Safety of Interlaminar Cervical Epidural Injections: Experience With 12,168 Procedures in a Single Pain Clinic

Abstract

Background: Cervical epidural steroid injections have long been utilized to treat intraspinal inflammation causing cervicalgia and/or cervical radiculopathy, and much has been written about safety and efficacy. There are published opinions, without evidence basis, that these injections should not be performed above C7-T1 for fear of dural puncture, spinal cord injury, and other complications that might occur more frequently at higher spinal levels. However, many experienced interventional pain physicians believe that epidural injections targeted to the level of spinal inflammation may be more effective. Although medication injected at the lowest cervical level C7-T1 may ascend to higher spinal levels, it often does not since inflammation and swelling at the cervical level of pathology may increase epidural pressure causing the injectate to move caudally down the path of least resistance.

Objectives: We sought to provide evidence for safety of posterior interlaminar epidural steroid injections at spinal levels at and above C7-T1 and to outline a 'best practices' approach to posterior cervical epidural injection based on experience with over 12,000 injections over 2 decades. We provide a discussion of cervical spinal anatomy, preferred technique for injection, and briefly review published literature to date regarding safety and efficacy of this procedure.

Study design: Retrospective case series.

Setting: Single center, private practice institution.

Methods: To document safety of interlaminar cervical epidural injections at levels above C7-T1, we conducted a retrospective study where we queried our electronic medical record database for information regarding 12,168 interlaminar cervical epidural steroid injections performed on 6,158 unique patients during a 14-year period by 5 different board-certified interventional pain physicians using similar technique within a single medical practice. Each injection was performed using fluoroscopic guidance with cervical epidurography routinely performed prior to injection of a therapeutic steroid and local anesthetic mixture. We found 129 minor complications (complications that did not require medical care beyond the post-anesthesia care unit [PACU] and 7 complications which we considered serious (required care beyond PACU stay), although no patients suffered paralysis or death. There was no correlation between spinal level of injection and complication rates.

Results: Our most common spinal level for injection was C5-6, followed closely by C6-7. Hundreds of injections were performed at spinal levels above C5-6 with the most cephalad level C2-3.

Limitations: Retrospective design.

Conclusion: Our article supports the contention that interlaminar cervical epidural injections above C7-T1 are safe. Complication rates were not increased with cervical injections cephalad to C7-T1.

Keywords: case series; cervical pain; cervical radiculopathy; chronic pain; complications; interventional pain; outcomes; Cervical epidural steroid injection.