Is it safe to perform a cervical epidural steroid injection at the C7-T1 level in a patient with grade 1 anterolisthesis?

Safety of Cervical Epidural Steroid Injection in a Patient with Grade 1 Anterolisthesis at C7-T1

Cervical epidural steroid injections at C7-T1 are considered safe and are actually preferred in patients with grade 1 anterolisthesis at this level, as C7-T1 is the recommended access point for cervical epidural injections due to its more generous dorsal epidural space.

Anatomical Considerations for C7-T1 Injections

The C7-T1 level offers several safety advantages for cervical epidural steroid injections:

• The dorsal epidural space is more generous at C7-T1 compared to higher cervical levels 1
• This reduces the risk of dural puncture and potential spinal cord injury 1
• C7-T1 is considered the preferred access point for cervical interlaminar epidural injections 1

Safety Evidence for C7-T1 Injections

A large retrospective study of 12,168 cervical epidural injections found:

• No correlation between spinal level of injection and complication rates 2
• No increased risk of complications at C7-T1 compared to other levels 2
• No patients suffered paralysis or death in this extensive series 2

Technical Considerations for Safe Injection

When performing a cervical epidural injection at C7-T1 with anterolisthesis, several technical factors should be considered:

1. Fluoroscopic guidance is essential:

   • Use AP view for optimal trajectory 1
   • Obtain a lateral or contralateral oblique safety view to confirm needle depth relative to the ventral margin of the lamina 1
   • Perform epidurography to confirm proper needle placement 2

2. Needle placement technique:

   • Use paramedian approach to avoid ligamentum flavum gaps that are most prevalent in the midline 1
   • This provides better tactile feedback with loss of resistance technique 1
   • Careful attention to loss of resistance is crucial to avoid inadvertent dural puncture 1

3. Sedation considerations:

   • Minimize sedation to ensure patient can provide verbal feedback 1
   • Deep sedation has been associated with catastrophic neurologic injuries 1

Important Warnings and Precautions

Despite the relative safety of C7-T1 injections, serious risks exist:

• The FDA warns that serious neurologic events including spinal cord infarction, paraplegia, quadriplegia, and stroke have been reported with epidural corticosteroid injections 3
• These serious events have occurred with and without fluoroscopy 3
• Rare but serious complications include cardiopulmonary arrest 4 and inadvertent subdural spread 5

Conclusion

The grade 1 anterolisthesis at C7-T1 does not contraindicate performing a cervical epidural steroid injection at this level. In fact, C7-T1 is the preferred access point for cervical epidural injections due to its more generous dorsal epidural space and lower risk profile. However, proper technique with fluoroscopic guidance, careful needle placement, and minimal sedation are essential to maximize safety.