Techniques in Regional Anesthesia and Pain Management (2010) 14, 106-112

Cervical epidural injections for radicular pain

Antonio C. Tamayo, MD,a Jorge Guajardo-Rosas, MD,b Andrs Hernandez-Ortiz, MDa

From the aPain Medicine and Palliative Care Unit, Instituto Nacional de Ciencias Mdicas y Nutricin Salvador
Zubirn, Mexico City, Mexico; and the
b
Department of Pain Clinic and Palliative Care, Instituto Nacional de Cancerologa, Mexico City, Mexico.

KEYWORDS: The most widely accepted indication for applying steroid injections at the cervical level is to control
Cervical epidural; radicular pain generated by a herniated disk. A cervical radiculopathy is a neurological disease
Interlaminar; characterized by a dysfunction of the spinal cervical nerves or their roots. It has been upheld that the
Transforaminal consequence of alleviating pain by applying epidural steroids may be the result of inhibiting the
steroids; synthesis or releasing a significant amount of proinflammatory mediators as well as by causing an
Radicular pain analgesic effect where contact takes place. The epidural injection of steroids may be carried out by an
interlaminar or transforaminal approach. The cervical interlaminar epidural steroid injection (CIESI) is
the intervention method used to manage radicular pain. The cervical transforaminal epidural steroid
injection (CTESI) theoretically allows a greater concentration of medicine to reach the region that has
been affected. Recently, several reports have been published about catastrophic complications, such as
cerebral medular stroke and even death. It is believed that such catastrophic complications are caused
by occlusion of a segmental artery by the particles of the steroids that are injected. Therefore, many
authors currently question whether the CTESI practices should be followed. Additionally, in terms of
the vaso-occlusive effect caused by corticosteroids, it cannot be overlooked that the latter may produce
a considerable amount of adverse effects. Consequently, new alternatives for radicular pain are being
explored; however, these require more analysis.
2010 Elsevier Inc. All rights reserved.

Epidural steroid injections for pain management first
emerged in 1952.1 This practice proliferated to such an
extent that it is now one of the most popular intervention
methods for pain management.
The most widely accepted application of a cervical ste-
roid injection is to control radicular pain caused by a hernia
of the disk. Other indications include a narrow cervical
channel, chronic cervical pain as the side effect of a surgical
intervention, in addition to others that are less accepted.2
Cervical radiculopathy is a neurological disease character-
ized by dysfunction of the spinal cervical nerves or their roots.
Address reprint requests and correspondence: Antonio C. Tamayo,
MD, Vasco de Quiroga 15 Colonia Seccin XVI, Tlalpan Mexico City,
14000 Mexico.
E-mail address: ancetaval@yahoo.com.mx.
This disease is commonly caused by the compression of the
nerve at the foramen due to the cervical espondilosis.3 The
second most common cause is a herniated intervertebral disk.
Disk herniation is the most common cause and occurs espe-
cially at the C5-6 and C6-7 levels, affecting the C6 and C7
roots, respectively. The herniation of an intervertebral disk is
typically related to the degenerative processes of aging but may
occur after trauma. Other possible causes of radicular pain are
infections and tumors. Clinically, cervical radiculopathy causes
cervical pain that irradiates toward the arm along with hypoestesia
and reduced strength that follow dermatomic patterns.3
Most patients with symptomatic cervical disk herniations
respond well to nonoperative treatment, including some
patients with nonprogressive radicular weakness. Reason-
ably good evidence shows that acute disk herniations de-
crease in size over time in the cervical region.

1084-208X/$ -see front matter 2010 Elsevier Inc. All rights reserved.
doi:10.1053/j.trap.2010.06.002
Tamayo et al Cervical Epidural Injections for Radicular Pain
It has been upheld that the effect of alleviating pain by
applying epidural steroids may be the result of inhibiting the
synthesis or releasing a significant amount of proinflamma-
tory mediators as well as by causing an analgesic effect
where contact takes place. Methods include blocking the
action of the phospholipase A2 (PLA2), inhibiting the ac-
tion of the neurological peptides, prolonging the suppres-
sion of the neurological impulse, and suppressing the sen-
sibilization of the neurons of the dorsal horns.4
The epidural injection of steroids may be carried out by
an interlaminar or transforaminal approach.
