What are the steps to perform a cervical epidural steroid injection?

Cervical Epidural Steroid Injection: Step-by-Step Technique

Critical Pre-Procedure Considerations

Before performing cervical epidural steroid injections, recognize that the 2025 BMJ guidelines provide a strong recommendation AGAINST epidural injections for chronic axial (non-radicular) spine pain, stating "all or nearly all well-informed people would likely not want such interventions." 1 These procedures should only be performed for true radicular pain with nerve root compression documented on MRI. 2, 3

Patient Selection Criteria

• Confirm true radiculopathy: Pain must radiate into the upper extremity in a dermatomal distribution, not just neck pain 2, 4
• Document failed conservative therapy: Minimum 4-6 weeks of physical therapy, NSAIDs, and activity modification 2, 3
• Obtain recent MRI: Must show nerve root compression, disc herniation, or spinal stenosis correlating with clinical symptoms 2, 3
• Exclude contraindications: Active infection, coagulopathy, severe spinal stenosis with cord compression 5, 6

Informed Consent Requirements

Discuss specific complications including dural puncture, insertion-site infections, cauda equina syndrome, sensorimotor deficits, spinal cord injury, epidural hematoma, and rare catastrophic events including paralysis and death. 1, 2, 7 The transforaminal approach carries higher risk than interlaminar. 2

Equipment and Setup

• Fluoroscopy C-arm positioned for optimal visualization 2, 5
• Sterile technique with full surgical prep and drape 5
• 18-20 gauge Tuohy needle with loss-of-resistance syringe 5
• Non-particulate steroid (dexamethasone preferred to avoid embolic complications) mixed with local anesthetic 7
• Contrast medium for epidurography 5

Interlaminar Approach: Detailed Technique

Step 1: Patient Positioning

• Position patient prone on fluoroscopy table 5
• Place small pillow under chest to flex cervical spine slightly 5
• Ensure head is in neutral position 5

Step 2: Level Selection and Imaging

• Target the level of pathology shown on MRI, not automatically C7-T1 5
• The most common injection levels are C5-6 and C6-7, though injections can safely be performed as high as C2-3 5
• Position C-arm for true AP view with endplates parallel 5
• Obtain lateral view to confirm posterior approach trajectory 5

Step 3: Skin Preparation and Anesthesia

• Prep skin with chlorhexidine or betadine using sterile technique 5
• Mark entry point at midline between spinous processes under fluoroscopic guidance 2, 5
• Infiltrate skin and subcutaneous tissue with 1% lidocaine 5

Step 4: Needle Insertion

• Insert Tuohy needle at midline between spinous processes 5
• Advance needle in true midline sagittal plane using intermittent AP fluoroscopy 5
• Direct needle slightly cephalad (10-15 degrees) to parallel the laminar slope 5
• Use loss-of-resistance technique with saline or air as needle advances through ligamentum flavum 5

Step 5: Epidural Space Confirmation

• Stop immediately upon loss of resistance 5
• Obtain lateral fluoroscopic view to confirm needle tip position in posterior epidural space 5
• Needle tip should be at or just past the posterior laminar line, not extending into spinal canal 5
• Perform epidurography: Inject 1-2 mL contrast medium under live fluoroscopy 5
• Confirm contrast spreads in epidural space without vascular uptake, subdural spread, or subarachnoid spread 5

Step 6: Therapeutic Injection

• After negative aspiration and satisfactory epidurography, inject 10-15 mL total volume 8
• Use mixture of non-particulate steroid (dexamethasone 10 mg) with 0.5% lidocaine 8
• Inject slowly over 1-2 minutes while monitoring patient for symptoms 5
• Watch for immediate adverse reactions including pain, paresthesias, or motor weakness 5

Step 7: Post-Procedure Monitoring

• Remove needle and apply sterile dressing 5
• Monitor patient in recovery area for 30-60 minutes 8
• Assess motor and sensory function before discharge 5
• Document final needle position, contrast pattern, and any complications 5

Common Pitfalls and Safety Considerations

Anatomic Hazards

• The cervical spinal cord occupies more of the spinal canal than in lumbar spine, leaving less margin for error 7, 6
• Severe central canal stenosis increases risk; consider alternative approaches or avoid injection entirely 6
• The cervical epidural space is narrower (1.5-2 mm) compared to lumbar (5-6 mm) 7

Technical Errors to Avoid

• Never advance needle beyond loss of resistance - this risks dural puncture or cord injury 5
• Never inject without epidurography - blind injection risks intravascular, subdural, or intrathecal placement 5
• Never use particulate steroids (methylprednisolone, triamcinolone) due to embolic stroke risk 7
• Do not perform injections above C7-T1 without specific training - contrary to older teaching, this is safe but requires experience 5

Complication Recognition

• Dural puncture occurs in <1% of cases; if CSF returns, abort procedure 5, 8
• Immediate severe pain or paresthesias during injection suggests nerve root irritation or intraneural injection - stop immediately 5
• Facial flushing occurs in 9.3% of patients and resolves within 12 hours 8
• Neck stiffness occurs in 13.2% of patients and resolves within 24 hours 8

Evidence Quality and Guideline Context

The 2025 BMJ guideline provides strong recommendations AGAINST cervical epidural injections for chronic axial spine pain without radiculopathy, noting patients would be "disinclined to receive treatment with an interventional procedure for which there is very low certainty of evidence for benefit." 1 However, the 2021 ASIPP guidelines provide moderate to strong recommendations FOR fluoroscopically-guided cervical interlaminar epidural injections specifically for radicular pain associated with disc herniation or spinal stenosis. 1

The key distinction is radicular versus axial pain - injections should only be performed when true radiculopathy with imaging correlation exists. 2, 3, 4 A retrospective series of 12,168 cervical epidural injections found no correlation between spinal level and complication rates, with only 7 serious complications and no paralysis or death, supporting safety when proper technique is used. 5