Cervical Epidural Steroid Injection

What is a cervical epidural steroid injection?

A cervical epidural steroid injection (cervical ESI) is an injection of anti-inflammatory medicine — a steroid or corticosteroid — into the epidural space around the spinal nerves in your neck.

The main goal of cervical epidural steroid injections is to help manage chronic pain caused by irritation and inflammation of the spinal nerve roots in your neck (the cervical region of your spine) due to certain conditions or injuries. This type of chronic pain is called cervical radiculopathy, which can radiate down from your neck to your shoulders, arms and/or hands.

“Cervical” comes from the Latin word “cervix,” which means “neck.” In the case of cervical ESIs, the injection is in your neck, not your cervix. The cervix, the narrow passage forming the lower end of the uterus, is called so because it’s a neck-like passage.

How does a cervical epidural steroid injection work?

Healthcare providers use cervical epidural steroid injections (cervical ESIs) for chronic pain management. Your provider injects a steroid or corticosteroid medication into the epidural space around the spinal cord in your neck.

The neck region of your spine is called the cervical spine. This region is made up of seven vertebrae. Your vertebrae are the 33 individual, interlocking bones that form your spinal column, which runs from the base of your skull to your tailbone. These bones help protect your spinal cord from injury. Between the vertebral bones are disks that provide cushioning for your vertebrae and flexibility for you.

The seven vertebrae in your cervical spine are named C1 through C7 from top to bottom. The cervical vertebrae have several important roles, including:

• Protecting your brain stem.
• Protecting your spinal cord.
• Supporting your skull.
• Allowing you to move your head.

Your spinal cord is a very important bundle of nerves that runs from your brain to your lower back. Your spinal cord acts like a highway that connects the nerves located all over your body to your brain so that your brain can send signals and communicate with the rest of your body.

Sometimes, nerve roots that are attached to the cervical region (neck region) of your spinal cord can become pinched or inflamed. This can happen, for example, if you have a herniated disk. The inflamed nerves can cause pain, and the pain may radiate down your shoulder and/or arm.

During a cervical epidural steroid injection procedure, your provider injects a steroid into the epidural space around your spinal cord. The epidural space surrounds your spinal cord like a sleeve and contains the following tissues:

• Fat.
• The dural sac.
• Spinal nerves.
• Blood vessels.
• Connective tissue.

The steroid coats the irritated nerve(s) that are causing your pain and works to reduce swelling and pressure on the nerves. The steroid allows the nerve(s) time to heal.

Cervical epidural steroid injections most often lead to temporary pain relief, but some people do not experience pain relief from the injection.

What are cervical epidural steroid injections used for?

Healthcare providers use cervical epidural steroid injections to manage a type of chronic pain known as cervical radiculopathy, which is caused by spinal nerve root inflammation and irritation in your neck. Cervical radiculopathy can cause the following symptoms, which can radiate down from your neck to your shoulder, arms and/or hands:

• Pain.
• Numbness.
• Muscle weakness.
• Tingling.

Many conditions can irritate your spinal nerve roots in your neck and cause cervical radiculopathy, including:

• Cervical herniated disk: This condition is also commonly called a slipped, ruptured or bulging disk. It’s one of the most common causes of neck pain. Disks have soft, gel-like centers and a firmer outer layer. Over time, the outer layer weakens and can crack. A cervical herniated disk happens when the inner substance pushes through a crack in one of the disks between two vertebrae in your neck. The leaked material may press on and pinch nearby spinal nerves.
• Cervical degenerative disk disease: This condition happens when the cushioning in between the vertebrae in your neck begins to wear away. A degenerated disk could cause local inflammation in your spinal nerve roots.
• Cervical osteoarthritis (cervical spondylosis): This condition involves changes to the bones, disks and joints in your neck caused by the normal wear-and-tear of aging. Cervical osteoarthritis can lead to narrowing of the interior of your spinal column in your neck or in the openings where spinal nerves exit, which can cause inflammation and irritation to the nerves.
• Cervical spinal stenosis: This condition is the narrowing of one or more spaces within your cervical spine (your neck). Less space within your spine reduces the amount of space available for your spinal nerve roots. A tightened space can cause the nerves to become irritated or pinched, which can lead to neck pain.

How common are cervical epidural steroid injections for pain management?

