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Chronic Cervical Radiculopathy: Lateral-Approach Periradicular Corticosteroid Injection¹

¹ From the Department of Radiology, Raymond Poincaré Teaching Hospital, University of Paris 5, 104 Blvd Raymond Poincaré, 92380 Garches, France. Received February 10, 2000; revision requested April 18; revision received July 5; accepted August 2. Address correspondence to C.A.V. (e-mail: christian.vallee@rpc.ap-hop-paris.fr).

	ABSTRACT

TOP ABSTRACT INTRODUCTION Materials and Methods Results Discussion REFERENCES

 
Thirty-two patients underwent periradicular corticosteroid injections with a lateral percutaneous approach under fluoroscopic guidance, to treat 34 foci of chronic cervical radiculopathy unresponsive to medical treatment alone. The mean evolutionary trends for radicular and neck pain relief were significant at 14 days (P < .001) and at 6 months (P < .001). The procedure did not produce any complications.

Index terms: Spine, arthritis, 31.77 • Spine, diseases, 31.148, 31.77, 31.78 • Spine, interventional procedures, 31.1269 • Spine, intervertebral disks, 31.1269, 31.148

	INTRODUCTION

TOP ABSTRACT INTRODUCTION Materials and Methods Results Discussion REFERENCES

 
Cervical radiculopathy is due to an abnormal process that involves the nerve root. It is caused mostly by cervical disk herniation or cervical spondylosis (1). The symptoms of cervical radiculopathy are neck and brachial-radicular pain, with or without motor weakness or paresthesia, in 80%–100% of patients (1). The precise mechanism whereby disk herniation or spondylosis causes radicular pain is, to our knowledge, still unclear. However, radiculopathy improves with nonsurgical treatment in a majority of patients.

Percutaneous injection therapies, including foraminal injections, are being reported and used for lumbar radicular pain with increasing frequency (2–4). These procedures are described less frequently in patients who have cervical radiculopathy, probably because of the higher risk due to the cervical anatomic environment, which involves the spinal cord, vertebral artery, carotid artery, and jugular vein. Furthermore, a majority of patients who have cervical radiculopathy improve within 1–2 months with appropriate medical treatment, which consists of rest, cervical immobilization, analgesics, antiinflammatory agents, and muscle relaxants (1). However, local corticosteroid injections may be indicated in patients who have persistent radicular pain (1). Some investigators have discussed the use of global epidural injections (5–7), but only a few have described their experience with selective periradicular injections (8–10). In the latter reports, the injections were performed through an anterolateral approach. The purpose of our study was to evaluate the feasibility and efficacy of cervical periradicular corticosteroid injections with a lateral percutaneous approach to control pain in patients with chronic radiculopathy that is resistant to conventional medical treatment.

	Materials and Methods

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Study Group
This pilot study was conducted in our university teaching hospital after it was approved by the institutional review board. Patient treatment required close collaboration between referring physicians and the interventional radiologists who administered the treatment.

The diagnosis of cervical radiculopathy was established by both the referring physician and interventional radiologist, in accordance with history and physical examination findings. The root level involved was determined from the radiating pain location, the distribution of paresthesia or motor weakness, or a combination of both. In each patient, radiographs of the cervical spine had initially been obtained and a computed tomographic (CT) or magnetic resonance imaging examination performed to determine the causal lesions and exclude an anatomic variant, especially for vascular and bone structures.

To be eligible for this prospective study, patients had to meet the following criteria: (a) have nerve roots involved at the levels of C3 through C8, (b) have refractory persistent symptoms after at least 2 months of appropriate medical therapy, (c) have a maximum intensity score of radicular pain on a 10-point pain scale, and (d) have an abnormal process involving the nerve root and linked to foraminal disorders (ie, disk herniation and/or foraminal narrowing due to spondylosis) (Fig 1).

