Cervical epidural steroid injections in complicated neck pain cases

Ross Hauser, MD

Many of the people we see at our center do not suffer from simple neck pain. They suffer from complicated neck pain. They are people who have a long medical history, multiple conditions, and symptoms, and have stories that go something like this:

Nerve blocks, epidural injections, and facet joint cortisone injections

I have chronic neck pain that is getting progressively worse. During the past few years I have tried physical therapy, TENS units every day, ice just about every day, exercise every day. I have had nerve blocks, epidural injections, and facet joint cortisone injections. I have a limited range of motion, constantly feel stiff and I crack and adjust my neck multiple times a day. Beyond the neck pain, I have a lot of cognitive issues, brain fog, concentration difficulties, a sensation that I do not get a lot of blood to my brain. My neurosurgeon tells me I do not need surgery, I can manage these symptoms with repeated cortisone when needed and physical therapy. I am not sure that this is the approach I want to follow, I have been doing this for years and my condition is not getting better. 

Epidural injections, nerve blocks & Botox injections

I have been suffering from severe neck pain for years. It started with C5-C6 bulging discs and progressed into cervical stenosis and terrible headaches. I was then diagnosed with occipital neuralgia from atlantoaxial instability. I have had epidural injections, nerve blocks & Botox injections. Disc replacement surgery was recommended.

Epidural and facet joint injections

I have a herniated disc at C-5 and C6. I was having pain from a pinched nerve that was not being helped by medications, physical therapy, or rest. My doctor recommended I look into getting some injections. At first, I had an epidural. It worked very well. But then it wore off. I then had a cortisone injection into the facet joint to see if we could pinpoint foraminal stenosis as the cause of my pain. That also worked for a time. My current treatment plan includes a rotation of these injections but not more than three times a year and as the pain flares. I know this is not a long-lasting answer and I have been told that I will need surgery down the line.

Are there alternatives to cervical epidural steroid injections, especially in complicated neck pain cases?

For many people with neck pain and the symptoms and conditions that may accompany it, anything that brings any type of relief is a good thing. Many people also understand that continued, frequent, or regular steroid injections can be harmful and detrimental to their long-term neck health and that this course of the treatment plan is likely to send them to neck surgery. But as many people who become our patients will tell us when we asked why did they have the cortisone injections, the answer is “I had so much pain, I did not know what else to do.”

Cervical steroid injections do not prevent surgery

A July 2021 study from doctors at the Sidney Kimmel Medical College at Thomas Jefferson University, Hospital for Special Surgery, and Weill Cornell Medical College was published in the Global Spine Journal. (1) According to the researchers the “objective of this study is to determine how often patients with degenerative cervical myelopathy (are) initially treated with cervical steroid injections and to determine whether these injections provided any benefit in delaying ultimate surgical treatment.”

Summary learning points:

Conclusions: While cervical steroid injections continue to be commonly performed in patients with degenerative cervical myelopathy, there is an overall increased odds of surgery after any type of cervical injection. Therefore injections should not be used to prevent surgical management of degenerative cervical myelopathy.

Cervical epidural steroid injections do help people. Independent research on the realistic outcomes of a cervical epidural steroid injection treatment plan.

A November 2020 study from doctors at Stanford University School of Medicine was published in The Spine Journal (2). Here the doctors outlined what doctor and patient could expect from cervical epidural steroid injections:

The paper highlights:

The study included 192,777 cervical epidural steroid injection patients (average age 51, 55.2% female) who underwent cervical epidural steroid injections for imaging-based diagnoses of cervical disc herniation or stenosis, a clinical diagnosis of radiculopathy, or a combination thereof.

Within 6 months of cervical epidural steroid injections, 11.2% of patients underwent surgery, increasing to 14.5% by 1 year and 22.3% by 5 years.

Results:

Over one in five patients underwent surgery within 5 years

Conclusions: Following cervical epidural steroid injections, over one in five patients underwent surgery within 5 years. Multiple patient-specific risk factors (mostly risk factors surrounding heart disease)  for subsequent surgery were identified, and patients undergoing repeated injections were at a lower risk.

Half the people get more than 50% pain relief after four weeks

A January 2020 study lead by doctors at the University of Utah (3) examined the effectiveness of fluoroscopically guided cervical transforaminal epidural steroid injection for the treatment of radicular pain. What they found was approximately 50% of patients experience more than 50% pain reduction at short (after four weeks)- and intermediate-term follow-up after cervical transforaminal epidural steroid injection.

