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 these:
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.
In this article we will explore the following topics:
- Are there alternatives to cervical epidural steroid injections, especially in complicated neck pain cases?
- Do cervical steroid injections prevent surgery? Research says no.
- Cervical epidural steroid injections do help people. Independent research on the realistic outcomes of a cervical epidural steroid injection treatment plan.
- 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.
- 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.
- Do you need the steroid? Does lidocaine work just as well?
- I am waiting for surgery, I need something to help me with my neck pain.
- Okay, epidurals may be bad for me, but I need options.
- Epidural steroid injections CANNOT be repeated without concern.
- Epidural Steroid Injections Risks and Concerns.
- “Too many patients, with or without significant cervical disease, unnecessarily undergo cervical epidural steroid injections.”
- Surgery after the epidural steroid injection.
- Comparing Retro-laminar cervical blocks to epidural steroid injection.
- Combined dorsal root ganglion pulsed radiofrequency and transforaminal anterior epidural steroid injection.
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.”
Do cervical steroid injections prevent surgery? Research says no. “Injections should not be used to prevent surgical management of degenerative cervical myelopathy.”
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 (cervical neck) surgical treatment.”
Summary learning points:
- A total of 686 patients with a new diagnosis of degenerative cervical myelopathy, without previous cervical spine surgery or steroid injections, were included in this study.
- Pre-surgical cervical spine steroid injections were utilized in 244 patients (35.6%).
- All patients underwent eventual surgical treatment.
- The average time from initial degenerative cervical myelopathy diagnosis to surgery was 75.5 days.
- Cervical steroid injections were associated with higher odds of surgery within 1 year (compared to patients without injections).
- Half the people get more than 50% pain relief after four weeks
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 researchers noted that while cervical epidural steroid injections are sometimes used in the management of cervical radicular pain in order to delay or avoid surgery, it is, however, uncertain how effective the cervical epidural steroid injection(s) are actually at delaying or helping someone in fact avoid a surgery.
- The researchers of this study sought to determine:
- (1) the proportion of patients having surgery following cervical epidural steroid injections, and
- (2) the timing of and factors associated with subsequent surgery.
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.
- Male patients and those aged 35 to 54 had an increased likelihood of subsequent surgery.
- Patients with radiculopathy were less likely to undergo surgery following cervical epidural steroid injections than those with stenosis or herniation, while patients with multiple diagnoses were more likely.
- Patients with comorbidities including congestive heart failure, other cardiac condition comorbidities, or chronic pain were less likely to undergo surgery
- Some 33.5% of patients underwent more than one cervical epidural steroid injection, with 84.6% of these occurring within 1 year.
- Additional injections were associated with reduced rates of subsequent surgery.
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 led 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.
Do you need the steroid? Does lidocaine work just as well?
A May 2022 paper in the journal BioMed research international (9) compared the effectiveness of cervical epidural injections of local anesthetic (lidocaine) vs. injections with lidocaine plus steroid. The researchers found strong evidence for short- and long-term improvements in pain relief and functionality with cervical epidural injections of local anesthetic alone or with a steroid in the management of neck pain. Pain scores were not significantly different.
I am waiting for surgery, I need something to help me with my neck pain
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 injections 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:
- Epidural steroid injections ease the pain temporarily by reducing the size of stressed nerve roots.
- There are however concerns over short-term gain versus long-term costs in the use of epidural steroid injection because of the well-documented side effects.
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.”
- Myth #1: Epidural steroid injections can be repeated without concern regarding the duration of time between injections.
- Myth #2: A “series” of epidural steroid injections are sometimes required regardless of the clinical response to a single epidural steroid injection.
Myths are busted you should not offer Epidural steroid injections in this way:
What was published as “fact,” was:
- After an epidural steroid injection, a period of up to 14 days may be needed to assess the clinical response.
- Systemic effects on the hypothalamic-pituitary-adrenal (HPA) axis may last three weeks or longer. (These are the well-known side effects of epidurals, they include Cushing’s syndrome where a fatty hump may develop between the shoulders, a rounded face (moon face), and pink or purple stretch marks.)
- These factors must be considered when determining if or when another Epidural steroid injection is indicated.
- There is no evidence to support the routine performance of a “series” of repeat injections without regard to the clinical response.”
The caption of the image reads: Transforaminal epidural injection. A transforaminal epidural requires the very precise placement of the needle into the spinal canal from the side. This allows the injected solution to travel to the area of nerve entrapment
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:
- including sleeplessness,
- non-positional headache,
- and increased radicular pain represents some of the most common immediate or delayed adverse events related to epidural steroid injections
Side-effects group 2:
The systemic effects of corticosteroids themselves. These include:
- hypothalamic-pituitary-adrenal axis suppression,
- decreased bone mineral density, and others.
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.
- “Too many patients, with or without significant cervical disease, unnecessarily undergo cervical epidural steroid injections. These include interlaminar cervical epidural steroid injections and transforaminal cervical epidural steroid injections . . . have no documented long-term efficacy, and carry severe risks and complications.”
- Major complications included;
- epidural hematomas,
- infection (abscess/meningitis),
- increased neurological deficits due to intramedullary (quadriparesis/quadriplegia),
- and intravascular injections (e.g., vertebral artery injections leading to cord, brain stem, and cerebellar strokes). The latter injections leading to strokes were typically attributed to the particulate steroid matter (e.g., within the methylprednisolone injection solution) that embolized into the distal arterial branches.
