A Randomized Comparative Trial of Targeted Steroid Injection via Epidural Catheter vs Standard Transforaminal Epidural Injection for the Treatment of Unilateral Cervical Radicular Pain: Six-Month Results

Abstract

Objectives Compare the effectiveness of catheter-directed cervical interlaminar epidural steroid injection (C-CIESI) with triamcinolone to cervical transforaminal steroid injection (CTFESI) with dexamethasone for the treatment of refractory unilateral radicular pain. Design Prospective, randomized, comparative trial. Methods Primary outcome: proportion of participants with ≥50% numeric rating scale pain score reduction from baseline “dominant pain” (the greater of arm vs neck) at one month postinjection. Secondary outcomes: ≥30% Neck Disability Index (NDI-5) reduction and Patient Global Impression of Change (PGIC) response indicating “much improved” or “very much improved.” Results One hundred twenty participants (55.6% females, 52.3 ± 12.5 years of age, BMI 28.2 ± 6.5 kg/m2), were enrolled. The proportions of participants who experienced ≥50% pain reduction at one, three, and six months were 68.5% (95% CI = 54.9–79.5%), 59.3% (95% CI = 45.7–71.6%), and 60.8% (95% CI = 46.7–73.2%), respectively, in the C-CIESI group compared with 49.1% (95% CI = 36.4–62.0%), 46.4% (95% CI = 33.8–59.6%), and 51.9% (95% CI = 38.4–65.2%), respectively, in the CTFESI group. The between-group difference at one month was significant (P = 0.038). The proportions of participants who experienced a ≥30% NDI-5 score improvement were 64.0% (95% CI = 49.8–76.1%) and 54.9% (95% CI = 41.1–68.0%) in the C-CIESI and CTFESI groups (P = 0.352). Participants reported similar PGIC improvement in both groups: At six months, 53.2% (95% CI 38.9–67.1%) and 54.5% (95% CI = 39.7–68.7%) of the C-CIESI and CTFESI groups reported being “much improved” or “very much improved,” respectively (P = 0.897). Conclusions Both C-CIESI with triamcinolone and CTFESI with dexamethasone are effective in reducing pain and disability associated with refractory unilateral cervical radiculopathy in a substantial proportion of participants for at least six months.

American Society of Regional Anesthesia and Pain Medicine contrast shortage position statement

“…However, studies showed no superiority of the targeted catheter approach over a standard C7-T1 IL ESI. Pain relief and other outcome measures were similar at 1 month, 6 months, and 1 year 25–27. The similar efficacy may be secondary to the small epidural space allowing the injectate to flow from C7-T1 to higher cervical levels.…”

Spinal intramedullary hematoma presenting years following a cervical epidural injection

“…[ 1 , 4 , 7 , 8 ] CESI may contribute to spinal epidural hematomas and intramedullary cord injections/hematomyelia. [ 2 , 3 , 5 , 6 , 9 ] In this case, the patient’s the MRI-documented intramedullary C3-C6 cystic lesion proved at surgery (i.e. midline myelotomy) to be a chronic intramedullary hematoma.…”

2. Cervical radicular pain

“…Medication can also be delivered to the epidural space through an epidural catheter. The rationale for this technique is also to obtain a more ventral and target‐specific administration of medication 74 . With this approach, a soft radiopaque catheter is advanced through an introducer needle to the level and side of pathology with the final position of the catheter tip located in either the posterior epidural space or in the lateral recess close to the site of the inflamed spinal nerve.…”

“…The rationale for this technique is also to obtain a more ventral and target-specific administration of medication. 74 With this approach, a soft radiopaque catheter is advanced through an introducer needle to the level and side of pathology with the final position of the catheter tip located in either the posterior epidural space or in the lateral recess close to the site of the inflamed spinal nerve. One RCT demonstrated that a catheter-directed interlaminar CESI was as effective as a transforaminal CESI in reducing pain and disability in patients with refractory unilateral cervical radicular pain for up to 1 year.…”