Cervical interlaminar epidural steroid
injection (CIESI)
CIESI is the most popular intervention method for radicular
pain. The idea behind this procedure is to reduce the in-
flammatory process at the nerve ending and the soft tissues
(Figures 1 and 2).5 The epidural space is approached with a
needle from the back, close to the halfway line between the
adjacent vertebrae.
Anatomical considerations
It is well known that vertebrae structure differs at the
various levels (cervical, dorsal, lumbar, and sacral). The
classic vertebra has two laminas that merge halfway,
thereby forming the spinous process. The angle of this
process changes at the different levels. In the cervical region
Figure 1 Interlaminar approach for epidural steroid injection.
Anteroposterior view demonstrating the needle in the interverte-
bral space.
107
Figure 2 Interlaminar approach for epidural steroid injection.
Lateral view showing the distribution pattern of the contrast.
as well as at the lumbar region, the spine is found to be more
perpendicular, which makes that approach easier.5
Epidural space is located in front of the laminates and
halfway in regard to pedicles.
The spinous process of the seventh cervical vertebra (C7)
is the most prominent. This causes the structure to be more
easily distinguished at the neck.5
While moving up in the cervical column, the epidural
space becomes narrower. Thus, CIESI is not recommended
above C6. On the posterior arch of C1, the small first
cervical nerve passes out between the vertebral artery and
the arch on each side under cover of the posterior atlanto-
occipital membrane. The dorsal ramus of C1 supplies the
suboccipital muscles; the proprioceptive innervation of
these small muscles makes them important in cervicocapital
postural control. One of these small muscles is partly in-
serted into the posterior cervical dura to maintain its smooth
outline during cervical extension.
The roots of the second cervical nerve leave the spinal
canal close to the medial capsule of C1-C2. They join as the
spinal nerve passes transversely behind the joint, where the
large dorsal root ganglion dwarfs the small anterior root.
The large dorsal ramus forms the greater occipital nerve,
which hooks under the inferior oblique muscle of the head
to ascend through semispinalis capitis muscle into the pos-
terior scalp.
The cervical spinal nerves pass through the lower parts
of the intervertebral foramina, on the gutter-shaped trans-
verse processes just below the levels of the facet joints and
uncovertebral joints. To reach the intervertebral foramina,
the cervical nerves pass obliquely forward and laterally
from the spinal cord, so that in either extension or side-
bending they are likely to be stretched. In the intervertebral
foramina, they pass behind the vertebral arteries in grooves
on the anterior surfaces of the articular pillars. The dorsal
root ganglia of C5 through T1 are very large.
108 Techniques in Regional Anesthesia and Pain Management, Vol 14, No 3, July 2010
Table 1 Complications associated with CIESI
Minor complications Major complications
Increased neck pain Epidural hematoma
Headache Postdural headache
Facial flushing Intracraneal hypotension
Dural puncture Spinal cord injury
The ligamentum flavum in the cervical region may not
always merge at the midline. When this ligament is not
found in the midline, then the epidural space may be
reached without any change in the loss of resistance test;
therefore, greater precaution must be taken.5
Efficacy
Although there are several publications regarding the use
of epidural steroids, few include blind testing in which the
efficiency of the interlaminary injection is described.6-8 Stav
and colleagues examined the efficiency of methylpred-
nisolone injection plus lidocaine administered interlami-
narly compared with the injection of the same drugs admin-
istered in the posterior cervical muscles.6 The intensity of
the pain, range of movement, and osteotendinous reflexes
were evaluated. Follow-up was undertaken 1 week and 1
year after this procedure. According to the results, pain was
reduced for 76% of the group that was administered the
CIESI contrary to 35.5% that was not; after 1 year, the differ-
ence was 68% and 11.8%, respectively. Similarly, the range of
movement increased; however, the osteotendinous reflexes did
not change.
Moreover, Castagnera and colleagues observed that pa-
tients could alleviate pain in short and even over the long
term (43 18.1 months).8 This alleviation did not change
significantly if morphine was added to the steroid that was
injected.
