Non-operative Treatments and Cervical Epidural Steroid Injection
Alexander C. Simotas, MD
Assistant Attending Physiatrist, Hospital for Special Surgery Assistant Professor of Clinical Rehabilitation Medicine, New York – Presbyterian Hospital
Overview of Cervical Radiculopathy
Evaluation and Diagnosis of Cervical Radiculopathy
Non-operative treatment of Cervical Radiculopathy
Epidural steroid injection treatment
Cervical Radiculopathy Surgical intervention
I. Overview of Cervical Radiculopathy
Cervical radiculopathy refers to a pinching or inflammation of a cervical nerve from its exit point in the spine, called the neuroforamen. Although most acute neck pain is a relatively common ailment that usually resolves within a couple of weeks, some neck pain can persist and may be also present in the shoulder or arm. The symptoms of cervical radiculopathy may also include pain, numbness, or weakness in different areas of the arm or hand. Different common conditions associated with cervical radiculopathy include:
Cervical disc herniation:
The spacer between vertebrae called the disc is actually a two-part structure. The circular outer layer, or annulus, is tough and ligament-like and contains the gel-like inner part, or nucleus. Gradual or severely sudden tears through annulus may allow changes in the outer contour of the disc to protrude like a pimple. While any slight protrusion of a disc is classified as a herniation, the most problematic ones often occur at the passageway of a spinal nerve.
Cervical spondylosis refers to gradual wear and tear or age-related (often referred to as degenerative) changes. Many of these changes can be diagnosed or identified on conventional X-rays and other imaging examinations and may include narrowing of the disc space, bulging of the contour of the disc, and calcification of the disc and vertebral margins that result in spurs. It is well-established that degenerative changes of the cervical spine increase with age and may occur in individuals without a history of neck pain. It remains unclear if degenerative changes are directly related to the pain, as normal or less degenerative disease in the spine may be symptomatic (and vise versa). In some cases, the spurring significantly narrows around the nerve root exit passage or foramen (referred to neuroforaminal stenosis). This condition can lead to repeated episodes of cervical radiculopathy.
II. Evaluation and Diagnosis of Cervical Radiculopathy
Neck pain and arm pain can occur simultaneously or separately over the course of cervical radiculopathy. Your physician may attempt to provoke the pain by extending your neck and head backward. Changes in reflexes, patches of sensation loss, and specific muscle weakness attributable to the dysfunction of a cervical spinal nerve may be detected on a careful physical examination.
Conventional X-ray of the cervical spine may show the margins of the bony vertebra and bony spur formation in the area of the nerve foramen. MRI or CT scans of the cervical spine demonstrate the spine in cross section as well as in other planes and also can visualize surrounding soft tissue structures, such as the disc and nerves that are not visible on conventional X-ray. The actual dimensions of existence and relative severity of disc herniation and foraminal stenosis can be more formally evaluated on these scans. Most importantly, these findings should be correlated with the patient’s symptoms and problems. A high rate of disc herniation and spondylosis has been noted to occur in individuals who never experience symptoms. This occurs in higher frequency, perhaps not surprisingly, as people age.(2;3)
III. Non-operative treatment of Cervical Radiculopathy
The logic of using non-operative treatment is reinforced by a variety of evidence from scientific studies. Some studies have shown that cervical radiculopathy usually improves with time without the need for surgery. Two studies of patients treated non-operatively for cervical radiculopathy have shown that disc herniation had significantly regressed after a period of time on repeated scans.(4;5) Other studies demonstrated good outcome results for patients suffering with significant cervical radiculopathy treated with non-operative therapies using oral anti-inflammatories, oral corticosteroids, collar immobilization, physical therapy, traction, and in many cases, epidural steroid injections.(6-8) Preliminary results from our study show that 65% of patients with cervical radiculopathy that have not responded to physical therapy and oral medications still can experience significant benefits with cervical epidural steroid injection.(9) The nature of some of these non-operative treatment modalities are noted below.
Relative rest and collar immobilization:
It may be important to refrain from repetitive movements of the neck and forceful or heavy lifting movements during the acute phase. A soft cervical collar is often helpful to limit neck motion and provide splinting or rest in a position of comfort.
Medication: Whenever possible, your physician may prescribe anti-inflammatory medication, particularly at the outset of the problem. Some radiculopathies will respond to non-steroidal anti-inflammatory medication alone, but a short course of oral corticosteroid medication is often prescribed as well.
The physical therapist can administer intermittent traction to help relieve pain. If traction is particularly effective, a patient can purchase a traction unit and self-administer traction at home on a regular basis. When pain is reduced, range of motion and strengthening exercises can help to gradually restore areas in the neck and shoulder that have been weakened by disuse and pain.
IV. Epidural steroid injection treatment
In many cases, the initial therapies for cervical radiculopathy are ineffective. Epidural steroid injection may benefit patients who would otherwise suffer with the kind of lasting pain that would sometimes necessitate surgical treatment. The procedure can be performed in an outpatient setting using fluoroscopy (x-ray guidance). A trained specialist will use an MRI scan and physical exam to identify to suspected area of injury. Under fluoroscopic guidance, a needle can be directed – in most cases under local anesthesia alone – to the target site. The membrane covering the spine and nerve roots is called the dura. The space surrounding the dura is the epidural space. An epidural injection places anti-inflammatory medicine into the epidural space to decrease inflammation of the nerve roots, reducing pain and hopefully aiding the healing process. It may provide permanent relief or pain relief for several months while the injury/cause is healing.
Improvement may occur immediately or within two weeks. Some patients will respond with one injection, but some may require up to three, interspersed over the course of a recovery period of one to three months. Most patients will benefit from a gradual exercise performed simultaneously with the supervision of a physical therapist.
Figure 1: Model showing needle positioning for transforaminal epidural steroid injection.
￼ Figure 2: Fluoroscopic image of a Left C6/7 transforaminal epidural injection. Contrast solution outlines the epidural space and exiting cervical nerve root. Immediately afterwards, a solution of corticosteroid and local anesthetic were injected.
V. Cervical Radiculopathy Surgical Intervention
Most patients recover with non-operative treatment. If pain continues in spite of these treatments, surgical treatment may be recommended. Additionally, patients with more severe radiculopathy can decide to have surgical treatment at an earlier point in time.
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