What are the most important tips for performing a cervical epidural steroid injection?

Critical Safety and Technical Tips for Cervical Epidural Steroid Injections

Patient Selection is Paramount

Cervical epidural steroid injections should ONLY be performed for true cervical radiculopathy with upper extremity pain in a dermatomal distribution, NOT for axial neck pain alone. 1, 2 The 2025 BMJ guideline provides a strong recommendation against epidural injections for chronic axial spine pain, stating "all or nearly all well-informed people would likely not want such interventions" given the very low certainty of benefit and risk of catastrophic complications. 1

Essential Pre-Procedure Requirements:

• Confirm true radiculopathy: Pain must radiate into the upper extremity in a dermatomal distribution, not just neck pain. 2
• Document failed conservative therapy: Minimum 4-6 weeks of physical therapy, NSAIDs, and activity modification must be completed first. 2
• Obtain recent MRI evidence: Imaging must demonstrate nerve root compression, disc herniation, or spinal stenosis that correlates anatomically with clinical symptoms. 2
• Rule out alternative diagnoses: Ensure symptoms are not from peripheral nerve entrapment or other non-radicular causes. 3

Mandatory Technical Safety Measures

Image Guidance is Non-Negotiable:

• Always use fluoroscopic guidance for both interlaminar and transforaminal approaches to ensure proper needle placement and minimize complications. 3, 4
• Perform cervical epidurography routinely prior to injection to confirm epidural placement and identify intravascular injection. 5
• Consider digital subtraction angiography (DSA) as an adjuvant to fluoroscopy for enhanced visualization of blood vessels, particularly for transforaminal approaches. 6

Needle Selection and Technique:

• Use blunt-beveled needles rather than sharp-beveled needles for transforaminal approaches, as they are less likely to penetrate blood vessels and cause bleeding complications. 6
• Advance the needle incrementally with intermittent fluoroscopic confirmation in both AP and lateral views. 3
• Target the injection to the level of pathology: Contrary to outdated opinions, injections above C7-T1 are safe when performed correctly, as medication injected at lower levels may not ascend adequately due to inflammation creating increased epidural pressure. 5

Critical Medication Safety

Steroid Selection:

• Use non-particulate steroids (dexamethasone) for cervical injections rather than particulate steroids (methylprednisolone, triamcinolone), as particulate steroids carry higher risk of spinal cord infarction if inadvertently injected into spinal arteries. 6
• Mix steroid with small doses of local anesthetic to assist in identifying intravascular injections that may be overlooked by conventional techniques. 6

Aspiration and Test Dosing:

• Always aspirate before injection and observe for blood return. 6
• Inject contrast first and observe the spread pattern to confirm epidural placement and rule out intravascular injection. 5
• Watch for immediate patient response during injection, as local anesthetic can help identify unrecognized intravascular placement. 6

Informed Consent Must Address Catastrophic Risks

Patients must be explicitly counseled about rare but devastating complications, including: 2, 3

• Spinal cord infarction and paralysis (quadriplegia)
• Death
• Stroke and cortical blindness
• Spinal epidural hematoma
• Dural puncture and post-dural puncture headache
• Cauda equina syndrome
• Infection (meningitis, epidural abscess)
• Seizures and brain edema

Between 1997 and 2014, the FDA Adverse Event Reporting System captured 90 serious adverse events occurring within minutes to 48 hours after cervical epidural injections, including death and paralysis. 1

Approach-Specific Considerations

Interlaminar Approach:

• Safer overall risk profile compared to transforaminal approach. 2
• Can be performed at any cervical level: A retrospective study of 12,168 injections found no correlation between spinal level (including C2-3 through C7-T1) and complication rates when proper technique was used. 5
• Most common injection levels: C5-6 followed by C6-7, though hundreds of injections above C5-6 were performed safely. 5

Transforaminal Approach:

• Higher risk than interlaminar due to proximity to spinal arteries. 2
• Requires meticulous technique with blunt needles and DSA when available. 6
• Posterior approach is equally safe and effective as anterolateral approach when performed under CT guidance. 7

Common Pitfalls to Avoid

• Do not perform injections for axial neck pain alone: This is explicitly not recommended and exposes patients to serious risks without evidence of benefit. 1, 2
• Do not skip imaging correlation: MRI findings must match the clinical presentation anatomically. 2
• Do not use particulate steroids: The risk of spinal cord infarction is not justified. 6
• Do not proceed without fluoroscopy: "Blind" injections are never acceptable. 3
• Do not repeat injections without documented benefit: Repeat injections are only appropriate if the initial injection provided at least 50% pain relief for at least 2 months. 3

Expected Outcomes and Limitations

• Short-term benefit only: Cervical epidural steroid injections are effective for short-term treatment of radicular pain (2 weeks to 3 months), not a long-term solution. 3, 4
• Part of multimodal treatment: Injections must be combined with physical therapy, patient education, and other conservative measures. 2, 3
• Not curative: If effective, injections typically require repetition every 2 weeks to 3 months. 1
• Approximately 35% of patients achieve >50% pain relief at 2 months. 7