This independent research confirms what we see in a lot of patients. Initial pain relief, diminishing pain relief with subsequent injections, worsening, and in some cases accelerated degenerative disc disease.

I am waiting for surgery, I need something to help me

While many people wait for their surgical date to arrive, their doctors do the best they can to help pain management until the surgical date. Cortisone or epidural injections may be recommended but there is always that patient confusion of, “if these injections did not help me before, what will make them help now?” And, “if they help me now, do I still need the surgery?”

Perhaps now that you are waiting for surgery you are being told to have more epidurals, only now with stronger and more frequent doses as a means to “hold you over” with pain management until you get the surgery. Of course, you may have been also recommended to have more painkillers as well.

If you have had a discussion with your doctor about the use of Epidural steroid injections, remember what they likely said about the realities of this treatment:

We are going to look at three types of patients:

1. The people who already had the epidural injection(s) and you have been told that the next step is surgery because the epidural injections have limited effect and you will need something else to help you.

2. You have tried the epidural and it did not help as much as you thought it would but your doctor is confident the next injection will help. Still, you are exploring whether to try it again or find something else.

3. You have been newly suggested to get the injection and you were advised of the benefits and risks and you are looking up information on the Epidural Steroid Injections. You still have hope that you will not need surgery and this may be your answer.

Okay, epidurals may be bad for me, but I need options.

We have been helping people in chronic pain for now approaching three decades. Pain is not a new phenomenon for us. We have seen people with varying degrees of pain and even patients who tell us on a scale of 1 – 10 their pain is a 12. We understand one of the hardest things to do is to help people get off their pain medications or treatments that suppress pain. Do understand that some people have had great success with epidural steroid injection. Some people even had a few of them. These are the people we typically do not see in our office. We see the ones who had the less than desired results or failure of the treatment. This is the group of patients this article is for.

Epidural steroid injections CANNOT be repeated without concern

In May 2020, the journal Pain Medicine, (4) published a section of the journal titled: “Fact Finders for Patient Safety.” In this section came the findings of the Spine Intervention Society’s Patient Safety Committee. What were these findings? The identification of “Two Myths.”

Myths are busted you should not offer Epidural steroid injections in this way:

What was published as “fact,” was:

Epidural Steroid Injections Risks and Concerns

Concern: What is that cortisone doing to your whole body?

Researchers at Vanderbilt University Medical Center published a December 2019 study in the journal Current Physical Medicine and Rehabilitation Reports. (5) What they were questioning is what were the side effects of “systemic absorption of corticosteroids occurs following epidural administration.”

Side-effects group 1:

Central steroid response:

Side-effects group 2:

The systemic effects of corticosteroids themselves. These include:

Suppression of the hypothalamic-pituitary-adrenal axis can impair digestive functions, the immune system, cause sexual dysfunction, problems of mood and emotional swings, and possible impairment of the body’s energy-producing systems that will lead to excessive fatigue.

“Too many patients, with or without significant cervical disease, unnecessarily undergo cervical epidural steroid injections”

Dr. Nancy Epstein is a researcher that we frequently cite in our own research and medical reviews. She is a Professor of Clinical Neurosurgery, School of Medicine, the State University of N.Y. at Stony Brook, and Chief of Neurosurgical Spine and Education, NYU Winthrop Hospital. In April 2018 she published a review study in the journal Surgical Neurology International (6) in which the major risks and complications of cervical epidural steroid injections are discussed. Here are her summary learning points.

Conclusions: Cervical epidural injections provide no long-term benefit, and are being performed for minimal to no indications. They contribute to significant morbidity and mortality. “Furthermore, these injections are increasingly required by insurance carriers prior to granting permission for definitive surgery, thus significantly delaying in some cases necessary operative intervention, while also subjecting patients at the hands of the insurance companies, to the additional hazards of these procedures.”

Treating and repairing cervical instability with Prolotherapy

In this section, we will explain the difference between Prolotherapy injections and epidural injections for neck pain. This section comes from excerpts and summarizations from Dr. Hauser’s article: Dextrose Prolotherapy for Unresolved Neck Pain, (7) published in the journal Practical Pain Management.

Current conventional therapy for unresolved neck pain includes medical treatment with analgesics, non-steroidal anti-inflammatory drugs, anti-depressant medications, epidural or other steroid shots, trigger point injections, muscle strengthening exercises, physiotherapy, weight loss, rest, massage therapy, intradiscal electrothermal therapy, manipulation, neck braces, implanted spinal cord stimulators or morphine pumps, surgical treatments that range from disc replacements to fusions, multidisciplinary group rehabilitation, education, and counseling. The results of such therapies often leave patients with residual pain. Because of this, many patients with chronic neck pain are searching for alternative treatments for their pain. One of the treatments they find promising is Prolotherapy.