Rowlingson and colleagues retrospectively found that, in
25 subjects with cervical radiculopathy that were adminis-
trated CIESI, the pain was alleviated in 75% in terms of
40% of the patients and the pain completely ceased in 24%
of the patients. However, 3 patients did not improve.9 The
mean follow-up was 8.9 months.
Complications
Although it is considered that the interlaminar approach
is less risky than the transforminal, like in most cervical
procedures, it is not exempt from complications that could
be potentially fatal.10
The incidence of complications of the CIESI is relatively
low. According to one study carried out by 17 instructors of
the International Spine Intervention Society (ISIS), only 23
complications were observed out of the 4389 procedures
carried out (0.32%). However, Waldman reported 16.8%
incidence.11
Complications may be classified as major and minor.
Minor complications include those that are resolved in less
than 24 hours without significant effects.12 Table 1 summa-
rizes the principle complications related to CIESI.
Cervical transforaminal epidural steroid
injection (CTESI)
CTESI approaches involve directly injecting the nerve root
where the lesion is located (Figure 3). This theoretically
allows greater concentration of the drug to be administered
to the affected area.13
CTESI is indicated for radicular pain management
caused by a herniated disk or foraminal stenosis. Transfo-
raminal injections may be done only with local anesthetics
for diagnostic purposes. Currently, debate continues about
whether or not to continue practicing this technique.
Anatomical considerations
Nerve roots are wrapped inside dura mater, which ends
in the proximinal margin of the dorsal root ganglion.13
Roots merge and form the spinal nerve that exits through the
foramen.
The spinal nerve is located in the lower half of the
foramen.14 The foramen is delimited in its higher and lower
parts by the pedicle.13 The superior articular process of the
facet joint delimits the posterior portion. The front part is
delimited both by the vertebral body and the intervetabral
disk. The spinal nerve is located posterior to the vertebral
artery.
The spinal cord is irrigated by descending branches of
the vertebral artery and by multiple radicular arteries de-
rived from the segmental artery.
The vertebral arteries emerge from the subclavia and
ascend in the front part of the transverse process of C7.14
Figure 3 Anteroposterior view of a transforaminal approach for
epidural steroid injection. Courtesy of Dr. Elizabeth Ditonto.
Tamayo et al Cervical Epidural Injections for Radicular Pain
From there, these enter into the transverse of C6 or C5 until
reaching C1 and from there to the magnum foramen.14
From the subclavia and vertebral arteries arise the seg-
mented vessels (ascending cervical arteries and profound
cervical), which cross the foramen and subdivide to form
the front and back radicular artery.15 The anterior and pos-
terior spinal arteries arise from radicular artery. Addition-
ally, the anterior spinal artery receives small arteries from
the radicular artery known as the radiculomedullar arter-
ies.15 The radicular arteries and radicularmeduar arteries
can be located in the lower posterior portion of the foramen
near the target where the needle is placed for the transfo-
raminal injection.15
Effectiveness
Scientific evidence that supports the effectiveness of the
CTESI is still limited. There are several observational stud-
ies that report on the progress of patients with radicular
cervical pain who received a CTESI. Because there are no
control groups, the downside is that the effectiveness of the
CTESI cannot be differentiated from the normal progress of
the ailment.14 To date, only one prospective, randomized,
controlled trial exists. Anderberg and colleagues divided 40
patients with cervical radicular pain in 2 groups.16 Each
group received transforaminal injections of the affected
root. In the first group, mepivacaine and 40 mg of methyl-
prednisolone were injected, whereas the second group only
received mepivacaine. No significant differences were
found in the clinical outcome of both groups. The absence
of positive results to support the effectiveness of CTESI in
this study casts serious doubts over its use; however, these
results could have been caused by the fact that the control
group received more than 1 transforaminal injection of local
anesthesic.17 Undoubtedly, it is necessary to carry out fur-
ther studies that are methodologically strong to be certain
that CTESI is effective in managing radicular pain.
