Information on chronic pain and addicton

Christopher Frandrup, M.D., DABPM, FIPP

Category: Cervical

Cervical Epidural Steroid Injection

Cervical Steroid Injection

What Is A Cervical Steroid Injection?

Recent estimates indicate that more than half of adults will experience symptoms of neck or back pain at some point during the course of their lives. For patients with chronic neck pain and cervical radiculitis, the recommended treatment is steroid injections in the cervical region. Many pain specialists prefer cervical steroid injections, as they are quick to perform and have been shown to be effective at reducing chronic and refractory neck and upper back pain.In many instances, patients will report an almost immediate benefit from the injection in terms of the severity of their pain. Most are expected to resume normal daily activities immediately after the procedure. A meta-analysis was recently conducted on studies examining the effectiveness of cervical steroid injections across the last ten years. The results of this analysis supported the effectiveness of these injections in providing patients with relief from cervical pain.

The precise mechanism of action that accounts for the effectiveness of cervical steroid injections is not fully understood. It is believed that reductions in nerve pain are achieved as the result of the anti-inflammatory effects of the steroids. Steroids have other pain relieving properties as well. This medication has been shown to stabilize irritated nerve membranes and inhibit the conductance of ions. Both these actions have been shown to also aid in the reduction of pain.

Studies examining the long-term benefits of cervical steroid injections are limited and findings from these studies are somewhat varied. While a portion of patients examined in these studies report lasting benefits from receiving cervical steroid injections, others do not. Nonetheless, cervical steroid injections are generally regarded as safe. Thus, patients who do not achieve full symptom relief from just one administration may return for repeat treatments until full symptom relief is achieved.

How Is A Cervical Steroid Injection Performed?

The spinal cord is located within the spinal canal and is protected by a padding of cerebrospinal fluid (CSF). The spinal canal is comprised of a tough and durable membrane that also acts as a protective layer for the spinal cord. Just outside the protective membrane of the spinal canal is the epidural space. This space is the target for a cervical steroid injection.In most instances, only a topical anesthetic is used to numb the surface of the skin where the injection will be performed. However, some patients may request an intravenous medication in order to make the procedure more comfortable.

The performing physician will make two injections. One injection is for the X-ray imaging device that is used to ensure that the physician is placing the injection needle into the appropriate area of the epidural space. In some instances, a contrast dye may be used to confirm the placement of the needle. Contrast dye may also be used to ensure that the medication will be appropriately distributed within the epidural space. After the physician has confirmed that the needle has been placed correctly, the anesthetic medication (i.e., corticosteroid) is injected. The aim of these injections is to administer steroids only to those areas with the most inflammation, so that the patient is not exposed to excessive amounts of the medication.

The procedure for cervical steroid injections does not generally require surgery and can be performed on an outpatient basis. In many instances, the patient does not report any pain associated with the procedure. The majority of patients receiving cervical steroid injections will report almost immediate reductions in their neck and upper back pain following the procedure. Studies examining the use of multiple injections to treat cervical pain have provided support for the benefit of repeat treatment for patients whose pain did not fully remit following initial treatment.

As with many other medical treatments, cervical steroid injections are associated with some risk, though they are generally mild and rare. Commonly reported side effects following the procedure include:

  • Bleeding (more common among patients with bleeding disorders)
  • Infection
  • Nerve damage following direct trauma from the injection needle
  • Dural puncture as the result of improper placement of the injection needle
  • Spinal cord injury (e.g., cord edema, cord syrinx, scarring, fluid within the cord)

Conditions Related To Cervical Steroid Injections

Cervical steroid injections are commonly used to treat a condition known as cervical radiculitis. This condition is caused by excessive pressure placed on the nerves located within the cervical, or neck, region. This compression can cause the nerves to become irritated, which is believed to be the source of pain and discomfort within the area. In many instances, patients will report the sensation that the pain radiates down the arm. Further, patients may also report weakness and numbing sensations along with the pain.Cervical steroid injections can be used for many other conditions involving neuropathic pain within the neck and upper back region. Such pain can be caused by compression placed on the cervical nerves as the result of inflammation within the area, excessive fluid retention, or a herniated or bulging intervertebral disc.

Conclusion

Cervical steroid injections are a highly effective treatment option for managing moderate to severe neuropathic pain within the cervical area. Many pain specialists prefer this procedure, as it is relatively quick and can be performed on an outpatient basis. Steroid medications are used for this procedure primarily because of their anti-inflammatory properties.A portion of patients receiving cervical steroid injections will report an almost immediate benefit from the injections. For patients who do not experience a full reduction in pain from the initial treatment, repeat injections may be warranted. Studies examining the effectiveness of these injections have provided ample support for their use in treating neuropathic cervical pain. Results from long-term follow-up studies remain mixed. Individuals are encouraged to speak with their doctor about the risks and benefits associated with cervical spinal injections.

