Role of Steroids in Degenerative Cervical Spondylosis
Systemic corticosteroids have no established role in the treatment of axial degenerative cervical spondylosis, but epidural and transforaminal steroid injections can provide meaningful short-term pain relief for cervical radiculopathy caused by spondylotic nerve root compression.
Systemic Corticosteroids: Not Recommended
Systemic glucocorticoids are not supported by evidence for axial cervical spondylotic disease 1. The ASAS/EULAR guidelines for axial spondyloarthropathies explicitly state that systemic glucocorticoids lack evidence for axial disease 1.
Oral or intravenous corticosteroids have no demonstrated benefit for mechanical neck pain or myelopathy from cervical spondylosis 1.
The evidence base for systemic steroids in spinal degenerative disease is derived primarily from ankylosing spondylitis studies, where they similarly show no efficacy for axial symptoms 1.
Epidural and Transforaminal Steroid Injections: Evidence-Based for Radiculopathy
When to Consider Injections
Cervical epidural steroid injections are most effective for patients with cervical radiculopathy caused by spondylosis or disc herniation 2. In a 6-month follow-up study, 41.4% of patients achieved excellent results (≥90% pain relief lasting 6 months), and patients with cervical spondylosis had statistically significantly better outcomes than other diagnoses (p<0.001) 2.
Transforaminal steroid injections should be considered for patients with unilateral cervical radiculopathy who have failed conservative management 3, 4. These injections target the specific inflamed nerve root and may reduce or eliminate the need for surgery 4.
Expected Outcomes
Approximately 49% of patients with cervical radiculopathy achieve >50% arm pain reduction with repetitive transforaminal steroid injections 3. This prospective study of 140 patients used three injections spaced 3 weeks apart, with follow-up at 12-14 weeks 3.
In a smaller prospective study, 24% (5 of 21) of surgical candidates cancelled their planned cervical disc surgery after receiving two transforaminal steroid injections, with statistically significant reduction in radicular pain (p=0.02) 4.
Long-term results show that 41.4% maintain excellent pain relief at 6 months, while 29% have good results (>50% relief lasting ≥6 weeks) 2.
Technical Considerations
Transforaminal injections should be performed under image guidance (fluoroscopy) by experienced practitioners 3, 4. The procedure targets the specific nerve root affected by spondylotic compression 3.
A diagnostic nerve root block with local anesthetic should demonstrate at least 50% temporary arm pain reduction before proceeding with therapeutic steroid injections 3.
The typical protocol involves 2-3 injections spaced 2-3 weeks apart 3, 4.
Intra-articular Facet Injections: Not Recommended
Intra-articular facet joint steroid injections are explicitly recommended against for chronic low back pain from degenerative disease 5, and this recommendation extends to cervical facet disease 1, 5.
The American College of Neurosurgery provides moderate (Level II) evidence against intra-articular facet injections for chronic pain from degenerative spinal disease 5.
If facet-mediated pain is suspected, facet medial nerve blocks or ablation are preferred over intra-articular steroid injections 5.
Clinical Algorithm for Steroid Use
Step 1: Identify the Pain Pattern
- Radicular arm pain with dermatomal distribution → Consider epidural or transforaminal steroid injections 3, 2, 4
- Axial neck pain only → Systemic or injected steroids are not indicated 1
- Myelopathy symptoms → Steroids have no role; surgical evaluation is appropriate 6
Step 2: Confirm Anatomical Correlation
- MRI or myelography must demonstrate nerve root compression at the level corresponding to clinical symptoms 3, 4
- Imaging findings of spondylosis without radicular symptoms do not justify steroid injections 5
Step 3: Document Conservative Treatment Failure
- Patients should have failed at least 6 weeks of conservative management including activity modification, physical therapy, and oral analgesics 5, 6
Step 4: Perform Diagnostic Block
- A selective nerve root block with local anesthetic should produce at least 50% temporary pain relief before proceeding with therapeutic steroid injections 3
Step 5: Therapeutic Injection Protocol
- Administer 2-3 transforaminal steroid injections spaced 2-3 weeks apart under fluoroscopic guidance 3, 4
- Reassess at 6 weeks and 3-4 months 3, 4
Important Caveats and Pitfalls
Do not use steroids for cervical myelopathy 6. Myelopathy requires surgical decompression, and steroids may delay appropriate treatment 6.
Complication risk must be considered 4. Transforaminal cervical injections carry rare but serious risks including spinal cord injury, stroke, and paralysis due to inadvertent arterial injection 4.
Responders to cervical epidural steroids improve both neck and arm pain equally 4, suggesting the mechanism may not be purely anti-inflammatory at the nerve root level 4.
Patients with disc herniation respond similarly to those with spondylosis 4, indicating that the underlying pathology (herniation vs. osteophyte) does not predict response 4.
The effect is temporary in most patients 2. Only 41.4% maintain excellent results at 6 months, so injections should be viewed as a bridge to other treatments or as a diagnostic/prognostic tool before surgery 2, 4.