Cervical Epidural Injection

Anatomy and Physiology

Cervical epidural corticosteroid injections, sometimes combined with local anesthetics, are delivered into the epidural space, a potential area between the vertebrae and the dural sac. This procedure is indicated when cervical nerves are compressed, leading to inflammation and pain. By reducing swelling and inflammation at the site of nerve compression, these injections alleviate not only pain in the neck but also pain in the shoulder and arm associated with cervical radiculopathy. A thorough knowledge of cervical spine anatomy is crucial for clinicians performing these procedures, particularly due to the limited posterior epidural space above the C7-T1 level.[11] Although compression is a factor, significant inflammation—specifically elevated 1T2k VT (a marker of inflammation) at the neuroforamina (P < 0.04) but not at the spinal cord—supports the use of corticosteroids as a targeted therapeutic approach.[12]

The posterior epidural space is triangular, extending from the foramen magnum caudally to the sacral hiatus. Internally, this space is bordered by the thecal sac, which is sheathed by the dura mater, enveloping the spinal nerves and dorsal root ganglia. Externally, the epidural space is confined by the spinal canal and periosteum, with the posterior longitudinal ligament forming the anterior border and the lamina and ligamentum flavum forming the posterior border. Notably, the ligamentum flavum often presents as loose at the midline in approximately half of the individuals, where the interspinous ligament may be absent.[13]

The lateral confines of the epidural space include the pedicles and the intervertebral foramen, constituted by the superior and inferior pedicles. The foramen's posterior and anterior walls are formed by the facet joint's superior articular process and the vertebral disk and endplate, respectively. The epidural space houses fatty tissue, cervical and radicular arteries, lymph, arachnoid granules, a venous plexus, and spinal nerve roots. Spinal nerve roots, emerging from the spinal cord, coalesce to form spinal nerves that exit via the foramina below, sheathed by the thecal sac as root sleeves. The dura mater terminates distally at the dorsal root ganglion at its proximal margin. The vascular supply to this region includes the vertebral, ascending cervical, subclavian, and deep cervical arteries, which penetrate the foramen and bifurcate into posterior and anterior cervical radicular arteries.[14]

Indications

Cervical epidural injections are indicated for patients with radicular pain or neck pain due to discogenic pathology. Symptoms typically include numbness, tingling, dysesthesia, or burning pain distributed in a dermatomal pattern. Before the procedure, clinicians should closely monitor for symptom progression—particularly worsening weakness or sensory deficits—through serial neurologic examinations, with attention to upper motor neuron signs. Corticosteroid injections are often favored over surgical intervention in patients with escalating pain absent of worsening neurological impairment. Imaging confirmation via magnetic resonance imaging (MRI) or computed tomography is essential to verify stable nerve root compression from degenerative changes or a herniated disc. Advanced imaging also helps avoid injections at critically stenotic levels, where the risk of complications, including high spinal block, is elevated.

Contraindications

Absolute contraindications to cervical epidural corticosteroid injections include active infections, uncontrolled coagulopathy or bleeding disorders (including the use of oral anticoagulants), uncontrolled hyperglycemia, and progressive neurological decline. Conditions such as worsening motor weakness, high-grade spondylolisthesis, or critical spinal stenosis requiring urgent surgical evaluation also preclude the procedure. Relative contraindications include poorly controlled chronic conditions like hypertension or diabetes, as well as pregnancy, due to the associated risks of fluoroscopic imaging. Careful patient selection and thorough pre-procedural evaluation are essential to ensure safety and minimize the risk of complications.

Equipment

Essential equipment for performing a cervical epidural corticosteroid injection includes topical anesthetics such as lidocaine, a low-resistance syringe, and an appropriate needle—typically a Tuohy epidural needle (17–20 gauge) or, for the transforaminal approach, a Quincke spinal needle (22–25 gauge). Real-time imaging is typically performed using a C-arm fluoroscope, and the interventionalist must wear a lead apron for radiation protection. Contrast dye is used to confirm proper needle placement. The injectate typically consists of a combination of preservative-free local anesthetic, preservative-free saline, and a corticosteroid such as dexamethasone, which may be particulate or non-particulate, depending on the technique.

Personnel

Cervical epidural injections are typically outpatient procedures performed by pain management specialists, often with training in physical medicine and rehabilitation or anesthesiology. Other specialists frequently performing these procedures include neurosurgeons, orthopedic surgeons, and interventional radiologists. The radiologic technician is usually present to operate the C-arm, but clinicians run it themselves using a foot pedal and careful positioning. Initial spot films are taken prior to skin prep. A circulator—such as a registered nurse, licensed practical nurse, physician assistant, or highly trained medical assistant—is present to assist with patient monitoring, procedure documentation, and maintaining the sterile field by opening and delivering sterile items as needed.