Cervical epidural steroid injections are a common form of therapy for certain causes of chronic neck pain. Cervical radiculopathy affects approximately 1 in 1000 adults per year, and neck pain is the fourth leading cause of disability in the United States. Over the past decade, the rate of cervical ESIs has doubled among people who have Medicare (the federal health insurance for people who are 65 years or older) in the United States.

Who performs a cervical epidural steroid injection?

Cervical epidural steroid injections are very technique-sensitive, so healthcare providers performing the injection must have significant specialized training. Healthcare providers who may perform cervical ESIs include:

• Physiatrists (physical medicine and rehabilitation providers).
• Radiologists.
• Anesthesiologists.
• Neurologists.
• Surgeons.

How do I prepare for a cervical epidural steroid injection?

Before your cervical ESI, it’s important to tell your healthcare provider if you are pregnant or might be pregnant due to the possible use of fluoroscopy imaging (a type of X-ray imaging) during the procedure. You also need to tell your provider which medications you are taking, including herbs, supplements and other non-prescription drugs.

Your healthcare provider will give you specific instructions about what you need to do to prepare for your ESI injection. Be sure to follow their instructions. Your provider may:

• Ask you not to eat or drink (fast) for a certain amount of time before your cervical ESI.
• Adjust certain medications you’re taking, especially blood thinner medications.
• Have you undergo an MRI or CT scan of your neck before your cervical ESI to help determine the exact area that needs to be treated.
• Make sure you have someone with you to drive you home if you’re going to take a sedative for your cervical ESI.

Questions that may be helpful to ask your healthcare provider before you get a cervical epidural steroid injection include:

• How often do you perform cervical ESIs?
• What do I need to do to prepare for my cervical ESI?
• What are the risks of getting a cervical ESI?
• What will my cervical ESI feel like?
• How long will my cervical ESI last?
• If a cervical ESI doesn’t relieve my pain, what other options do I have?

What happens during a cervical epidural steroid injection procedure?

You will likely have your epidural steroid injection in a hospital or an outpatient clinic. In most cases, a cervical ESI takes 15 to 30 minutes. It’s important to be very still during this procedure.

The two most common approaches to cervical epidural steroid injections are transforaminal (TFESI) and interlaminar (IESI). These two methods describe the path your healthcare provider uses to get to the epidural space around your spinal cord.

For an interlaminar ESI, the path of the needle is in between two laminae in your spine to get to the epidural space. A lamina is the flat plate of bone that’s part of each vertebra in your spine. The laminae in your spine form the outer wall of the spinal canal and protect your spinal cord.

For a transforaminal ESI, the path of the needle is through the foramina, which are openings through which nerve roots exit your spine.

The general steps of a cervical epidural steroid injection procedure include:

• You’ll change into a medical gown and lie on a comfortable table on your belly.
• Your healthcare provider will thoroughly clean the area of your neck where they’ll insert the epidural needle to minimize the risk of infection.
• Your provider may inject local anesthesia with a small needle near the area where they’ll insert the epidural needle. This is so you won’t feel as much pain when they insert the epidural needle, which is larger than a standard shot needle. They may also give you medicine to relax, such as a sedative.
• Once the area is numb, your provider will most likely use a type of imaging guidance called fluoroscopy (X-ray, or radiology imaging) to help guide the epidural needle to exactly the right position.
• When the epidural needle is in the epidural space around your spinal cord, your provider may inject contrast material. The contrast material will make it easier for your provider to see the area they’re targeting on the screen of the imaging machine. This helps to make sure that the medication will reach the inflamed nerves they are targeting. If you have a contrast material allergy, your provider will not do this step.
• Your provider will then slowly inject the medication, which is usually an anti-inflammatory medication, such as a steroid or corticosteroid. Some providers may inject a mixture of a corticosteroid and a local anesthetic.
• When your provider is done with the injection they’ll apply pressure to the site to prevent bleeding, clean the area again and apply a dressing to the site. You’ll move into a chair or bed to rest for a few minutes to an hour. This is so your provider can make sure you don’t have any reactions to the medication before you go home.

Is a cervical epidural steroid injection painful?

You’ll likely experience a minor pinch when your provider injects the local anesthetic to numb the area before your cervical epidural steroid injection.

You may not feel anything during your cervical ESI injection, or you may feel the following:

• Pressure.
• Tingling.
• A burning sensation.
• Momentary pain.

If you have any discomfort during the injection, it usually disappears once the injection is finished. If you feel intense, sharp pain during or after your ESI injection, tell your provider immediately.