View larger version (179K): [in this window] [in a new window] [Download PPT slide]   Figure 1. Transverse CT image obtained at the C5-6 level shows left posterolateral disk herniation (arrow) in a patient who had left C6 radiculopathy.

All patients included in the study received complete information prior to therapy; this information included the possibility of recurrence of radicular symptoms during the injection and/or transient exacerbation after the treatment. The treatment took place after patients had given informed consent to participate in the study.

Technique
The procedure was performed under fluoroscopic guidance by a well-trained physician (C.A.V.) and under strictly aseptic conditions. With the assistance of experienced technicians, patients were positioned in an upright sitting position to obtain a lateral view of the cervical spine. A foam pad was placed between the patient’s head and the radiographic table to help the patient maintain the required position. First, the skin was thoroughly cleansed with iodinated alcohol. Then, following the x-ray beam axis, a 21-gauge spinal needle (Becton-Dickinson France, Rungis, France) was gently pushed toward the anterosuperior margin of the articular process with the patient under local anesthesia (2 mL of lidocaine, 95% Xylocaine; Laboratoires Astra, Rueil-Malmaison, France) (Fig 2a). Once the tip of the needle had reached this bone, it was slowly displaced and advanced 5–10 mm anteriorly toward the intervertebral foramen. In the anteroposterior and oblique views, fluoroscopic control ensured accurate intraforaminal positioning of the needle tip (Fig 2b, 2c) without contrast medium injection. After careful aspiration to exclude blood or cerebrospinal fluid, 50 mg of a slow-acting corticosteroid (2 mL of prednisolone, Hydrocortancyl; Laboratoires Roussel-Diamant, Paris, France) was injected with a 2-mL syringe. The entire procedure, including patient positioning, lasted about 10 minutes. One hour later, patients were discharged and instructed to continue medical treatment, which including wearing a cervical collar, for 1 week.

View larger version (160K): [in this window] [in a new window] [Download PPT slide]   Figure 2a. Radiographs obtained during periradicular corticosteroid injections in a patient who had radiculopathy on the left side of the body at the C7 level. (a) Lateral view of the cervical spine shows the 21-gauge spinal needle tip (arrow) against the anterosuperior margin of the C7 posterior articular process. This stopping point at the bone provides a means to prevent deep penetration of the needle tip into the spinal canal before positioning it in the intervertebral foramen. (b) Anteroposterior and (c) oblique views of the cervical spine accurately show the C6-7 intraforaminal position of the needle tip (arrow).

View larger version (173K): [in this window] [in a new window] [Download PPT slide]   Figure 2b. Radiographs obtained during periradicular corticosteroid injections in a patient who had radiculopathy on the left side of the body at the C7 level. (a) Lateral view of the cervical spine shows the 21-gauge spinal needle tip (arrow) against the anterosuperior margin of the C7 posterior articular process. This stopping point at the bone provides a means to prevent deep penetration of the needle tip into the spinal canal before positioning it in the intervertebral foramen. (b) Anteroposterior and (c) oblique views of the cervical spine accurately show the C6-7 intraforaminal position of the needle tip (arrow).

View larger version (158K): [in this window] [in a new window] [Download PPT slide]   Figure 2c. Radiographs obtained during periradicular corticosteroid injections in a patient who had radiculopathy on the left side of the body at the C7 level. (a) Lateral view of the cervical spine shows the 21-gauge spinal needle tip (arrow) against the anterosuperior margin of the C7 posterior articular process. This stopping point at the bone provides a means to prevent deep penetration of the needle tip into the spinal canal before positioning it in the intervertebral foramen. (b) Anteroposterior and (c) oblique views of the cervical spine accurately show the C6-7 intraforaminal position of the needle tip (arrow).

Patients were considered to have improved when radicular and neck pain relief were excellent or good and medical therapy was stopped completely or required only occasionally.

Radiculopathy was evaluated by both the referring physician and interventional radiologist (J.N.V.) 14 days after periradicular injection; during follow-up at 3, 6, and 12 months; and then at the last follow-up consultation.

