Introduction
Epidural injections of anesthetic agents and steroids have been used for the treatment and diagnosis in low back pain for more than 40 years. White, Derby and Wynne reported in a prospective study in 1980 1 the usefulness of lumbar epidural injections in diagnosis and treatment. They reported initial relief in 82% of patients which was reduced to 7% relief at six months or longer follow up. The technique was found to be useful in restoring mobility and alleviating discomfort quickly. A similar technique has been applied to the neck as a therapeutic intervention. This paper documents the usefulness of this technique in 33 consecutive patients.
Few reports have been published on cervical epidural corticosteroid injections (CECI).2,3,4 There has been only one study on the technique as a therapeutic modality in cervical discogenic disease. Rowlingson and Kirschenbaum reported on a retrospective study on 25 patients. They noted a 24% excellent clinical result rate, with very short follow up. Of the 25 patients, 18 had an average follow up of only 1.8 months. Of the 24% excellent results of 6 patients, four patients had one-month follow up, one patient had three-month follow up, and one patient had ten-month follow up.
Materials
Thirty-three cervical epidural corticosteroid injections were performed in 30 patients. All patients had a history of neck pain and 21 patients (70%) had concurrent shoulder and/or upper extremity pain.
The mean age was 43 years, with a range of 27 to 68 years. There were
16 females and 14 males. The average duration of symptoms prior to the injection was 22 months. The diagnoses are shown in Table 1.
TABLE 1
| Diagnosis |
Number of
Patients |
| Cervical disc herniation |
25 |
| Degenerative disc disease |
4 |
| Foraminal stenosis |
1 |
All patients had undergone extensive conservative treatment, including
rest (off work), traction, nonsteroidal antiinflammatory drugs, physiotherapy,
and attempts at physical conditioning and rehabilitation. Eight patients
were also placed on tapering doses of oral prednisone. Transient, limited
relief was obtained in only one of these patients. The average time in physical
therapy and rehabilitation was 8.8 months, with a range of two to 15 months.
All patients were evaluated with cervical spine radiographs, CT and/or
MRI and EMG. Two patients had myelograms and eight patients had discograms.
All patients were considered to have exhaustive conservative care, without
improvement, and were stationary at an unacceptable level of symptoms or
function. Patients were then referred for CECI.
METHODS
All CECI were performed by one skilled anesthestiologist, using the following
procedure:
Patient was placed in the prone position on the fluoroscopy table and
the exact level to be blocked was identified under fluoroscopy in the AP
projection. Skin was marked, prepped and draped. Skin and subcutaneous tissue
were infiltrated with local anesthetic. An 18-gauge Crawford type needle
was advanced to the lower lamina. Eighty percent of the injections were
at the C7-T1 level, and the remainder of injections were at the C6-7 level. The needle was then walked up the lamina until it contacted the ligamentum flavum. The needle was then carefully advanced through the ligamentum flavum, using loss of resistance to injection of fluid to gauge when the ligamentum flavum was perforated. Careful aspiration was done in all planes. .5cc of 1% Xylocaine was then injected as a test dose. After three or four minutes, 8cc of .5% Xylocaine mixed with 80mg of DepoMedrol was injected.
Patients were followed up at an average of nine months, with a range
of seven to 13 months.
RESULTS
Based on standardized pain questionnaires and analog pain scales which were filled out by the patients and reviewed by an independent examiner, patient results were categorized into one of four categories:
Excellent..........100% relief of all symptoms
Good...............Greater than 80% relief of symptoms
Fair...............50% to 79% relief of symptoms
Fail...............Less than 50% relief of symptoms
Initial results are shown in Table 2. Fourteen patients had an excellent
initial response to CECI. Nine of these 14 patients have continued to do
well and have resumed normal daily activities, without neck pain. The remaining
five patients had the following results: Two patients' symptoms returned
to a dysfunctional level at three and four months. Both received a second
CECI and were returned to therapy, still symptomatic but somewhat improved.
At four and five months post second CECI, both patients are pain free and
doing well. Two patients who had diagnoses of herniated discs had several
weeks of excellent relief of symptoms with gradual return of symptoms. They
then elected to have surgery. The last of the five patients received an
excellent result from CECI but was lost to follow up four months later.
Five patients were categorized as having an initial good result. Three
of these were able to return to their physical therapy programs with continued
gradual improvement and good results at the time of last follow up. One
patient had a relapse of symptoms and was treated with a second CECI. The
second injection only conferred fair relief. The fifth patient had good
relief for less than one week only.
Six patients had fair results from their cervical epidural corticosteroid
injections. One returned to work and a pain free state after continued physical
therapy. The other two patients had fair relief for 3.5 weeks, followed
by return of their pre-injection symptomatology. Three of the patients with
initial fair results showed continued partial improvement after injection.
Five patients received little or no benefit from the injection. Two patients
went on to surgery, with only fair results. The remaining three patients
had no relief from any treatment offered, including tapering doses of oral
prednisone. It is of note that these last three patients all are involved
in pending litigation over injuries related to their symptoms.
TABLE 2
| |
Initial Results |
Repeat Injection |
| Excellent |
14 |
2 |
| Good |
5 |
1 |
| Fair |
5 |
|
| Fail |
5 |
|
TABLE 3
| Initial Response to CECE |
End Result |
| Excellent |
Good |
Fair |
Fail |
| Excellent |
14 |
11 |
0 |
0 |
3 |
| Good |
5 |
3 |
0 |
1 |
1 |
| Fair |
6 |
0 |
1 |
3 |
2 |
| Fail |
5 |
0 |
0 |
0 |
5 |
CONCLUSIONS
Cervical epidural corticosteroid injection is a safe and effective therapeutic modality for cervical degenerative disease which is refractory to conservative treatment.
The study results show marked initial relief in 63% (19/30), with relief
lasting an average of eight months in 50% (15/30) of all injected patients
(Table 3). Seventy-six percent of injected patients who had relief initially
sustained their improved state or improved further during follow up.
Although this is a preliminary retrospective study, the fact that the
pre-injection treatment period was prolonged (average 22 months), with no
significant clinical improvement, suggests the technique is a valid therapeutic
intervention.
The technique appears to be useful in rapid control of pain in many patients, facilitates quick return to a more normal lifestyle, and makes further conservative care more feasible. When performed by an expert with resuscitation skills, we have seen no complications in over 100 cases to date.
REFERENCES
1. White AII, Derby R, Wynne G: Epidural Injections for the Diagnosis and Treatment of Low Back Pain. Spine 5:78-86, 1980. back
2. Rowlingson JC, Kirschenbaum LP: Epidural Analgesic Techniques in the Management of Cervical Psin. Anesth Analg 65:938-43, 1986. back
3. Dirksen R, Rutgers MJ, Coolen MW: Cervical Epidural Steroids in Relfex Sympathetic Dystrophy. Anesthesiology 66:71-73, 1987. back
4. Kainuma M, Shimada Y, Matsuura M: Cervical Epidural Anaesthesia in Carotid Artery Surgery. Anaesthesia 41: 1020-1023, 1986. back |
