Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
From the aPain Medicine and Palliative Care Unit, Instituto Nacional de Ciencias Mdicas y Nutricin Salvador
Zubirn, Mexico City, Mexico; and the
b
Department of Pain Clinic and Palliative Care, Instituto Nacional de Cancerologa, Mexico City, Mexico.
KEYWORDS: The most widely accepted indication for applying steroid injections at the cervical level is to control
Cervical epidural; radicular pain generated by a herniated disk. A cervical radiculopathy is a neurological disease
Interlaminar; characterized by a dysfunction of the spinal cervical nerves or their roots. It has been upheld that the
Transforaminal consequence of alleviating pain by applying epidural steroids may be the result of inhibiting the
steroids; synthesis or releasing a significant amount of proinflammatory mediators as well as by causing an
Radicular pain analgesic effect where contact takes place. The epidural injection of steroids may be carried out by an
interlaminar or transforaminal approach. The cervical interlaminar epidural steroid injection (CIESI) is
the intervention method used to manage radicular pain. The cervical transforaminal epidural steroid
injection (CTESI) theoretically allows a greater concentration of medicine to reach the region that has
been affected. Recently, several reports have been published about catastrophic complications, such as
cerebral medular stroke and even death. It is believed that such catastrophic complications are caused
by occlusion of a segmental artery by the particles of the steroids that are injected. Therefore, many
authors currently question whether the CTESI practices should be followed. Additionally, in terms of
the vaso-occlusive effect caused by corticosteroids, it cannot be overlooked that the latter may produce
a considerable amount of adverse effects. Consequently, new alternatives for radicular pain are being
explored; however, these require more analysis.
2010 Elsevier Inc. All rights reserved.
Epidural steroid injections for pain management first This disease is commonly caused by the compression of the
emerged in 1952.1 This practice proliferated to such an nerve at the foramen due to the cervical espondilosis.3 The
extent that it is now one of the most popular intervention second most common cause is a herniated intervertebral disk.
methods for pain management. Disk herniation is the most common cause and occurs espe-
The most widely accepted application of a cervical ste- cially at the C5-6 and C6-7 levels, affecting the C6 and C7
roid injection is to control radicular pain caused by a hernia roots, respectively. The herniation of an intervertebral disk is
of the disk. Other indications include a narrow cervical typically related to the degenerative processes of aging but may
channel, chronic cervical pain as the side effect of a surgical occur after trauma. Other possible causes of radicular pain are
intervention, in addition to others that are less accepted.2 infections and tumors. Clinically, cervical radiculopathy causes
Cervical radiculopathy is a neurological disease character- cervical pain that irradiates toward the arm along with hypoestesia
ized by dysfunction of the spinal cervical nerves or their roots. and reduced strength that follow dermatomic patterns.3
Most patients with symptomatic cervical disk herniations
respond well to nonoperative treatment, including some
Address reprint requests and correspondence: Antonio C. Tamayo,
MD, Vasco de Quiroga 15 Colonia Seccin XVI, Tlalpan Mexico City, patients with nonprogressive radicular weakness. Reason-
14000 Mexico. ably good evidence shows that acute disk herniations de-
E-mail address: ancetaval@yahoo.com.mx. crease in size over time in the cervical region.
1084-208X/$ -see front matter 2010 Elsevier Inc. All rights reserved.