Statistical Methods
The data used for statistical testing were pain scores, which were recorded as independent events after the first periradicular injection. If the radiculopathy had to be treated twice, the treatment was considered a failure. The mean evolutionary trends for radicular and neck pain scores (continuous variables) during the periods of treatment and follow-up were each tested by performing the Wilcoxon signed-rank test for paired values, with Bonferroni correction and a significance level of .05, to take into account the multiple comparisons. Correlations between radicular and neck pain scores (continuous variables) were evaluated by performing Spearman rank correlation. To test the relationship between the duration of symptoms prior to periradicular injection and improvement independent of other patient characteristics (ie, age, sex, spinal level of radiculopathy, and side of the body on which radiculopathy occurred), we performed polychotomous multivariate regression (Biomedical Data Package; University of California, Los Angeles) after categorization of the pain relief for radicular and neck pain in one of four classes (excellent, good, fair, or poor). Correlations between radicular pain recurrence during periradicular injection and the pain relief outcome and between radicular pain exacerbation shortly after the injections and the pain relief outcome were tested by performing the Wilcoxon rank-sum test for unpaired variables.

The pain scores and percentages of pain relief given in the response to treatment and follow-up section were calculated after the last periradicular injection.

	Results

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Study Group
During a 3-year period, 32 patients (nine women and 23 men; mean age, 50.5 years; age range, 35–81 years) were entered into this prospective study. Patients’ baseline characteristics are given in Table 1. Two patients presented with bilateral cervical radiculopathy for a total of 34 foci. All patients had maximum intensity neck and radicular pain at admission. The mean duration of pain prior to periradicular injection was 9.5 months (range, 2.0–60.0 months).

During the 6-month follow-up period, three patients (three [14%] of 21 foci) who had been relieved of pain had a recurrence of radicular pain of the same intensity as that of the initial pain, and two (10%) of 20 had recurrent neck pain of lesser intensity than that of the initial pain. It was noteworthy that the patients with no improvement at 14 days experienced no subsequent clinical improvement.

After 6 months of follow-up, both radicular and neck pain relief were excellent or good in 18 (53%) radiculopathy foci and fair or poor in 16 (47%). Thus, at 6 months, periradicular corticosteroid injections were successful in 18 (56%) patients who resumed their full lifestyle, and unsuccessful in 14 (44%), who were unable to resume their previous work capacity. These 14 patients did not experience progressive weakness or new cervical myelopathy during follow-up and refused surgery in spite of unremitting pain.

No complications occurred in this series. Minor neurovegetative manifestations occurred during or after eight (19%) of the 43 procedures, but there were no significant side effects.

Statistical Results
According to the Wilcoxon signed-rank test for paired measurements of radicular and neck pain scores before periradicular injection (i) and 14 days (j), 3 months (k), and 6 months (l) thereafter, radicular and neck pain relief after Bonferroni correction were significant at 14 days (P < .001), 3 months (P < .001), and 6 months (P < .001). At 12 months, this statistical test was inappropriate because certain radicular and neck pain findings were not available.

The significance level for comparison of the paired measurements of radicular and neck pain scores (j,k), (j,l), and (k,l) was greater than .05 for all three. Radicular and neck pain relief was significantly stable throughout the 6-month follow-up period.

Radicular pain relief correlated with neck pain relief 14 days, 3 months, and 6 months after periradicular injection, by using Spearman rank correlation coefficients of 0.887, 0.883, and 0.895, respectively, with a corresponding significance level of less than .001 at all three times.

The duration of symptoms was a predictive factor of radicular pain relief that was independent of the other patient characteristics (ie, age, sex, spinal level of radiculopathy, and side of the body on which radiculopathy occurred) at 14 days (P = .020) and was on the border of significance at 3 months (P = .055) and 6 months (P = .075). The duration of symptoms was not a predictive factor of neck pain relief. Recurrence of radicular pain during injection and exacerbation of radicular pain shortly afterward did not correlate with pain relief outcome for either radicular or neck pain.

