Image Guided Cervical Nerve Root Sleeve Corticosteroid Injection

Authors: Prof Mark Khangure*
                            Dr Jason Wenderoth *

What are the generally accepted indications for a cervical nerve root sleeve injection?

• Cervical radiculopathy from disc protrusion or degenerative disease narrowing the intervertebral foramen.
• Inflammation of a cervical nerve root as a result of postoperative scarring after discectomy and/or fusion.
• As a diagnostic procedure to ascertain the cause of neck/shoulder/arm pain when exact root involvement is uncertain. However, there is limited evidence for this indication.

What are the prerequisites for having a cervical nerve root sleeve injection done?

Clinical evidence of radiculopathy without acute muscle weakness as a result of degenerative changes and not malignancy or infection.

CT or magnetic resonance imaging will have been carried out before this procedure is considered, and will often show degenerative changes and/or disc compression of the neural foramen. Discussion with the patient about other conservative (e.g. anti-inflammatory medications, physiotherapy) and surgical options for management of the pain is recommended.

A general anaesthetic is not appropriate, as patient input is required for safety of the procedure. However, the procedure may at times be carried out with sedation in patients with an intellectual disability or dementia. An interpreter may be required with language difficulties.

What are the absolute contraindications for a cervical nerve root sleeve injection?

• Imaging and/or clinical evidence of spinal cord compression due to any cause.
• Local infection involving the injection site in the skin or deeper soft tissues.
• Acute muscle weakness in the distribution of the compressed root.

What are the relative contraindications for a cervical nerve root sleeve injection?

• Patient unwell (septic, uncontrolled coughing bouts or delirious).
• Severe uncontrolled hypertension; systolic blood pressure of 200+ and a diastolic blood pressure of 140+ increases the risk of haemorrhage.
• Known allergy to iodinated contrast media without any steroid premedication.

Antiplatelet agents and other anticoagulants may need dose adjustment or cessation. Generally, an INR of 1.5 or less and cessation of antiplatelet agents for 10 days before the procedure is recommended, although aspirin is usually allowed to continue. It is recognised that this may pose a significant risk to some patients; for example, those with atrial fibrillation or recent coronary stents. Therefore, there needs to be discussion with the radiologist in this situation about the relative risks of ceasing medication versus the haemorrhagic complications of the procedure.

What are the adverse effects of a cervical nerve root sleeve injection?

Immediate:

• Exacerbation of pain from direct root injection;
• syncope from a vasovagal response;
• bleeding;
• swallowing difficulty;
• Horner’s syndrome (usually temporary).

Delayed:

• Hot flushes and redness (as a result of response to the corticosteroids);
• infection (local, epidural, meningitis);
• cerebrospinal fluid leak with low-pressure headache days after the procedure is usually self limiting and responds to lying flat in bed, pushing oral fluids and paracetamol; and
• persistent radiculopathy and muscle weakness from direct root injection.

There are several severe and immediate, but rare, complications including:

• posterior circulation stroke;
• quadriparesis – temporary (as a result of a inadvertent epidural injection) or permanent; and
• anaphylaxis.

Is there any specific post procedural care required following a cervical nerve root sleeve injection?

• In general, anticoagulant drugs may be started the day following the procedure, but it is advised to check this with the radiologist on the day of the procedure.
• Avoidance of strenuous activity for a couple of days.
• Driving should be avoided on the day of the procedure (it is advisable to have someone drive the patient to and from the practice).
• Patients are advised to continue any regular pain relief medications they are taking, particularly for the first 24 hours post-procedure, because the injection may in fact exacerbate symptoms during this period. After that, they are advised to wean off any medications they are on, tapering to zero on day 4–5 post-injection to assess the effect of the injection. If they are not on any medication at the time of the procedure, they are advised to take 1g paracetamol every 6 hours for 24 hours post-procedure, then as needed according to the directions on the packaging thereafter.

Most patients are able to continue normal activities the next day.

In the event further complications develop, immediate review is advised.

Are there alternative imaging tests, interventions or surgical procedures to a cervical nerve root sleeve injection?

Surgical decompression of the foramen.

Further information about cervical nerve root sleeve injection:

Accurate localisation with imaging confirmation of the pathology is essential. This is a very useful procedure for the right patient, as it may delay or avoid the need for surgery, but has potential catastrophic complications.

*The author has no conflict of interest with this topic.

Page last modified on 26/7/2017.