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You must be logged in to access this feature. Many remain severely disabled and require treatment. Surgery is the mainstay of treatment. Conservative therapy, typically including graduated exercise and oral analgesics, is supported only by observational studies, which have not controlled for natural history or nonspecific effects of treatment.
The failure of conventional, conservative treatments to provide a cure for cervical radicular pain fostered the development of alternatives. Prominent among these has become transforaminal injection of steroids. The rationale for injecting steroids is that they suppress inflammation of the nerve, which, in many instances, is believed to be the basis for radicular pain. This ensures that the medication reaches the site of the suspected pathology in maximum concentration.
At typical cervical levels, the ventral and dorsal roots of the spinal nerves descend in the vertebral canal to form the spinal nerve in their intervertebral foramen.
The foramen faces obliquely forward and laterally. Its roof and floor are formed by the pedicles of consecutive vertebrae. Its posterolateral wall is formed largely by the superior articular process of the lower vertebra and in part by the inferior articular process of the upper vertebra and the capsule of the zygapophysial joint formed between the two articular processes.
The anteromedial wall is formed by the lower end of the upper vertebral body, the uncinate process of the lower vertebra, and the posterolateral corner of the intervertebral disc.
Immediately lateral to the external opening of the foramen, the vertebral artery rises closely in front of the articular pillars of the zygapophysial joint fig. Illustration of an axial view of the cervical intervertebral foramen and adjacent structures at the level of C6 with a needle inserted parallel to the axis of the foramen along its posterior wall.
Note the proximity of adjacent structures: The spinal nerve, in its dural sleeve, lies in the lower half of the foramen. The upper half is occupied by epiradicular veins. The ventral ramus of the spinal nerve arises just lateral to the intervertebral foramen and passes forward and laterally onto the transverse process.
Radicular arteries arise from the vertebral artery and the ascending cervical artery and accompany the spinal nerve and its roots to the spinal cord. Cervical transforaminal injections can be performed with the patient lying in a supine, an oblique, or a lateral decubitus position, depending on operator preference and patient comfort.
The position must allow adequate visualization of the cervical intervertebral foramina in anteroposterior, lateral, and oblique planes. The critical first step is to obtain a correct oblique view of the target foramen.
In this view, the foramen is maximally wide transversely, and the anterior wall of the superior articular process projects onto the silhouette of the lamina.
Through a puncture point overlying the posterior half of the target foramen, a needle is passed into the neck. Its tip should always lie over the anterior half of the superior articular process, lest it be inserted prematurely and too far into the foramen.
When the needle has reached the superior articular process, the needle is then readjusted to enter the foramen tangential to its posterior wall, opposite the equator of the foramen fig. Above this level, the needle may encounter veins; below it, the needle may encounter the spinal nerve and its arteries. The needle lies halfway between the medial and lateral borders of the articular pillars. Using an anteroposterior view, the tip of the needle should finally be adjusted to lie opposite the sagittal midline the articular pillars.
Insertion beyond this depth risks puncturing the dural sleeve or thecal sac. The final position should be checked and recorded on an oblique view fig. Under direct, real-time fluoroscopy in the anteroposterior view, a small volume of nonionic contrast medium 1. The solution should outline the proximal end of the exiting nerve root and spread centrally toward the epidural space fig.
Real-time fluoroscopy is essential to check for inadvertent intraarterial injection, which may occur even if the needle is correctly placed fig. Intraarterial injection is manifest by rapid clearance of the injected contrast. Contrast medium may also fill epiradicular veins, which are recognized by the slow clearance of the contrast, characteristic of venous flow. An anteroposterior view of an angiogram obtained after injection of contrast medium, before planned transforaminal injection of corticosteroids.
The needle lies in the left C7—T1 intervertebral foramen no further medially than its mediolateral point. Contrast medium outlines the exiting nerve root arrowhead. The radicular artery appears as a thin thread passing medially from the site of injection small arrow. Only a small volume of contrast medium 1. As it spreads onto the thecal sac, the contrast medium assumes a linear configuration fig.