	Discussion

TOP ABSTRACT INTRODUCTION Materials and Methods Results Discussion REFERENCES

 
In a review of the literature, Ellenberg and colleagues (1) concluded that when groups of patients with proved cervical radiculopathy are treated nonsurgically, ideal outcomes may occur in 80%–90% of cases. Surgery should be reserved for patients who have unremitting pain despite careful nonsurgical treatment, progressive weakness, and/or new or progressive cervical myelopathy (1). However, in a randomized study by Persson and colleagues (11), surgery, physiotherapy, or a cervical collar in patients who had cervical radicular pain of at least 3 months duration was equally effective in the long term. Surgery is not always successful and may lead to complications (12,13). Good surgical outcomes vary between 64% and 96% (1). The use of local corticosteroid injections to control pain may therefore be considered in the sequence of treatments prior to surgery if there is neither improvement nor worsening of pain and the neurologic deficit is stable. Such injections should usually be performed after 2–3 months of medication (1).

In most reported series concerning percutaneous therapy for cervical radiculopathy (5–7), only global epidural steroid injections were performed. Shulman (7) found that the response was good to excellent in 16 (64%) of 25 patients who had no relief after conservative therapy and were given 45 epidural steroid injections. However, this procedure involves many nerve roots, with no possible selective nerve block of radicular pain, and is used infrequently and with great care by experienced operators, because the cervical spine’s anatomy makes it vulnerable (1).

Morvan and colleagues (8) performed cervical foraminal injections with an anterolateral approach that were derived from the technique of cervical diskography. The needle was gently advanced up to the foramen and along its axis under fluoroscopic control. This method had three drawbacks: first, the risk of puncturing vital structures (the trachea, esophagus, carotid artery, and jugular vein), which can be avoided by pushing medially with the fingers; second, the possibility of perforating the vertebral artery, which cannot be manually displaced; and third, the absence of means to prevent deep penetration of the needle tip into the spinal canal, with the attendant risk of spinal cord lesion. Complete long-lasting relief was experienced by seven (14%) of the 51 patients treated with 73 procedures. Morvan and colleagues (8) were unable to recommend this technique for routine treatment of cervicobrachial pain, in view of its relatively invasive nature and their unsatisfactory overall results. Bush and Hillier (9) also reported on a prospective series of 68 patients who had cervical radiculopathy and were treated with serial anterolateral periradicular and/or epidural corticosteroid injections, with a mean of 2.5 injections per patient. The mean duration of symptoms prior to presentation was 2 months. Forty-eight (76%) of the 63 patients followed up during a mean of 39 months after their initial presentation no longer experienced radicular pain after the injections.

In our study, the fluoroscopically guided lateral percutaneous approach was easy and safe to perform. Below the C3 level, the lateral approach protected vital structures (Fig 3) without manual deviation of the vessels and provided a safe stopping point at the bone for the needle tip before its positioning in the intervertebral foramen. The sitting position of the patient, which was compatible with fluoroscopic guidance, allowed an easier lateral approach to the inferior cervical intervertebral foramen than did the supine position required at CT guidance. This was because, in the sitting position, the patient’s shoulders are naturally at a lower level. Moreover, under fluoroscopic guidance, the procedure was rapid, lasting 10 minutes on average, and its cost was lower than that of a procedure under CT guidance. Fluoroscopic control, as visualized in both the anteroposterior and oblique views, accurately ensured intraforaminal positioning of the needle tip without intraforaminal injection of contrast medium before corticosteroid injection. Contrast medium injection might be responsible for (a) creating additional septic risk, (b) reproducing radicular pain, because of the pressure exerted on the affected nerve root by the amount of contrast medium injected, and (c) prolonging the procedure.

View larger version (56K): [in this window] [in a new window] [Download PPT slide]   Figure 3. Lateral vertebral artery angiogram shows the distance between the point of puncture (arrowhead) and the vertebral artery (arrow).

