LAUSR

C radiculopathy is a common condition encountered by spine surgeons with a reported annual incidence of 83 per 100,000 (107 in men, 64 in women).1 A trial of nonoperative care is usually recommended before consideration of surgical intervention. Cervical epidural steroid injection (CESI) has been a popular treatment modality when noninvasive conservative measures such as nonsteroidal anti-inflammatory medications or physical therapy fail to provide symptomatic relief. The theoretical benefits of dampening the proinflammatory pathways from steroid medications placed in the epidural space have translated to clinical results in patients experiencing cervical radiculopathy. Although there have been case reports of rare complications, several studies have found CESIs to be safe and efficacious for the treatment of cervical radiculopathy in the setting of disc herniation or spondylosis without myelopathy. In a retrospective study, Lin et al2 reviewed 70 patients with symptomatic cervical disc herniations who failed a trial of physical therapy and nonsteroidal anti-inflammatory medications. They were indicated for operative intervention, but offered a trial of CESI as an additional nonoperative treatment to delay or prevent surgery. Forty-four (63%) of the 70 patients had a significant decrease in their symptoms and chose to not proceed with surgical treatment. Within this population, 53 (76%) patients reported that they would try epidural steroid injections again in the future. Bush and Hillier3 prospectively evaluated the clinical outcomes of 68 consecutive patients who underwent CESI for cervical radiculopathy. One patient was excluded due to lack of pathology on imaging. Sixty-three patients of the original cohort were followed for an average of 39 months, and 48 (76%) of the patients experienced complete relief of radicular arm pain. All but 4 patients reported that CESIs were beneficial, and no patients required surgical intervention. The results of this study along with the aforementioned findings by Lin et al suggest that CESI should have a role in the treatment algorithm of cervical radiculopathy. Several other publications have also supported the safety and efficacy of CESI in patients with cervical radiculopathy who did not meet surgical indications.4–8 Castagnera et al4 randomized 24 patients with at least 12 months of cervical radicular pain to 2 investigational arms: cervical epidural space injections with steroid and morphine versus steroid and lidocaine. Although clinical outcomes between the groups showed no statistically significant differences, at a mean follow-up of 43 months, 19 (79.2%) of the patients showed decrease of pain on visual analog scale—2 with > 50 mm and 17 with > 75 mm. Most recently, McCormick et al8 compared standard C7– T1 interlaminar CESI (ICESI) against a newer proposed technique with epidural catheter advancement to the side and level of pathology in a single-blinded, prospective, randomized trial of 79 patients. The authors found no difference between the groups with regard to clinical outcomes, with 72% in the catheter group and 60% in the noncatheter group reporting a ≥ 50% reduction in pain on the Numerical Rating Scale. At 6-months, 56% of the overall patients demonstrated a ≥ 30% improvement in Oswestry Neck Disability Index score. Just as important, there were no serious adverse events or complications in either treatment groups. The safety of the CESI has previously been called into question; however, advances in injection techniques and image guidance have improved the safety profile. Specifically, fluoroscopy with epidurography,9,10 computed tomographic guidance,11 digital subtraction technology,12 softtipped catheter, nonparticulate steroid formulation,13 and interlaminar approach at C6–C7 or C7–T18 have been described. In a study by Ma et al,14 the authors analyzed 1036 fluoroscopically guided extraforaminal cervical nerve blocks and found no incidence of catastrophic complications to include: death, paralysis, stroke, spinal cord injury, vertebral artery injury, or infection. Minor complications occurred in Received for publication December 30, 2018; accepted January 4, 2019. From the *Madigan ArmyMedical Center, Joint Base Lewis-McChord, WA; and †Eisenhower Army Medical Center, Fort Gordon, Augusta, GA. H.H.Y., P.V.S., N.J.D., K.L.J., and D.G.K. are active duty service members. The views expressed are those of the authors and do not reflect the official policy of the Department of the Army, the Department of Defense, or the US Government. The authors declare no conflict of interest. Reprints: Daniel G. Kang, MD, Department of Orthopaedic Surgery, 9040A Jackson Ave, Joint Base Lewis-McChord, WA 98431 (e-mail: [email protected]). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. CONTROVERSIES IN SPINE SURGERY