Intravenous sedation is not typically needed and has a higher rate of complications than local anesthesia in isolation; in such cases, a trained person capable of monitoring and administering sedation would need to be present. During the procedure, adequate personnel and equipment (crash cart) must be available to handle an emergency, including high cervical block, cardiac, or respiratory arrest. Post-procedure care depends on the presence or absence of sedation. Sedated patients need a higher degree of care.

Preparation

Cervical epidural injections are ideally performed in ambulatory surgical centers or hospitals equipped with fluoroscopy capabilities; however, with appropriate training, equipment, and qualified personnel, they can also be safely and effectively conducted in well-prepared outpatient office settings. Given the potential for catastrophic complications, a competent clinician in interventional spine and pain procedures should perform the procedure.[15] The epidural injection may take up to 30 minutes, depending on the patient's anatomy. Minimal to no sedation should be given as patient communication and cooperation are critical for a safe outcome. Advanced imaging, such as MRI or computed tomography—with or without myelography if MRI is contraindicated—should be obtained before the injection to confirm the underlying cause of the patient’s symptoms and ensure appropriate treatment planning. If imaging is non-diagnostic or not possible, further testing may be required, such as electrodiagnostic studies.[16]

Technique or Treatment

The procedure is typically performed under fluoroscopy guidance.[15][17] Computed tomography fluoroscopy offers superior visualization but is rarely used due to the high levels of radiation exposure associated with this imaging.[18][19] Proper patient positioning is crucial for optimizing access to the epidural space; the patient should lie prone with arms positioned at the sides and the head supported in a flexed position to help widen the interlaminar spaces. The injection site must be prepared using sterile technique, typically with iodine or chlorhexidine. The procedure can be performed using different approaches, most commonly the interlaminar technique, which accesses the epidural space between the laminae, or the transforaminal technique, which delivers medication through the neural foramen.[20][21][22][23] 

Once a loss of resistance is detected, indicating that the needle has likely passed through the ligamentum flavum and entered the epidural space, contrast is injected to verify proper epidural spread. After confirming appropriate contrast distribution, aspiration is performed to check for cerebrospinal fluid or blood presence. If the aspiration is negative, a corticosteroid—either particulate, such as triamcinolone, or non-particulate, such as dexamethasone—combined with preservative-free saline and possibly a local anesthetic is administered. Clear communication with the patient throughout the procedure is essential to monitor for emerging neurologic symptoms. The C7-T1 level is generally preferred for injection, as the ligamentum flavum is consistently present at that level, reducing the risk of complications such as intrathecal or spinal cord puncture.

The transforaminal approach is infrequently used due to the risk of inadvertent vascular puncture. This technique involves utilizing oblique fluoroscopic views to enhance visualization of the lateral foraminal space. A spinal needle, such as a Quincke, is inserted beneath the superior vertebra's pedicle into the neural foramen's posterior aspect. The fluoroscope is angled approximately 70° toward the ipsilateral side to optimize foraminal visualization. This oblique orientation facilitates precise needle placement while helping to avoid critical vascular structures located within the foramen.[24] Anteroposterior and oblique views are used to advance the needle, and once the needle enters the foramina, live contrast is injected to ensure no vascular spread. A nonparticulate corticosteroid—preferred due to the risk of vascular thrombosis associated with particulate formulations—is mixed with local anesthetic and saline and then injected while maintaining close communication with the patient throughout the procedure.

Of note, ultrasound-guided rather than fluoroscopy-guided transforminal cervical epidural injection is a prospective new imaging modality. A small prospective study demonstrated effective and safe results. This modality has the significant benefit of visualizing the vascular structure.[25] However, ultrasound may be of limited value given the bone, preventing penetration into the epidural space during an interlaminar approach. 

Complications

Serious complications from epidural corticosteroid injections are uncommon, though fatal events have been reported, particularly with the transforaminal technique.[4][26][27] The overall complication rate associated with cervical epidural injections is estimated at approximately 16.8%.[28] These complications can occur if the needle becomes contaminated or inadvertently contacts the spinal cord, blood vessels, or spinal nerves.[18][29][30] Although the exact mechanisms are not fully understood, proposed causes include embolism and thrombus formation, aortic dissection leading to hemorrhage, arterial vasospasm, and dural puncture.[27][28][31][32] Potential adverse events include epidural hematoma, spinal abscess, hemorrhage, or infarction. Notably, no severe complications have been reported with the corticosteroid dexamethasone.

