Epidural for Neck Pain Safer Using Ultrasound

Epidural steroid injections for neck pain are not always a preferred treatment as there are concerns about accidental damage to the complex structures in the cervical spine. Lumbar epidural steroid injections are more common for pain relief however and are also often used to determine the exact site of nerve irritation prior to back surgery. Recent research suggests that ultrasound guidance can reduce the risks associated with epidural steroid injections in the cervical spine and so many neck pain sufferers may now consider this a viable treatment option.

Why Use Epidural Injections for Neck Pain?

Research presented earlier this month at the European Congress of Radiology 2012 outlined the usefulness of ultrasound to guide transforaminal epidural steroid injections (TF-ESIs) in the treatment of cervical radiculopathy. Inflammation causing pinched nerves in the neck can result not only in neck pain but also in shooting pains, numbness, weakness, and paraesthesia in the arms, shoulders, hands, chest, and up into the head. Using oral steroids to reduce the inflammation is ill-advised over the longer terms due to the potential side-effects of steroids. Targeted injections to reduce inflammation risk damage to the cervical spine however and necessitate the use of a fluoroscope or CT guidance during the procedure. Where steroid injections are not possible, unresponsive cases of cervical spinal pain and radiculopathy often require neck surgery.

Dangers of Epidural Spinal Injections

Complications of more invasive interventions can be severe with an increasing volume of evidence demonstrating the potential for brain and spinal cord infarction following epidural injections in the cervical spine. Lead author of the new study, Waseem A. Bashir, MD, from the Department of Radiology, Ealing Hospital NHS Trust in London, United Kingdom, noted that ultrasound permits safe, accurate, and real-time injections for such patients with neck pain and radicular pain. It also avoids the risks associated with ionizing radiation and complications from use of contrast dye to help visualize the cervical spinal anatomy when using fluoroscope or CT guidance.

Sonography vs. CT and Fluoroscope Guidance

In the study carried out in London, Dr. Bashir looked at forty patients with cervical radiculopathy who had not responded to conservative treatments and had been referred for cervical spinal epidural steroid injections using fluoro-guidance or CT-guidance. The patients instead had ultrasound-guided injections using a 35-gauge spinal needle to apply steroid medication directly into the foraminal space where the irritated nerve roots were present. The nerve root levels were determined during the procedure by counting nerve roots from the cranium and locating the transverse processes in the spinal column. The ultrasound transducer was positioned to identify the carotid and jugular blood vessels before moving to the side to identify the nerve roots. Affected nerve roots were frequently noted as thickened in the patients with neck pain and cervical radiculopathy symptoms.

Avoiding Blood Vessel Damage in the Neck

Using ultrasound to guide the injections allowed the physician to keep the needle in view at all times and also to map bloodflow using color Doppler analysis so as to reduce the risk of injection into a blood vessel in the neck. Patients reported reductions in pain after sic months from baseline and repeat ultrasound identified a reduction in nerve thickness after the guided steroid injections. There were no reported complications and so it appears that sonographic guidance of epidural steroid injections for cervical radiculopathy are advantageous over current methods. Real-time visualization of cervical spinal structures and a high resolution visual of needle placement appears to help in reducing the risks of such injections in the neck. It is, unfortunately, quite a common occurrence for the nerve to block visual access to the blood vessel when conducting epidural steroid injections in the cervical spine with currently available methods such as fluoroscope guidance, meaning that injection of the steroid into the blood vessel rather than the epidural space occurs and pain relief is not achieved. More significant complications such as paralysis, stroke, and death after transforaminal cervical injection have also been reported dozens of times in the past decade, prompting this kind of research into better treatment options.

Ultrasound Use May Increase Epidurals for Cervical Radiculopathy

The technique is new and, whilst appearing much safer than current methods, it may take physicians a little time and effort to become familiar with the method. Not likely to be available instantly for those with cervical radiculopathy, the ultrasound guided epidural steroid injections for neck pain look set to become standard treatment in the next two to five years.

Reference

European Congress of Radiology (ECR) 2012: Abstract B-0298. Presented March 2, 2012.