Background

Prolotherapy is the injection of a solution for the purpose of tightening and strengthening weak tendons, ligaments, or joint capsules. Prolotherapy works by stimulating the body to repair these soft tissue structures. It starts and accelerates the inflammatory healing cascade by which fibroblasts proliferate. Fibroblasts are the cells through which collagen is made and by which ligaments and tendons repair.

Is Prolotherapy like cortisone? 

Prolotherapy is a regenerative injection treatment used to treat neck and spine pain by repairing damaged and weakened ligaments and tendons.

Research on 21 patients with cervical instability and chronic neck pain

Prolotherapy is a regenerative injection technique that utilizes substances as simple as dextrose to repair and regenerate damaged ligaments.

In 2015, Caring Medical published findings in the European Journal of Preventive Medicine (8) investigating the role of Prolotherapy in the reduction of pain and symptoms associated with increased cervical intervertebral motion, structural deformity, and irritation of nerve roots.

Twenty-one study participants were selected from patients seen for the primary complaint of neck pain. Following a series of Prolotherapy injections, patient-reported assessments were measured using questionnaire data, including a range of motion (ROM), crunching, stiffness, pain level, numbness, and exercise ability, between 1 and 39 months post-treatment (average = 24 months).

We concluded that statistically significant reductions in pain and functionality, indicating the safety and viability of Prolotherapy for cervical spine instability.

In our clinical and research observations, we have documented that Prolotherapy can offer answers for sufferers of cervical instability, as it treats the problem at its source. Prolotherapy to the various structures of the neck eliminates the instability and the sympathetic symptoms without many of the short-term and long-term risks of cervical fusion. We concluded that in many cases of chronic neck pain, the cause may be underlying joint instability and capsular ligament laxity. Furthermore, we contend that the use of Comprehensive Prolotherapy appears to be an effective treatment for chronic neck pain and cervical instability, especially when due to ligament laxity. The technique is safe and relatively non-invasive as well as efficacious in relieving chronic neck pain and its associated symptoms.

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

We hope you found this article informative and it helped answer many of the questions you may have surrounding cervical epidural steroid injections in your complicated neck pain case. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form

 

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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References
1 Manzur MK, Samuel AM, Vaishnav A, Gang CH, Sheha ED, Qureshi SA. Cervical Steroid Injections Are Not Effective for Prevention of Surgical Treatment of Degenerative Cervical Myelopathy [published online ahead of print, 2021 Jul 5]. Global Spine J. 2021;21925682211024573. doi:10.1177/21925682211024573
2 Kleimeyer JP, Koltsov JC, Smuck MW, Wood KB, Cheng I, Hu SS. Cervical epidural steroid injections: incidence and determinants of subsequent surgery. The Spine Journal. 2020 Nov 1;20(11):1729-36. [Google Scholar]
3 Conger A, Cushman DM, Speckman RA, Burnham T, Teramoto M, McCormick ZL. The effectiveness of fluoroscopically guided cervical transforaminal epidural steroid injection for the treatment of radicular pain; a systematic review and meta-analysis. Pain Medicine. 2020 Jan 1;21(1):41-54. [Google Scholar]
4 Mattie R, Schneider BJ, Smith C. Frequency of Epidural Steroid Injections. Pain Medicine. 2020 May 1;21(5):1078-9. [Google Scholar]
5 Rosati R, Schneider BJ. Systemic Effects of Steroids Following Epidural Steroid Injections. Current Physical Medicine and Rehabilitation Reports. 2019 Dec 1;7(4):397-403. [Google Scholar]
6 Epstein NE. Major risks and complications of cervical epidural steroid injections: an updated review. Surgical neurology international. 2018;9. [Google Scholar]
7 Hauser R, Hauser M, Blakemore K. Dextrose prolotherapy for unresolved neck pain. Practical Pain Management. 2007;7(8):58-69. [Google Scholar]
8 Ross Hauser, MD, Steilen-Matias D, Gordin K. The biology of prolotherapy and its application in clinical cervical spine instability and chronic neck pain: a retrospective study. European Journal of Preventive Medicine. 2015;3(4):85-102. [Google Scholar]

This article was updated July 7, 2021

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