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.”
Surgery after the epidural steroid injection
In some medical research, success of treatment or failure of treatment is measured by the costs of healthcare a patient or their insurance had to incur following a procedure. The more medical costs after the procedure the less effective the treatment is deemed to have been. This is what an October 2021 paper in the Global spine journal (12) assessed: “the effect of preoperative epidural steroid injection on quality outcomes and costs in patients undergoing surgery for cervical degenerative disease.”
In this study, 97,117 patients underwent cervical degenerative surgery, of which 29,963 (30.7%) had an epidural steroid injection prior to the surgery.
In comparison analysis
- Overall, 90-day complication rate was not significantly different between the patients who had epidural steroid injection prior to the surgery and those who did not.
- The epidural steroid injection groups had shorter length of stay, but higher 90-day readmission and reoperation rates.
- Epidural steroid injection can offer pain relief in some patients who are not responding to other conservative management techniques, but those who eventually undergo surgery have greater healthcare resource utilization.
Comparing Retro-laminar cervical blocks to epidural steroid injection.
Israeli and Spanish researchers writing in the journal Spine (10) published a June 2022 paper comparing Retro-laminar cervical blocks to epidural steroid injection.
Retro-laminar cervical blocks (in simplest terms an epidural who has a shallower needle puncture than traditional epidural) may be considered safer than epidural steroid injection as they do not require entering the neuroaxis (spinal cord area). In this study, the researchers evaluated the outcome of Retro-laminar cervical blocks in patients with cervical radiculopathy who had failed conservative treatment and were candidates for cervical spine decompression surgery.
- Ninety-eight patients were included in the analysis, with a total of 139 procedures.
- A significant pain reduction was achieved for most patients immediately after the procedure and at the final follow up at about 17 weeks.
- Average pain scores for the whole group showed significant pain improvement.
- A functional evaluation was carried out by a questionnaire (Neck Disability Index – NDI). Overall, 83% of patients had a lower post procedural Neck Disability Index than pre-procedural Neck Disability Index.
- For 80% of patients the improvement of Neck Disability Index surpassed the minimal clinically important change (MCID) at the final assessment.
- Most patients (61%) were discharged after just one Retro-laminar cervical blocks.
- Eight patients (8%) eventually underwent surgery.
The researchers conclusion were: “These findings suggest that Retro-laminar cervical blocks can be performed as an alternative to cervical epidural steroid injection and decompressive surgery in patients with cervical radicular pain that’s refractory (not responding) to non-invasive treatment.”
Combined dorsal root ganglion pulsed radiofrequency and transforaminal anterior epidural steroid injection
Researchers in Turkey published a January 2022 paper (11) in which they examined the effectiveness of combined dorsal root ganglion pulsed radiofrequency and transforaminal anterior epidural steroid injection on radicular neck pain.
Here, results of 84 patients with cervical radicular pain who underwent combined combined dorsal root ganglion pulsed radiofrequency and cervical epidural steroid injection under fluoroscopy were evaluated.
After the procedure, patients were assessed at 1st, 3rd, and 6th months after the interventional treatment.
The researchers found statistically significant decrease in the pain scores of the patients in the 1st, 3rd, and 6th months compared to the pre-intervention. After the procedure, the patients expressed their satisfaction level as 69.1% at the 1st month, 71.5% at the 3rd month, and 72.6% at the 6th month as “very good or good”. While the operation was mostly performed at the C5-6 level on both sides, it was seen that 61.9% of the operations were applied from the right side and 38.1% from the left side.
The researchers concluded: “Although the efficacy and complications of cervical transforaminal anterior epidural steroid injection and dorsal root ganglion pulsed radiofrequency treatment are controversial in the literature, we think that this combined treatment can provide effective pain palliation in experienced hands with appropriate patient selection.”
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.
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?
- The difference between Prolotherapy and Cortisone is extensive.
- Cortisone when injected into the joint can successfully mask pain. Many people have very successful treatments with Cortisone. We typically see patients who have a long history of Cortisone injection and these injections are no longer effective for them.
- Cortisone has been shown, in many studies, to accelerate degenerative osteoarthritis
- Over the years we have seen many patients who have received corticosteroid (cortisone) injections for neck pain. Unfortunately for many, excessive cortisone treatments lead to a worsening of chronic pain. Again, while some people do benefit from cortisone in the short term – the evidence however points to cortisone causing more problems than it helps.
Prolotherapy is a regenerative injection treatment used to treat neck and spine pain by repairing damaged and weakened ligaments and tendons.
- Prolotherapy is considered a viable alternative to surgery, and as an option to pain medications, cortisone, and other steroidal injections.
- The Prolotherapy procedure is considered a safe, affordable option that allows the patient to keep working and/or training during treatment.
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).
- Ninety-five percent of patients reported that Prolotherapy met their expectations with regard to pain relief and functionality. Significant reductions in pain at rest, during normal activity, and during exercise were reported.
- Eighty-six percent of patients reported overall sustained improvement, while 33 percent reported complete functional recovery.
- Thirty-one percent of patients reported complete relief of all recorded symptoms. No adverse events were reported.
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.
Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C
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This article was updated August 9, 2022