Rapid dilution of the contrast medium implies subarachnoid spread, which may occur if the needle has punctured the thecal sac or a lateral dilatation of the dural root sleeve into the intervertebral foramen. When the target nerve has been correctly outlined, a small volume of a short-acting local anesthetic and corticosteroid are injected. The indication for cervical transforaminal injection of steroids is for the treatment of cervical radicular pain with or without radiculopathy.
The difficulties in making this diagnosis have been reviewed elsewhere. Paresthesias, segmental numbness, weakness, and loss of reflexes are reliable and valid signs of radiculopathy that allow the diagnosis to be made clinically, without recourse to investigations. Disc protrusion and foraminal stenosis are the most common causes, but diagnostic imaging is required to exclude tumors and other infrequent causes such as infection, trauma, or inflammatory arthritides.
Outcomes were measured using a functional outcome categorization that combined measures of pain, work status, medication use, and patient satisfaction. Using a prospective cohort design, Vallee et al. Together, the studies of Slipman et al. However, these studies were observational studies without any comparison treatment. Their outcomes may be due to the natural history of cervical radicular pain syndromes or nonspecific treatment effects.
Cervical epidural steroids placed by the interlaminar route have also been advocated for the treatment of radicular pain. Some investigators have reported no complications resulting from the use of cervical transforaminal injection of steroids.
The literature reports one case of fatal spinal cord infarction attributed to a transforaminal injection of corticosteroids. In some of the unpublished cases, it seems that steroids have been injected into the vertebral artery. Correct needle placement should ensure that the needle is not in the vertebral artery, and due attention to the flow of a test dose of contrast medium would reveal if it is. In the published case, and in most of the unpublished cases, no radiographic records are available to establish exactly where the needle was placed.
In these cases, the basis for neurologic complications remains unclear. The leading conjecture has been that, somehow, a radicular artery was compromised. Digital subtraction, real-time fluoroscopic imaging revealed contrast medium filling a tiny vessel that ran transversely, directly to the spinal cord: On seeing this image, the operator promptly abandoned the procedure.
The patient experienced no ill effects. These cases provide circumstantial evidence of the mechanism of spinal cord injury after cervical transforaminal injection of steroids. Material can be injected inadvertently into radicular arteries. It seems feasible that particulate matter in depot preparations of corticosteroids might act as an embolus, and if it enters an artery that happens to be a critical reinforcing supply to the anterior spinal artery, the spinal cord would be infarcted.
Large caliber vessels that reinforce the anterior spinal artery are variable in incidence and in location and can occur anywhere from C3 to C8.
Longitudinal spread of intraneuronally injected local anesthetic can lead to unexpected spinal anesthesia. A compelling evidence base for conservative treatment of cervical radicular pain is lacking, and patients with severe pain may not benefit from conservative therapy. The choice then lies between surgery and transforaminal injection of steroids. There have been no controlled studies of cervical transforaminal injection of steroids.
Consequently, their efficacy has not been established. Nevertheless, the results of observational studies render transforaminal injection of steroids an option. Similarly, the efficacy of surgery has not been demonstrated by a prospective, randomized, controlled trial. No studies, however, have reported exactly what proportions of patients are rendered completely pain free or for how long. The singular disadvantage of cervical transforaminal injection of steroids is the risk of serious complications.
Were it not for the risk of spinal cord injury, cervical transforaminal injection of steroids would probably find a place in the management of cervical radicular pain, even in the absence of controlled studies.
The incidence of serious complications from cervical surgery is not known. If these are similar in nature and similar in incidence to those of cervical transforaminal injections, some proponents of injections would argue that the risk of complications is not grounds for denying patients the option of treatment with injections. There is clearly a need for better data on the efficacy of cervical transforaminal injection of steroids as well as surgery for radicular pain.
To this end, a comparison of surgery and cervical transforaminal injection of steroids in a prospective clinical trial is warranted. There is also a need for accurate data on the incidence of complications from either treatment.
It is disappointing that lawyers, the practitioners involved, and their patients have not released the available material regarding complications. That information could shed light on how the complications occurred. Intraarterial injection might prove not to be the mechanism of injury.