Specific complications associated with interlaminar cervical epidural corticosteroid injections include dural puncture, vasovagal reactions, nerve root injury, epidural hematoma, subdural hematoma, transient paresthesias, transient blindness, epidural abscess, spinal cord injury, paralysis, and death. Transforaminal cervical epidural corticosteroid injections have been linked to transiently increased radicular pain, vasovagal reactions, dural puncture, temporary lightheadedness, transient global amnesia, paralysis, vertebral artery injury, cerebellar infarction, and death. The most frequently reported side effects were neck pain (6.7%), headache (1.7%), insomnia (1.7%), and vasovagal reactions (1.5%). The incidence of dural puncture with the transforaminal approach is approximately 0.3%, while the intralaminar approach shows a dural puncture rate between 0.25% and 2.0%.[33][34][35] Headaches have been reported in 4.5% of patients receiving interlaminar injections, and a temporary increase in radicular pain has been noted in up to 18% of cases.[36]

Clinical Significance

The efficacy of cervical epidural injections largely depends on the underlying mechanism of injury and the extent of the pathology. Up to one-third of patients with compressive cervical radiculopathy experience a recurrence of symptoms following initial treatment.[2] Subsequent injections within a year may enhance pain relief synergistically. Cervical epidural corticosteroid injections are notably effective for short-term pain relief, yet study results comparing different techniques remain limited.[37] Intralaminar injections have been more thoroughly researched compared to cervical transforaminal epidural injections. The limited evidence for the transforaminal approach is less compelling and associated with a higher risk of adverse events.[38] There is robust evidence supporting the use of cervical epidural injections for pain resulting from cervical disc herniation, central spinal stenosis, and post-surgical syndrome.

There is a limited number of high-quality randomized controlled trials available. For short-term pain relief (<6 weeks), cervical epidurals are supported by moderate evidence, although long-term data are still lacking.[39] Results of one study highlighted significant pain relief from corticosteroid epidurals compared to local anesthetic injections, although corticosteroid injections showed no significant pain reduction at a 3-week follow-up.[40] Results of another study found that 24% of patients experienced complete symptom resolution following a cervical epidural, with 40% achieving at least 75% pain relief and 32% experiencing no relief.[35][41] Among patients with cervical radiculitis and structural abnormalities on imaging, only 35% reported a 50% or greater reduction in pain.

Enhancing Healthcare Team Outcomes

Cervical epidural injections are considered a minor outpatient procedure with a relatively low risk profile; however, serious complications have been reported and can lead to increased patient morbidity. Patients who have experienced stable radicular pain for at least 4 to 6 weeks due to cervical nerve compression may benefit from a cervical epidural corticosteroid injection. Before the procedure, a comprehensive patient evaluation and careful identification of potential risk factors are crucial. An interprofessional team approach enhances care for patients with cervical radiculopathy by reducing complications and improving outcomes and satisfaction. Patients should undergo the following assessments both before and after the injection:

• Evaluation by their primary care clinician. The patient should be considered for an epidural injection only after unsuccessful attempts at conservative management of cervical radiculopathy.
• Complete advanced imaging, including x-ray, computed tomography, or MRI, confirms the underlying pathology causing cervical radiculopathy by a radiologist. 
• When imaging results are inconclusive, a neurologist or physical medicine specialist may conduct nerve conduction studies or electromyography to aid in diagnosis.
• Consult with a pharmacist regarding the use of blood thinners before the procedure.
• In cases of worsening or severe symptoms, a neurosurgeon should be consulted for surgical decompression of the spinal cord rather than a minimally invasive epidural injection.
• Various specialists may perform cervical epidural injections based on the severity and duration of the patient’s neck pain. Primary care clinicians can refer patients to specialists such as anesthesiologists, pain medicine physicians, physical medicine and rehabilitation clinicians, or interventional neurologists.
• Specially trained nurses in radiology, neuroscience, and rehabilitation are essential for the care of these patients. 
• A fluoroscopy technician should be present for the procedure.
• Following the procedure, nurses should monitor the patient for post-procedure sequela.

Nursing, Allied Health, and Interprofessional Team Interventions

Patients can typically return to full activity the day after a cervical epidural injection. While some may experience soreness at the injection site, this can usually be alleviated with ice and over-the-counter pain relievers like acetaminophen. The clinician or nursing staff typically reviews potential adverse events with the patient after the procedure. Opinions vary, but sometimes 3 doses are performed, up to 1 to 4 weeks apart, following an initial injection. Transient paralysis has been reported following injection; however, numbness or weakness of muscles usually resolves within 8 hours of onset. Occasionally, a patient may need to be monitored for more than 30 minutes after the epidural.

Nursing, Allied Health, and Interprofessional Team Monitoring

After the procedure, patients are typically monitored for 20 to 30 minutes. In some severe cases, or if sedation is given intravenously, intramuscularly, or orally, patients should be driven home, and it is recommended that someone stay with them that night. The corticosteroid's analgesic effects can relieve pain for a few weeks to a few months, making it easier for patients to engage in physical therapy. Physical therapy focuses on improving posture, mobility, and strength, addressing potential underlying causes or contributing factors to pain, and creating a personalized home exercise program to support long-term spinal health.