In our series, the 34 foci of chronic cervical radiculopathy that we studied were similar to those described in a published series reviewed by Ellenberg and colleagues (1). In accordance with the time required for prednisolone to act, a short period elapsed between periradicular injection and significant radicular and neck pain relief. This observation, combined with the significant absence of subsequent clinical improvement in radicular or neck pain for the follow-up period that started 14 days after the procedure, suggests that periradicular injection was responsible for the improvement that occurred in the 20 patients. The shorter duration of symptoms (mean, 4.5 months vs 17.5 months in the patients who did not improve) also contributed to this benefit in cases of radicular pain.

These results suggest that periradicular corticosteroid injections should be proposed early (after 1–2 months) in patients who have chronic radiculopathy that is resistant to conventional medical treatment. Radicular and neck pain relief were significantly durable at 6 months. At this time, the stability of radicular pain relief was 86% (18 of 21 foci) and the stability of neck pain relief was 90% (18 of 20). When the initial injection was ineffective, a second injection administered at the same level greatly diminished radicular and neck pain in three (43%) of seven patients. Therefore, if initial relief is insufficient or relapse occurs, periradicular injection may be repeated once or twice, although no conclusions can be drawn in this respect because of the small number of patients in this subgroup. The recurrence of radicular pain during the procedure and its exacerbation shortly afterward did not correlate with pain relief outcome.

Our results also suggest that periradicular corticosteroid injections should be considered as a complementary step in the course of conservative treatment, should be combined with the gradual discontinuation of medical treatment, and may constitute an alternative to surgery in cases of chronic cervical radiculopathy.

Steroid medication is indicated for pain relief or presumably to reduce inflammation around the nerve root. An inflammatory response at the level of the lumbar nerve root or disk herniation has been demonstrated (14–18). The proposed mechanisms of pain in radiculopathy include an increased discharge by dorsal root ganglia whose axons have undergone neurotmesis, mechanosensitivity or chemosensitivity of the nerve root itself, or direct pressure on chronically injured axons or normal dorsal root ganglia (18). The dorsal root ganglion contains thin unmyelinated C fibers that play a major role in nociceptive transmission by conducting afferent stimuli to the spinal cord (19,20). Because steroids have been proved to block C fiber activity (21), their injection near the dorsal root ganglion in the intervertebral foramen may explain the previously reported break in the self-maintained pain cycle (21). The correlation between radicular and neck pain relief after periradicular injection suggests that the effects of steroids on the disease process that involves the nerve root include the relief of not only radicular pain but also neck pain and that the nerve root that causes radicular pain might also be responsible for neck pain.

In conclusion, results of this study show that in more than half the patients who had chronic cervical radiculopathy and were not responsive to medical therapy, substantial durable pain relief occurred shortly after periradicular corticosteroid injection; the fluoroscopically guided lateral percutaneous approach ensures the safety of vital structures and provides a safe stopping point at the bone for the needle tip before it is positioned in the intervertebral foramen. This treatment may be considered as a complementary step before more invasive treatments in the course of therapy.

	FOOTNOTES

 
Author contributions: Guarantors of integrity of entire study, J.N.V., R.Y.C., C.A.V.; study concepts, J.N.V., A.F., D.M., C.A.V.; study design, J.N.V., R.Y.C., C.A.V.; definition of intellectual content, J.N.V., D.M., C.M., C.A.V.; literature research, J.N.V., A.F., D.M.; clinical studies, J.N.V., A.F., C.M.; data acquisition, J.N.V., R.Y.C., D.M., C.A.V.; data analysis, J.N.V., R.Y.C., C.M.; statistical analysis, J.N.V.; manuscript preparation, J.N.V., D.M.; manuscript editing, J.N.V., A.F.; manuscript review, J.N.V., A.F., R.Y.C., C.A.V.

	REFERENCES

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