doi:10.1053/j.trap.2010.06.002
Tamayo et al Cervical Epidural Injections for Radicular Pain 107
Complications
From there, these enter into the transverse of C6 or C5 until retrospective studies about the use of CTESI. According to
reaching C1 and from there to the magnum foramen.14 their research, efficiency is very low for patients suffering
From the subclavia and vertebral arteries arise the seg- from radicular pain due to secondary espondilosis related to
mented vessels (ascending cervical arteries and profound traumatic injury.21 Moreover, positive outcome has been
cervical), which cross the foramen and subdivide to form shown in patients in which CTESI for radicular pain not
the front and back radicular artery.15 The anterior and pos- related to nontraumatic cervical espondilosis, with excellent
terior spinal arteries arise from radicular artery. Addition- results in up to 60% of the patients.21
ally, the anterior spinal artery receives small arteries from
the radicular artery known as the radiculomedullar arter-
ies.15 The radicular arteries and radicularmeduar arteries Complications
can be located in the lower posterior portion of the foramen
near the target where the needle is placed for the transfo- In a survey carried out by ISIS instructors, it was re-
raminal injection.15 ported that the incidence of complications due to the trans-
foraminal injection was relatively low (0.32%); moreover,
Effectiveness Ma and collaborators reported that complications were
present early on after applying the CTESI in 1.66%. Despite
Scientific evidence that supports the effectiveness of the the fact that both studies report a relatively low incidence of
CTESI is still limited. There are several observational stud- complications, recently there have been reports about cata-
ies that report on the progress of patients with radicular strophic complications, such as a spinal and brain stem
cervical pain who received a CTESI. Because there are no infarction and even death.22-25 Therefore, many authors
control groups, the downside is that the effectiveness of the now question whether to continue applying CTESI.26
CTESI cannot be differentiated from the normal progress of It is believed that these catastrophic complications are
the ailment.14 To date, only one prospective, randomized, the result of an occlusion in the segmental artery by the
controlled trial exists. Anderberg and colleagues divided 40 steroid particles that are injected.15,27 Particulated steroid
patients with cervical radicular pain in 2 groups.16 Each may function as an embolus and occlude blood vessels that
group received transforaminal injections of the affected may condition brainstem and spinal infarction.
root. In the first group, mepivacaine and 40 mg of methyl- There are many variations in the level and location of the
prednisolone were injected, whereas the second group only origin of the radicular arteries and other vessels of lesser
received mepivacaine. No significant differences were importance that can nurture it. This was demonstrated in an
found in the clinical outcome of both groups. The absence article written by Hoeft and colleagues, who performed a
of positive results to support the effectiveness of CTESI in cadaveric dissection in which they observed that three
this study casts serious doubts over its use; however, these prominent branches of the radicular artery entered through
results could have been caused by the fact that the control
anterior portion of the foramen next to the left nerve root of
group received more than 1 transforaminal injection of local
C5, and through the right nerve root at C6 and C8.28 In C7,
anesthesic.17 Undoubtedly, it is necessary to carry out fur-
two prominent branches of the radicular artery enter by the
ther studies that are methodologically strong to be certain
posterior of the foramen in C7 bilaterally.28
that CTESI is effective in managing radicular pain.
The unpredictable irrigation of the cervical spine makes
In terms of observational studies, the information seems
it almost impossible to determine a safe manner to approach
different. Kolstad and colleagues for 4 months followed-up
to perform a CTESI without having the risk of intravascular
21 patients with cervical radiculopathy pain caused by es-
pondilosis or herniated disks in which CTESI was admin- injection. As a matter of fact, there have been many reports
istered. This study found a lower need for surgery (5 out of about unnoticed intravascular injections.29,30 Aspiration as a
the 21 patients decided not to have surgery) and significant method for verification to know whether we have reached a
clinical improvements at 6 weeks and at 4 months after vessel is the most ineffective method because, if the needle
CTESI. This clinical improvement was only seen in patients is located at a low-caliber vessel, when aspirating we may
with radicular pain irradiating to the arm but not for neck collapse it and not observe blood flowing into our syringe.
pain.18 Vallee and colleagues performed CTESI for patients Therefore, the practitioner could mistakenly believe that a
with cervical radicular pain. According to their studies, 56% vessel has not been reached. Injecting contrast media and
of the patients reduced the intensity of the radicular pain in later observing the image to confirm whether we are located
half 6 months after the CTESI was performed.19 Addition- in a blood vessel is also an inefficient method because the
ally, Cyteval and colleagues, during an observation prospec- time that has elapsed between the injection of the contrast
tive study consisting of 30 patients, found clinical improve- and the moment of obtaining an image at times is enough
ment in 60% of patients. From an initial mean VAS score of for the dye to be cleared from the vessel.31 To reduce the
6.3/10, the patients who improve had a reduced mean VAS risk of puncturing a blood vessel, it is highly recommended
score of 1.2/10 at 2 weeks and 0.7/10 at 6 months.20 Slip- to visualize the distribution of the contrast media in real
man and colleagues published several observational and time with digital subtraction.
110 Techniques in Regional Anesthesia and Pain Management, Vol 14, No 3, July 2010
40C group was considered the sham group. Both groups, further studies are warranted to establish safety and effi-
surprisingly, had a significant pain reduction with pain ciency.
scores at 1.5 and 3 several months after the procedure. After
this study, attention has been directed toward PRF.48
In PRF, high-frequency current is delivered in short
bursts followed by a silent period, allowing the generated References
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