What should I expect after my cervical epidural steroid injection?

After your injection, you may feel some discomfort where your healthcare provider inserted the needle. This is normal and should only last a few hours.

If your cervical ESI procedure involved a local anesthetic, your neck, shoulder, arm and/or hand may feel heavy or numb after your ESI. This is normal and shouldn’t last very long.

Your provider may tell you to take it easy and minimize your activity level for the rest of the day.

Your pain may become worse for two to three days after your cervical ESI before it begins to improve. Epidural steroid injections start working within two to seven days, and the pain relief can last several days to a few months or longer.

What are the advantages of cervical epidural steroid injections?

The advantages of cervical epidural steroid injections include:

• You may experience temporary pain relief.
• You may have enough pain relief to participate in rehabilitation exercises to help treat the cause of your neck pain.
• You may have a better quality of life and an improved ability to do daily activities due to pain relief.
• Cervical epidural steroid injections may reduce the need for more invasive procedures, such as surgery, for pain management.

What are the risks and possible complications of cervical epidural steroid injections?

Cervical epidural steroid injections are usually safe, but there are risks of certain side effects and complications. Although rare, risks and complications that apply to all types of ESI injections include:

• Having low blood pressure, which can make you feel lightheaded.
• Experiencing a severe headache caused by spinal fluid leakage.
• Getting an infection from the epidural procedure, such as an epidural abscess, discitis, osteomyelitis or meningitis.
• Having a negative reaction to the medications, such as hot flashes or a rash.
• Experiencing bleeding if a blood vessel is accidentally damaged during the injection, which could cause a hematoma or a blood clot to form.
• Experiencing strokes to the spinal cord, brain stem and/or cerebellum due to an accidental injection into a blood vessel.
• Having damage to the nerves at the injection site.
• Getting ESI injections too often or receiving higher doses of steroid medication may weaken the bones of your spine or nearby muscles. Because of this, most healthcare providers limit the number of ESIs they give to a person per year.

Can having a cervical epidural steroid injection cause long-term side effects?

While it’s very rare, receiving a cervical epidural steroid injection can lead to some long-term complications, including:

• Permanent neurologic deficit due to spinal cord or nerve root damage from the epidural injection. This could lead to conditions such as monoparesis (a partial loss of voluntary motor function) and quadriplegia (paralysis of your arms and legs).
• Chronic pain due to spinal cord or nerve root damage from the epidural injection.
• Permanent paralysis from a hematoma that occurs if there’s an accumulation of blood between the dura mater and the spinal cord.

What is the outlook (prognosis) for cervical epidural steroid injection therapy?

Approximately 40% to 84% of people who receive a cervical epidural steroid injection experience at least partial pain relief. However, some people do not experience any pain relief.

The goal of a cervical epidural steroid injection is typically to provide adequate short-term pain relief so that you can begin or continue physical therapy or to try to avoid more intensive pain relief procedures. Physical therapy may help promote long-term pain relief by strengthening the muscles that support your spine.

If a cervical ESI works for you and results in pain relief, your healthcare provider may recommend another injection later on. However, most providers limit people to two to three cervical ESIs per year.

How long do cervical epidural steroid injections last?

In many cases, cervical epidural steroid injections provide effective short-term pain relief. Your pain relief may last for several days to months or longer. One study revealed that people who had cervical interlaminar ESIs had pain relief for 12 to 24 months. Cervical ESIs very rarely lead to permanent pain relief.

Unfortunately, some people don’t experience any pain relief from cervical ESIs.

When should I see my healthcare provider?

If you experience any of the following symptoms after you’ve returned home from your cervical ESI injection, be sure to contact your healthcare provider or go to the nearest hospital as soon as possible:

• Experiencing a severe headache while you’re standing up or sitting that feels better after lying down. This could be a sign of a dural puncture or spinal headache.
• Having a fever, which could be a sign of an infection.
• Feeling prolonged numbness and/or weakness in your arms, which could be a sign of nerve injury.

A note from Cleveland Clinic

When performed by a skilled healthcare provider, cervical epidural steroid injections are an often effective and generally safe therapy option for chronic neck pain caused by certain conditions. It’s important to remember that a cervical ESI will most likely not cure your neck pain. Rather, it will provide temporary pain relief so that you can return to your normal activities and/or physical therapy. If you’re feeling anxious about receiving a cervical ESI, don’t be afraid to ask your healthcare provider about it and the procedure. They can answer any questions you may have.