In terms of observational studies, the information seems
different. Kolstad and colleagues for 4 months followed-up
21 patients with cervical radiculopathy pain caused by es-
pondilosis or herniated disks in which CTESI was admin-
istered. This study found a lower need for surgery (5 out of
the 21 patients decided not to have surgery) and significant
clinical improvements at 6 weeks and at 4 months after
CTESI. This clinical improvement was only seen in patients
with radicular pain irradiating to the arm but not for neck
pain.18 Vallee and colleagues performed CTESI for patients
with cervical radicular pain. According to their studies, 56%
of the patients reduced the intensity of the radicular pain in
half 6 months after the CTESI was performed.19 Addition-
ally, Cyteval and colleagues, during an observation prospec-
tive study consisting of 30 patients, found clinical improve-
ment in 60% of patients. From an initial mean VAS score of
6.3/10, the patients who improve had a reduced mean VAS
score of 1.2/10 at 2 weeks and 0.7/10 at 6 months.20 Slip-
man and colleagues published several observational and
109
retrospective studies about the use of CTESI. According to
their research, efficiency is very low for patients suffering
from radicular pain due to secondary espondilosis related to
traumatic injury.21 Moreover, positive outcome has been
shown in patients in which CTESI for radicular pain not
related to nontraumatic cervical espondilosis, with excellent
results in up to 60% of the patients.21
Complications
In a survey carried out by ISIS instructors, it was re-
ported that the incidence of complications due to the trans-
foraminal injection was relatively low (0.32%); moreover,
Ma and collaborators reported that complications were
present early on after applying the CTESI in 1.66%. Despite
the fact that both studies report a relatively low incidence of
complications, recently there have been reports about cata-
strophic complications, such as a spinal and brain stem
infarction and even death.22-25 Therefore, many authors
now question whether to continue applying CTESI.26
It is believed that these catastrophic complications are
the result of an occlusion in the segmental artery by the
steroid particles that are injected.15,27 Particulated steroid
may function as an embolus and occlude blood vessels that
may condition brainstem and spinal infarction.
There are many variations in the level and location of the
origin of the radicular arteries and other vessels of lesser
importance that can nurture it. This was demonstrated in an
article written by Hoeft and colleagues, who performed a
cadaveric dissection in which they observed that three
prominent branches of the radicular artery entered through
anterior portion of the foramen next to the left nerve root of
C5, and through the right nerve root at C6 and C8.28 In C7,
two prominent branches of the radicular artery enter by the
posterior of the foramen in C7 bilaterally.28
The unpredictable irrigation of the cervical spine makes
it almost impossible to determine a safe manner to approach
to perform a CTESI without having the risk of intravascular
injection. As a matter of fact, there have been many reports
about unnoticed intravascular injections.29,30 Aspiration as a
method for verification to know whether we have reached a
vessel is the most ineffective method because, if the needle
is located at a low-caliber vessel, when aspirating we may
collapse it and not observe blood flowing into our syringe.
Therefore, the practitioner could mistakenly believe that a
vessel has not been reached. Injecting contrast media and
later observing the image to confirm whether we are located
in a blood vessel is also an inefficient method because the
time that has elapsed between the injection of the contrast
and the moment of obtaining an image at times is enough
for the dye to be cleared from the vessel.31 To reduce the
risk of puncturing a blood vessel, it is highly recommended
to visualize the distribution of the contrast media in real
time with digital subtraction.
