What is the recommended approach for a cervical interlaminar steroid (corticosteroid) injection?

Cervical Interlaminar Steroid Injection: Recommended Approach

Critical Safety Considerations

Cervical interlaminar epidural steroid injections (ICESI) can be safely performed at levels above C7-T1 when using fluoroscopic guidance with epidurography, contrary to outdated opinions suggesting these should only be performed at the lowest cervical level. 1

Fluoroscopic Guidance is Mandatory

• All cervical interlaminar injections must be performed under fluoroscopic guidance with epidurography prior to therapeutic injection to confirm proper needle placement and avoid catastrophic complications including spinal cord injury, stroke, and quadriplegia 1, 2
• Digital subtraction angiography should be available to detect inadvertent vascular injection, particularly during transforaminal approaches 3

Major Complications to Discuss During Informed Consent

• Spinal cord damage from intracord injection can cause immediate quadriplegia, though favorable recovery is possible with emergent methylprednisolone therapy within 8 hours 4
• Vertebral artery injection with particulate steroids can cause embolic strokes to the spinal cord, brainstem, and cerebellum 2
• Epidural hematoma, infection (abscess/meningitis), and dural puncture with post-dural puncture headache 5, 2
• Minor complications include transient neck stiffness (13.2%), facial flushing (9.3%), vagal episodes, and prolonged paresthesias 5, 3

Technical Approach

Patient Selection and Indications

• Cervical radiculopathy with MRI-confirmed nerve root compression is the primary indication 6, 7
• Patients must have failed at least 4-6 weeks of conservative therapy including physical therapy, NSAIDs, and activity modification 6
• Do NOT perform for non-radicular neck pain - this has no evidence basis and carries a strong recommendation against use 7, 8

Injection Technique

• Target the injection to the specific level of pathology rather than defaulting to C7-T1, as inflammation at the pathologic level may prevent cephalad spread of injectate 1
• Use a 27-gauge needle for cervical injections 9
• Inject 10-15 mL of 0.5% lidocaine containing 1 mg/kg methylprednisolone acetate (or equivalent steroid) 5
• Perform epidurography routinely before therapeutic injection to confirm epidural placement and rule out intravascular or intrathecal positioning 1

Spinal Level Selection

• The most common injection levels are C5-6 and C6-7, though injections can be safely performed as high as C2-3 when clinically indicated 1
• In a series of 12,168 injections, complication rates were not increased at higher cervical levels compared to C7-T1 1

Comparative Safety Data

Interlaminar vs Transforaminal Approaches

• Interlaminar approach: 0.52% minor complication rate in expert hands 3
• Transforaminal approach: 0.32% minor complication rate, but carries higher risk of catastrophic vascular complications 3, 2
• When performed by experienced interventionalists, major complications are rare but can occur - it may take years of practice before encountering a serious complication 3

Post-Procedure Monitoring

• Patients should be observed in a post-anesthesia care unit setting 1
• Monitor for immediate neurological changes including weakness, sensory deficits, or loss of consciousness 4
• Warn patients about expected minor side effects: neck stiffness lasting 12-24 hours and facial flushing lasting approximately 12 hours 5

Critical Pitfalls to Avoid

• Never perform these injections for mechanical neck pain or spondylosis without radiculopathy - this exposes patients to serious risks without evidence of benefit 7, 8
• Do not proceed without fluoroscopic guidance - "blind" cervical epidurals are contraindicated 1, 2
• Avoid particulate steroids if there is any concern for vascular injection, as these can cause embolic strokes 2
• Do not delay necessary surgical intervention by performing multiple ineffective injections at insurance company request 2