References

  1. Bicket MC, Gupta A, Brown CH, Cohen SP. Epidural injections for spinal pain: A systematic review and meta-analysis evaluating the “control” injections in randomized controlled trials. 2013; 119(4):907-31.
  2. Boswell MV, Trescot AM, Datta S, et al. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. American Society of Interventional Pain Physicians. Pain Physician. 2007;10(1):7-111.
  3. Kwon JW, Lee JW, Kim SH, Choi JY, Yeom JS, Kim HJ, Kwack KS, Moon SG, Jun WS, Kang HS. Cervical interlaminar epidural steroid injection for neck pain and cervical radiculopathy: effect and prognostic factors. Skeletal Radiol. 2007;36(5):431-6.
  4. Huston CW. Cervical epidural steroid injections in the management of cervical radiculitis: Interlaminar versus transforaminal. A review. Curr Rev Musculoskelet Med. 2009;2(1):30-42.
  5. Manchikanti L, Cash KA, Pampati V, Wargo BW, Malla Y. A randomized, double-blind, active control trial of fluoroscopic cervical interlaminar epidural injections in chronic pain of cervical disc herniation: Results of a 2-year follow-up. Pain Physician. 2013;16(5):465-78.
  6. Pasqualucci A, Varrassi G, Braschi A, Peduto VA, Brunelli A, Marinangeli F, Gori F, Colò F, Paladini A, Mojoli F. Epidural Local Anesthetic Plus Corticosteroid for the Treatment of Cervical Brachial Radicular Pain: Single Injection Versus Continuous Infusion. Clin J Pain. 2007;23(7):551-7.
  7. Scanlon CG, Moeller-Bertram T, Romanowsky SM, Wallace MS. Cervical transforaminal epidural steroid injections: More dangerous than we think? Spine. 2007;32(11):1249-1256.

Cervical Facet Radiofrequency Neurotomy

Cervical Facet Radiofrequency Neurotomy

What Is Cervical Facet Radiofrequency Neurotomy?

Cervical-Facet-Radiofrequency-Neurotomy-1There are a number of factors that have been associated with cervical pain that arises in the neck and upper back region. In fact, previous estimates have suggested that more than two-thirds of adults can expect to have some form of neck or back pain during their lifetime. In most cases, direct trauma or injury, muscle strain, pinched nerve, or even a herniated or slipped intervertebral disc can cause pain in the cervical region.Several treatments are available and most are regarded as non-surgical and minimally invasive. One of these treatment options is cervical facet radiofrequency neurotomy. In fact, radiofrequency neurotomy of the cervical facet joint is regarded as one of the most commonly employed treatments for pain that arises from the cervical facet joint.

Cervical-Facet-Radiofrequency-Neurotomy-4Previous studies have supported cervical facet radiofrequency neurotomy as effective in reducing the severity or even eliminating neuropathic pain. Studies examining the long-term effects of this treatment have revealed that patients report being free from debilitating symptoms of pain and discomfort for 15 months or more. Additionally, half of the patients examined in these studies reported being free from symptoms for two years.

How Is Cervical Facet Radiofrequency Neurotomy Performed?

The facet joints of the body are located on the posterior sides of the spinal column. Most of the facet joints within the body have a decreased range of motion given their shape. Facet joints that are found in the neck and upper back area are known as cervical facet joints. Cervical facet joints have a somewhat different shape and, therefore, have a broader range of motion. When the structures of these joints become damaged or injured, the result is inflammation, joint stiffness, soreness, and even pain. Generally, these symptoms are limited to the neck and upper back area.Cervical-Radiofrequency-Ablation-Procedure-3Within the nervous system, the spinal cord is the primary pathway by which information travels from the peripheral areas of the body to the brain. Given its crucial role in overall bodily function, the spinal cord must remain highly protected. Thus, it is surrounded by a durable membrane that is also surrounded by a bony structure known as the spinal column. Branching off of the spinal cord are medial nerves that transmit sensory information and provide muscle control to the facet joints.Though the exact function of cervical facet radiofrequency neurotomy is not fully understood, it is believed to be effective in decreasing cervical facet joint pain by inhibiting the function of the medial nerves.

The procedure is regarded as relatively safe. It can be conducted on an outpatient basis and, typically, only requires the use of a local anesthetic.

In some instances, the patient may request the use of intravenous medication in order to make the procedure more comfortable.