110 Techniques in Regional Anesthesia and Pain Management, Vol 14, No 3, July 2010
Complications related to steroids
The size of the particles of the various steroids that are
injected to the epidural space is also a factor to be consid-
ered. The greater the size of the steroid, the greater the
possibilities of conditioning the occlusion of a vessel. Ben-
zon and collaborators compared the size of the particles of
methylprednisolone (40 mg/dL), methylprednisolone (80
mg/mL), triamcinolone (40 mg/mL), bethametazone sodium
phosphate (3 mg/mL), bethametazone sodium phosphate/
betamethasone acetate (6 mg/dL; Celestone Soluspan), be-
thametazone sodium phosphate/betamethasone acetate (6
mg/dL; betamethasone repository) alone and diluted with
lidocaine, with a saline solution and dexamethasone sodium
phosphate not diluted. They observed that methylpred-
nisolone 80 mg/mL had a greater concentration of particles
and a greater size than the rest of the steroids.32 It is
important to point out that, even when diluted with saline
solution, the number of larger particles in methylpred-
nisolone increased. Moreover, in dexametazone and be-
thametazone sodium phosphate 3 mg/mL, particles were not
observed; from the remainder of the compounds the one
with the smallest particles was bethametazone sodium phos-
phate/betamethasone acetate (Celestone Soluspan).32
The aforementioned study makes us suppose that dex-
ametazone is less susceptible to conditioning vessel occlu-
sion phenomena. It is important to note that soluble steroids
are eliminated more quickly through the spinal channel,
thereby shortening their effects.32 The efficiency of the
dexametazone for CTESI has been discretely less than tri-
amcinolone when compared33; however, it is important to
underline that one of the preserving agents for the conven-
tional preparation of dexametazone is methylparaben, a
substance that can cause lesions to the nerve structures with
the correct concentration.34 Because information is sparse
regarding the safety of administering dexametazone by this
method (additionally efficiency studies are also scarce), it is
perhaps best not to employ this agent until more quality
control studies have been conducted.
Other substances that may lesion the nerve structure are
benzyl alcohol and polyethylene glycol, both found in com-
pounds such as methylprednisolone and traimcinolone di-
acetate.4 These factors must be taken into account when
selecting the steroid to be used in these cases. Table 2 lists
the vehicles and preservatives found in the steroids that are
most commonly used.
Table 2 Component vehicles and preservatives commonly found in different steroids.4,32
Triamcinolone Triamcinolone
Methylprednisolone diacetate acetonide
Polyethylene glycol
Benzyl alcohol
Methylparaben
Systemic effect of steroids
In addition to the vessel occlusion observed with steroids,
it should be remembered that they can produce considerable
adverse effects. The suppression of the suprarenal cortex
could produce grave complications. Prolonged therapy with
steroids can suppress the function of the hypothalamus
pituitaryadrenal axis (HPA) and recovery may be slow.4
The incidence of the systemic effects of the steroids has
been reported in 2.2% of the cases.4 Kay and collaborators
observed that the weekly application of steroids through the
epidural for 3 weeks might generate a very important sup-
pression of the HPA axis. Recovery could take up to 3
months after applying the last steroid.35
Cushing syndrome has been reported after administering
60 mg of methylprednisolone through the epidural as well
as myopathy due to steroids after applying triamcinolone.36
These agents have been related to the psychiatric effects,
such as depression, mania, and psychosis.37 Rasmin and
collaborators observed bouts of psychosis in a patient that
received an epidural injection at the cervical level.37
In patients with diabetes, these agents must be used with
great precaution. Gonzalez and collaborators documented
glucose elevation to 106 mg/dL on average.38
All the complications related to the use of steroids have
forced researchers to test other substances for radicular pain
management. Table 3 lists substances that are being devel-
oped for radicular pain management.39-45
Pulsed radiofrequency of the dorsal root ganglion
The use of pulsed radiofrequency (PRF) is considered an
alternative for radicular pain management, specifically for
patients for whom the use of corticosteroids may be detri-
mental.
Evidence suggesting efficiency and safety of this proce-
dure is scarce. Van Kleef and collaborators conducted a
prospective control study. They studied two groups of pa-
tients with cervical radicular pain. One group received dor-
sal root ganglion (DRG) radiofrequency at 67C for 60
seconds. The number of patients with a positive outcome
was higher in the RF-DRG lesion therapy group, compared
with the sham group, and this difference was statistically
significant.46 The number needed to treat (NNT) for the RF
group was 1.4.47
Slappendel and colleagues did not observe any differ-
ence when comparing RF treatment at 40C with 67C. The
bethametazone sodium phosphate/
beta-methasone acetate Dexamethazone
Tamayo et al Cervical Epidural Injections for Radicular Pain
Table 3 New alternatives for radicular pain
Substance Mechanism of action Authors
Etanercept Soluble TNF- Genevay et al. 40
receptors TNF-
Tobnick et al.41
Infliximab Monoclonal antibodies Karppinen et al.42
of TNF-
Korhonen et al.43
Korhonen et al.44
IL-1Ra Blocks the biological Becker et al.45
effect of IL-1
Abbreviations: IV, intravenous; SC, subcutaneous; IL-1Ra, interleukin-1 receptor antagonist.
