Top: William Strub with Brian Stainken.
Middle: Patient positioning for translaminar cervical ESl.
Bottom: an epidural spinal needle is inserted followed by an epidurography (bottom of article) to confirm placement.
At the recent Society of Interventional Radiology (SIR) meeting held in Seattle, WA, March 1-6, 2007, results from the largest series of patients to date showed that the translaminar approach to cervical spinal steroid injections can reduce neck pain in 83% of those treated. The paper has been accepted for publication in the Journal of Vascular and Interventional Radiology.
As a part of a collaborative effort with Interventional Radiologists at the Christ Hospital in Cincinnati, Ohio, lead researcher Dr William M Strub, University of Cincinnati, OH, presented the results and explained that in addition to being an effective treatment, the translaminar approach was found to be an extremely safe procedure as no major complications were observed.
The purpose of the study was to assess the efficacy of translaminar cervical epidural steroid injection in the management of neck pain and assess for any categorical factors that can help predict the clinical outcome.
In the study, 161 patients were recruited (69 males and 92 females) with an average age of 53. Patients suffered from pain for four months on average before undergoing their initial injection. One hundred and nineteen patients had multiple injections, 87 underwent two and 32 underwent three. The average length between treatments was four weeks and there were no major complications observed. Follow-up was up to six months.
The neck pain treated by these steroid injections was due to aging of the spine, including degenerative changes such as osteoarthritis of the spine, bone spurs, disc degeneration and narrowing of the spinal canal. During the procedure, the interventional radiologist uses real-time, continuous X-ray imaging to guide a small needle into the base of the neck between C7 and T1 vertebrae, and injects a small amount of medication. The medication then spreads up and down the spinal canal.
Methods
A retrospective analysis was performed of all patients who underwent a cervical translaminar epidural steroid injection between December 1, 2003 and April 31, 2006. Injections were performed by five different interventional radiologists at three separate institutions. All patients were assessed by telephone ten days after the procedure to determine the efficacy, using a 4 level scale (0 = no relief, 1 = minor relief, 2 = some relief, and 3 = substantial relief). Any complications that occurred during or after the procedure were also noted, explained Strub.
Strub explained that the procedure is performed while the patient is placed prone on the fluoroscopy table after the skin of the posterior neck is prepped in sterile fashion.
Positioning is aided by the placement of a pillow under the chest and a towel roll under the forehead (Figure 1). This helps widen the interlaminar space by flexing the spine. Using a 22 gauge Tuohy (Hyua Medics) epidural spinal needle, the epidural space is accessed, and epidurography with Isovue M 200 (Bracco Diagnostics) is performed to confirm needle placement (Figure 2). Contrast injection documents epidural placement of the needle tip by visualising free flow of contrast (Figure 3). This is followed by injection of 3.0-3.5ml of a solution containing 2.0ml of Kenalog (40mg/ml) and 1.0-1.5ml of preservative free normal saline (Figure 4). The 3.0ml volume is used as it is felt to be sufficient enough to allow distribution throughout the epidural space but not too large to cause mass effect.
The most common means to access the epidural space other than the interlaminar approach is transforaminally. According to Strub, with this technique, the needle tip is steered more ventrally where the posterior annulus interfaces with the ventral aspect of the nerve root and the thecal sac. Ascending and deep cervical arterial branches, which occasionally supply anterior radicular and segmental medullary arteries to the spinal cord, enter the intervertebral foramen near the target area for the transforaminal injections and must be avoided1. It is also technically more difficult and requires a more precise needle placement that the interlaminar ESI2, explained Strub.
In this study, the translaminar technique avoids this risk by injecting the steroids into the posterior epidural space in the neck, away from the small blood vessels, enabling the steroid solution to spread along the spine and reduce inflammation and hence alleviate pain. The translaminar procedure is an outpatient treatment, requiring only local anaesthetic, and patients can return to their normal activities within a day. However, the injection does not treat the underlying cause of pain, such as arthritis or herniated disc. "Although the other approach offers pain relief, there is likely an increased risk of major complications such as paralysis," explained Strub.
Study results
A total of 280 injections were performed and the median (range) duration of symptoms until the time the procedure was performed was four months. Radiculopathy with symptoms in hand/finger, shoulder, neck, arm and other locations was reported in 65 (41%), 99 (62%), 79 (49%), 113 (71%), and two (1%) patients, respectively. Strub reported that 145 patients had multilevel spondylitic changes (93%), and 15 patients reported prior surgical history of the cervical spine (9%). Narcotics were required for pain relief prior to the procedure in 44% of the patients.
Eighty seven and 32 patients (54% and 20%) underwent the second and the third procedures, respectively. The median (range) length of two concessive procedures was 28 (13, 273) days, and the median (range) length between procedure and follow-up was ten (3, 56) days. A total of 13 patients went to surgery after their second or third injections (8%).
The average pain relief rate and complication rate were 83% and 5% respectively. Strub explained that most of the procedures (87%) were performed on levels C7-T1. On clinical follow-up three patients reported an increased in neck pain. Additionally, there were five patients who each reported different symptoms that were felt to be side effects of the steroids: weight gain, difficulty sleeping, facial flushing, hot flashes, and emotional lability.
Patients with the presence of multilevel degenerative changes were more likely to report improved pain relief than those who presented with single level degenerative discogenic changes (OR = 4.13, p-value = 0.0055). Patients with hand/finger symptoms also showed higher odds of improved pain relief (OR = 2.72, p-value = 0.0011) compared to other symptoms elsewhere.
Procedures performed at levels C7-T1 were more likely to produce improved pain relief for patients (OR = 2.44, p-value = 0.0034), said Stub. Patients who required narcotics for pain control prior to the procedure, rather than traditional non-steroidal anti-inflammatory medications, did not experience as much pain relief after the procedure (OR = 0.80, p-value = 0.4367). There was no evidence of operator effect (five interventional radiologists) and site effect (three institutions) in our analysis, said Strub.
Minor complications that can occur after epidural steroid injections include insomnia, transient headaches, increased extremity pain, facial flushing, vasovagal reaction, nausea, hypertension, and arachnoiditis2.
Corticosteroid effects can cause fluid retention, low grade fever, elevated serum glucose levels, mood swings, fat atrophy, depigmentation of skin, and pain flair3. The researchers observed many of the same complications observed by others with no adverse outcomes.
In terms of contra-indications, Strub explained, "The patient needs to have a safe level to perform the injection, ie. enough epidural space for the medication to be injected without causing mass effect on the cord. This is why the pre-procedural MRI is so useful, so we can avoid C7-T1 if there is severe central stenosis at this level."
He concluded, "This procedure can help provide pain relief in patients with neck pain from bulging discs, arthritis, and even patients who continue to have pain after cervical spine surgery. It's well tolerated, outpatient, non-surgical, safe and effective, and as such, we expect this approach to become the gold standard for reducing patients' neck pain."
The manuscript recently received conditional acceptance for publication in the Journal of Vascular and Interventional Radiology.
References
1. Huntoon MA. Anatomy of the cervical intervertebral foramina: vulnerable arteries and ischemic neurologic injuries after transforaminal epidural injections. Pain 2005; 117:104-111.
2. Watanabe AT, Nishimura E, Garris JK. Image-guided epidural steroid injections. Tech Vasc Interv Radiol. 2002; 5:186-193.
3. Botwin KP, Castellanos R, Rao S, Hanna AF, Torres-Ramos RM, et al. Complications of fluoroscopically guided interlaminar cervical epidural injections.
Arch Phys Med Rehabil 2003; 84:627-633.
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