Cervical-Radiofrequency-Ablation-Procedure-6Using an X-ray imaging device as a guide, the performing physician will insert a cannula (i.e., a small needle-sized tube) to the area of the affected nerve. The physician will then feed a small electrode into the cannula. Before performing the neurotomy, the physician must check the placement of the electrode. To do so, the performing physician will run a very low current through the electrode. This will trigger temporary pain signals and muscle contractions. Once the physician has confirmed the placement, a numbing agent is applied to the nerve tissue. Next, the physician will deliver a high level of heat to the area. The application of heat is used to create a lesion. This damage then inhibits the function of this nerve, thereby preventing the transmission of pain information to the spinal cord and brain.Once the procedure is performed, patients are monitored closely for the possibility of adverse side effects. In most instances, patients are advised to arrange for a ride home following the procedure. Additionally, patients must use caution before returning to typical daily activities. For instance, many patients will report experiencing muscle weakness and even soreness in the area following a cervical facet radiofrequency neurotomy procedure.

Cervical-Radiofrequency-Ablation-Procedure-8In most instances, damaged medial nerves can take up a month to completely atrophy. During this time it is not uncommon for patients to report ongoing complaints of muscle soreness and weakness. Some patients may wish to talk to their doctor about possible medications that may be used temporarily to manage these symptoms of pain.As with many other medical procedures, there is some risk to patients who are considering cervical facet radiofrequency neurotomy. These risks are regarded as relatively rare and include:

  • Pain or discomfort in the area of the injection
  • Numbing in the area of skin above the treated area
  • Muscle spasms
  • Allergic reactions to the medication
  • Infection
  • Permanent nerve damage and pain

Conditions Related To Cervical Facet Radiofrequency NeurotomyCervical-Facet-Radiofrequency-Neurotomy-3

In general, cervical facet radiofrequency neurotomy is used to treat symptoms of pain and discomfort associated with conditions affecting the facet joint. The goal is to provide patients with relief from pain, but not all patients will respond to the procedure in the same way. Thus, it is important to talk to your doctor about cervical facet radiofrequency neurotomy and whether this procedure is appropriate for managing your particular symptoms of pain.Some studies have supported the use of cervical facet radiofrequency neurotomy in treating the pain and discomfort associated with whiplash. Other common conditions that are treated with cervical facet radiofrequency neurotomy include:

  • Pain in the upper back
  • Pain that worsens upon twisting or lifting something heavy
  • Pain that improves when lying down

ConclusionCervical-Facet-Radiofrequency-Neurotomy-2

Cervical facet radiofrequency neurotomy is an effective treatment for managing the pain and discomfort associated with neuropathy in the cervical region. This treatment is regarded as non-invasive, is done on an outpatient basis, and is typically considered after other techniques have failed to provide relief from symptoms. The aim of this treatment is to inhibit the transmission of pain information within the cervical facet joint areas. Patients who are considering this procedure are encouraged to speak to their doctors about the risks and benefits associated with cervical facet radiofrequency neurotomy.

References

  1. Cohen SP, Husang JH, Brummett C. Facet joint pain – advances in patient selection and treatment. Nat Rev Rheumatol. 2013;9(2):101-16.
  2. Davis CG. Mechanisms of chronic pain from whiplash injury. J Forensic Leg Med. 2013;20(2):74-85.
  3. Falco FJ, Datta S, Manchikanti L, Sehgal N, Geffert S, Singh V, Smith HS, Boswell MV. An updated review of the diagnostic utility of cervical facet joint injections. Pain Physician. 2012;15(6):E807-38.
  4. Falco FJ, Manchikanti L, Datta S, Wargo BW, Geffert S, Bryce DA, Atluri S, Singh V, Benyamin RM, Sehgal N, Ward SP, Helm S, Gupta S, Boswell MV. Systematic review of the therapeutic effectiveness of cervical facet joint interventions: An update. Pain Physician. 2012;15(6):E839-68. Review.
  5. Husted DS, Orton D, Schofferman J, Kine G. Effectiveness of repeated radiofrequency neurotomy for cervical facet joint pain. J of Spinal Disorders & Techniques. 2008;21(6):406-408.
  6. Mukai A, Kancherla V. Interventional procedures for cervical pain. Phys Med Rehabil Clin N Am. 2011;22(3):539-49.
  7. Van Eerd M, de Meij N, Dortangs E, Kessels A, can Zundert J, Lataster A, Patijn J, van Kleef M. Long-term follow-up of cervical facet medial branch radiofrequency treatment with the single posterior-lateral approach: An exploratory study. Pain Pract. 2013;18.

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