40C group was considered the sham group. Both groups,
surprisingly, had a significant pain reduction with pain
scores at 1.5 and 3 several months after the procedure. After
this study, attention has been directed toward PRF.48
In PRF, high-frequency current is delivered in short
bursts followed by a silent period, allowing the generated
heat to be washed out.47 The generator output is set for the
electrode tip temperature not to exceed 42C.47
Finally, Van Zundert and collaborators found that, after
follow-up for 6 months, the PRF held an NNT at a 1.6 value
more than the control group.49 It is important to underline
that, because of the scarcity of studies, it is still too early to
affirm that it is an efficient alternative for radicular pain
management.
Conclusions
The epidural injection of steroids at a cervical level contin-
ues to be a widely accepted practice for radicular pain
management. There are two methods of approaching the
epidural space: interlaminar and transforminal. The inter-
laminar approach is the most widely accepted method. In
regard to the transforaminal, if the risks and benefits are
placed in a balance, this method offers more risks than
benefits. There are various reports of catastrophic compli-
cations, such as spinal and brain stem stroke and even death.
These complications are related to blockage that may be
caused to blood vessels by corticosteroids with particles.
The dexametazone is a steroid free of particles; however, it
contains conservatives that limit its use.
Presently, new alternatives are being developed to sub-
stitute the steroids for radicular pain management; however,
111
Study Outcome
Etanercept (IV) vs 75% pain reduction in the etanercept
methyprednisolone (IV) group vs 17% methylprednisolone
Retrospective review of 55% reduction in the consumption of
patients that received analgesic
etanercept, 25 mg (SC)
Infliximab infusion 3 mg/kg 75% of pain reduction in 60% of the
(IV) vs placebo patients in the infliximab group vs 17%
of the placebo group
1-year follow-up of 80% of the patients treated with
Karppinen study infliximab persisted a 75% pain
reduction
Infiximab 5 mg/kg vs No significant differences were observed
placebo between both groups
Enriched serum with IL-1Ra There was a favorable tendency in the
(epidural) vs triamcinolone group that received IL-1Ra even though
5 mg y 10 mg (epidural) significance in reduction in VAS score
was only seen in week 22 of the follow-
up in favor of IL-1Ra vs 5 mg
triamcinolone
further studies are warranted to establish safety and effi-
ciency.
References
1. Kaplan M, Derby R: Epidural corticosteroid injections: when, why,
and how? J Musculoskel Med 15:39-46, 1998
2. Benjamin R, Singh V, Parr A, et al: Systematic review of the effec-
tiveness of cervical epidurals in the management of chronic neck pain.
Pain Physician 12:137-157, 2009
3. Carette S, Fehlings MG: Cervical radiculopathy. N Engl J Med 353:
392-399, 2005
4. Manchikanti L: Role of neuraxial steroids in interventional pain man-
agement. Pain Physician 5:182-199, 2002
5. Rathmell JP (ed): Interlaminar epidural injection, in Atlas of Image-
Guided Intervention in Regional Anesthesia and Pain Medicine. Phil-
adelphia, PA, Lippincott Williams & Wilkins, 2006, pp 31-52
6. Stav A, Ovadia L, Sternberg A, et al: Cervical epidural steroid injec-
tion for cervicobrachialgia. Acta Anaesthesiol Scand 37:562-566, 1993
7. Pasqualucci A, Varrassi G, Braschi A, et al: Epidural local anesthetic
plus corticosteroid for the treatment of cervical brachial radicular pain:
single injection versus continuous infusion. Clin J Pain 23:551-557,
2007
8. Castagnera L, Maurette P, Pointillart V, et al: Long term results of
cervical epidural steroid injection with and without morphine in
