZJ) related pain (or lumbar facet pain) might be indicated to optimize outcomes with CR. This would apply primarily to those cases where the presenting radicular pain has subsided, but there remains sufficient axial pain to effect patients’ reporting of pain, healthcare utilization, and disability. Use of standard techniques for CZJ related intra-articular, medial branch (MB) block, and MB radiofrequency neurotomies is required. (Fenton, Czervionke et al. 2003; Bogduk 2004) CZJ (or LZJ) procedures may be offered according to practice parameters based on parallel (lumbar) guidelines offered by Noridian in their coverage determination for Lumbar Z-Joint procedures (See Noridian Facet Coverage Determination), as well as the work of Lord, Barnsley, and others. (Lord, Barnsley et al. 1995; Lord, Barnsley et al. 1995; Lord, Barnsley et al. 1996; Lord, Barnsley et al. 1996) These guidelines (Noridian) were based on a multi-specialty, multi-society collaborative effort to reach consensus on the proper utilization of these (lumbar) procedures.

The judicious use of trigger point injections, dry needling, or similar myofascial approaches is acceptable, up to a maximum of 4-8 sessions(Goldman and Rosenberg 1991; Stav, Ovadia et al. 1993; Peloso, Gross et al. 2005; Dommerholt and Shah 2010).

Cervical Epidural Steroid (and other) Injections:

1. 1 – 2 (see exception below) and up to 56 total cervical ESIs [transforaminal (fluoroscopy, DSA if available, test dose, soluble steroid) and/or interlaminar (fluoroscopy, contrast, particulate steroid)] per first year of treatment, with up to 3 the subsequent year.
a. Second ESI 2 weeks after first, if less than 90% sustained relief of pain
b. If less than 50% sustained relief with first injection, second ESI should be through opposite route from first (TFESI vs. ILESI)
c. Third and subsequent injections may be done if > 50% sustained (> 2 weeks with second or > 6 weeks with third or subsequent injections) relief from earlier procedure(s). Goal of extinction of symptoms or re-instatement of initial response. 4th and subsequent ESIs should be spaced at least 3 months apart.
d. Avoid total corticosteroid exposure (from all sources – ESI, intra-articular, or p.o.) of > 5 mg/kg (triamcinolone or equivalent) per 6 month period.
e. See above for rationale and references

Optional:
2. CZJ/LZJ procedures may be included when indicated (may include intra-articular steroid injection and/or median branch block with subsequent radiofrequency ablation if successful) (Appendix II)
3. Trigger point injections or dry needling when indicated (maximum 6 sessions)