Can Cervical Epidural Steroid Injections Worsen Symptoms?
Yes, cervical epidural steroid injections can worsen symptoms, though serious complications are rare—the most common adverse effect is transient increased pain at the injection site, while catastrophic complications like spinal cord injury, paralysis, and death occur but are extremely uncommon.
Common Transient Worsening
- Increased pain during or immediately after injection occurs in less than 1% of cases and is generally self-limited, resolving within days with conservative management including NSAIDs and acetaminophen 1
- Post-injection pain typically presents as localized neck or injection site discomfort rather than worsening radicular symptoms 2
- Minor adverse events including non-specific headache, vasovagal response, and transient nerve blocks occur at similar rates in both steroid and placebo groups, suggesting they relate to the procedure itself rather than the medication 3
Serious Complications That Worsen Symptoms
Intrinsic Spinal Cord Damage
- Direct spinal cord penetration during cervical epidural injection can cause permanent neurological injury, particularly when patients are sedated and cannot report pain or paresthesias during needle advancement 4
- Patients who sustain cord injury develop increased pain and new neurologic symptoms within 24 hours of injection, which may be permanent 4
- Fluoroscopic guidance does not guarantee prevention of intrathecal perforation or spinal cord penetration 4
Epidural Air Injection Complications
- Unintentional air injection into the cervical epidural space can cause severe delayed radicular pain through nerve root stretching or entrapment 5
- Pneumocephalus (air in the cranial cavity) following cervical epidural injection presents with severe persistent headache and requires several days of conservative treatment 6
- The loss-of-resistance technique using air carries specific risks in the cervical region due to anatomical considerations 6
Other Catastrophic Complications
- Epidural hematoma and epidural abscess are surgical emergencies presenting with progressive neurologic deficit, severe unrelenting pain, or fever 2
- Between 1997 and 2014,90 serious adverse events from epidural injections were reported, including death, spinal cord infarction, and paralysis 2
- Additional serious complications include dural puncture, cauda equina syndrome, sensorimotor deficits, discitis, epidural granuloma, and retinal complications 7
Critical Safety Measures to Minimize Risk
Patient Selection
- Patients must have true radicular symptoms with MRI-confirmed nerve root compression—cervical epidural injections are not indicated for axial neck pain alone 3, 7
- Avoid sedation during cervical epidural injections to allow patients to report pain or paresthesias that signal needle misplacement 4
Technical Requirements
- Fluoroscopic guidance is mandatory but does not eliminate all risks 7, 4
- Consider using saline rather than air for loss-of-resistance technique to avoid air-related complications 6, 5
- Shared decision-making must include specific discussion of catastrophic risks including paralysis, spinal cord infarction, and death 2, 7
When to Suspect Complication
Immediate evaluation is required if post-injection symptoms include:
- Severe persistent or worsening pain beyond expected transient discomfort 2
- New or progressive neurologic deficits 2, 4
- Fever or signs of infection 2
- Severe headache (suggests pneumocephalus or dural puncture) 6
- Pain that changes in character or distribution 2
Obtain urgent neuroimaging and neurosurgical consultation for any of these warning signs 2.