chronic cervical radicular pain. Pain 58:239-243, 1994
9. Rowlingson JC, Kirschenbaum LP: Epidural analgesic techniques in
the management of cervical pain. Anesth Analg 65:938-942, 1986
10. Abbasis A, Malhorta G, Malanga G, et al: Complications of interlami-
nar cervical epidural steroid injections. Spine 32:2144-2155, 2007
11. Waldman S: Complications of cervical epidural nerve blocks with
steroids: a prospective study of 790 consecutive blocks. Reg Anesth
14:149-151, 1989
12. Abbasi A, Malhotra G, Malanga G, et al: Complications of interlami-
nar cervical epidural steroid injections: a literature review. Spine
332:2144-2151, 2007
112 Techniques in Regional Anesthesia and Pain Management, Vol 14, No 3, July 2010
13. Rathmell J, Aprill C, Bogduk N: Cervical transforaminal injection of
steroids. Anesthesiology 100:1595-1600, 2004
14. Huston C: Cervical epidural steroid injections in the management of
cervical radiculitis: interlaminar versus transforaminal. A review. Curr
Rev Musculoskelet Med 2:30-42, 2009
15. Huntoon MA: Anatomy of the cervical intervertebral foramina: vul-
nerable arteries and ischemic neurologic injuries after transforaminal
epidural injections. Pain 117:104-111, 2005
16. Anderberg L, Annertz M, Persson L, et al: Transforaminal steroid
injections for the treatment of cervical radiculopathy: a prospective
and randomised study. Eur Spine J 16:321-328, 2007
17. Yabuki S, Kawaguchi Y, Nordborg C, et al: Effect of lidocaine on
nucleus pulposus-induced nerve root injury: a neurophysiologic and
histologic study of the pig cauda equina. Spine 23:2383-2390, 1998
18. Kolstad F, Leivseth G, Nygaard OP: Transforaminal steroid injections
in the treatment of cervical radiculopathy. A prospective outcome
study. Acta Neurochir 147:1065-1070, 2005
19. Vallee JN, Feydy A, Carlier RY, Mutschler C: Chronic cervical ra-
diculpathy: lateral-approach periradicular corticosteroid injection. Ra-
diology 218:886-892, 2001
20. Cyteval C, Thomas E, Decoux E, Sarrabere MP: Cervical radiculop-
athy: open study on percutaneous periradicular foraminal steroid in-
filtration performed under CT control in 30 patients. AJNR Am J
Neuroradiol 25:441-445, 2004
21. Slipman CW, Lipetz JS, DePalma MJ, Jackson HB: Therapeutic se-
lective nerve root block in the nonsurgical treatment of traumatically.
Induced cervical spondylotic radicular pain. Am J Phys Med Rehabil
83:446-454, 2004
22. Brouwers PJ, Kottink EJ, Simon MA, Prevo RL: A cervical anterior
spinal artery syndrome after diagnostic blockade of the right C6-nerve
root. Pain 91:397-399, 2001
23. Baker R, Dreyfuss P, Mercer S, Bogduk N: Cervical transforaminal
injection of corticosteroids into a radicular artery: a possible mecha-
nism for spinal cord injury. Pain 103:211-215, 2003
24. Rozin L, Rozin R, Koehler SA, et al: Death during transforaminal
epidural steroid nerve root block (C7) due to perforation of the left
vertebral artery. Am J Forensic Med Pathol 24:351-355, 2003
25. Ludwig MA, Burns SP: Spinal cord infarction following cervical
transforaminal epidural injection: a case report. Spine 30:E266-E268,
2005
26. de Leon-Casasola O: Transforaminal cervical epidural injections. Reg
Anesth Pain Med 33:190-191, 2008
27. Tiso RL, Cutler T, Catania JA, Whalen K: Adverse central nervous
system sequelae after selective transforaminal block: the role of cor-
ticosteroids. Spine J 4:468-474, 2004
28. Hoeft M, Rathmell J, Monsey R, Fonda B: Cervical transforaminal
injection and the radicular artery: variation in anatomical location
within the cervical intervertebral foramina. Reg Anesth Pain Med
31:270-274, 2006
29. Furman MB, Giovanniello MT, OBrien EM: Incidence of intravas-
cular penetration in transforaminal cervical epidural steroid injections.
Spine 28:21-25, 2003
30. Furman MB: Incidence of intravascular uptake in transforaminal lum-
bar epidural steroid injections. Spine 25:2628-2632, 2000
31. Jasper J: Role of digital subtraction fluoroscopic imaging in detecting
intravascular Injections. Pain Physician 6:369-372, 2003
32. Benzon H, Chew TL, Mcarthy R, et al: Comparison of the particle
sizes of different steroids and the effect of dilution: a review of the
relative neurotoxicities of the steroids. Anesthesiology 106:331-338,
2007
33. Dreyfuss P, Baker R, Bogduk N: Comparative effectiveness of cervical
epidural steroid injections with particulate and nonparticulate cortico-
steroid preparations for cervical radicular pain. Pain Med 7:237-242,
2006
34. Adams H, Astri A, Charron D: Morphological effects of subarachnoid
methylparaben on rabbit spinal cord. Pharmacol Res Commun 9:547-
551, 1977
35. Kay JK, Findling JW, Raff H: Epidural triamcinolone suppresses the
pituitary-adrenal axis in human subjects. Anesth Analg 79:501-505,
1994
36. Boonen S, Van Distel G, Westhovens R, et al: Steroid myopathy
induced by epidural triamcinolone injection. Br J Rheumatol 34:385-
386, 1995
37. Benyamin R, Vallejo R, Kramer J, Rafeyan R: Corticosteroid induced
psychosis in the pain management setting. Pain Physician 11:917-920,
2008
38. Gonzalez P, Laker SR, Sullivan W, et al: The effects of epidural
betamethasone on blood glucose in patients with diabetes mellitus. PM
R 1:340-345, 2009
39. Burnett C, Day M: Recent advancements in the treatment of lumbar
radicular pain. Curr Opin Anaesthesiol 21:452-456, 2008
40. Genevay S, Stingelin S, Gabay C: Efficacy of entanercept in the
treatment of acute, severe sciatica: a pilot study. Ann Rheum Dis
63:1120-1123, 2004
41. Tobinick E, Davoodifar S: Efficacy of etanercept delivered by perispi-
nal administrationfor chronic back and/or neck disc-related pain: a
study of clinical observations in 143 patients. Curr Med Res Opin
20:1075-1085, 2004
42. Karppinen J, Korhonen T, Malmivaara A, et al: Tumor necrosis fac-
tor-a monoclonal antibody infliximab, used to manage severe sciatica.
Spine 28:750-754, 2003
43. Korhonen T, Karppinen J, Malmivaara A, et al: Efficacyof infliximab-
for disc herniation-induced sciatica: one-year follow-up. Spine 29:
2115-2119, 2004
44. Korhonen T, Karppinen J, Paimela L, et al: The treatment of disc
herniation induced sciatica with infliximab: results of a randomized,
controlled, 3-month follow-up study. Spine 30:2724-2728, 2005
45. Becker C, Heidersdor S, Drewlo S, et al: Efficacy of epidural perineu-
ral injections with autologous conditioned serum for lumbar radicular
compression: an investigator initiated, prospective, double-blind, ref-
erence-controlled study. Spine 32:1803-1808, 2007
46. van Kleef M, Liem L, Lousberg R, et al: Radiofrequency lesion
adjacent to the dorsal root ganglion for cervicobrachial pain: a pro-
spective double blind randomized study. Neurosurgery 38:1127-1131,
1996
47. van Boxem K, van Eerd M, Brinkhuize T, et al: Radiofrequency and
pulsed radiofrequency treatment of chronic pain syndromes: the avail-
able evidence. Pain Pract 8:385-393, 2008
48. Slappendel R, Crul BJ, Braak GJ, et al: The efficacy of radiofrequency
lesioning of the cervical spinal dorsal root ganglion in a double blinded
randomized study: no difference between 40 degrees C and 67 degrees
C treatments. Pain 73:159-163, 1997
49. Van Zundert J, Patijn J, Kessels A, et al: Pulsed radiofrequency
adjacent to the cervical dorsal root ganglion in chronic cervical radic-
ular pain: a double blind sham controlled randomized clinical trial.
Pain 127:173-182, 2007