CASE REPORT
Year : 2020 | Volume
: 6 | Issue : 3 | Page : 41--44
Epidural steroid and facet joint injection neck in elderly patient: A combined approach
Nandita Mehta, Rishika Jandial, Sayyidah Aasima Tu Nisa Qazi
Department of Anaesthesia and Intensive Care, Acharya Shri Chander College of Medical Sciences, Sidhra, Jammu, India
Correspondence Address:
Nandita Mehta
Department of Anaesthesia and Intensive Care, Acharya Shri Chander College of Medical Sciences, Jammu, Jammu and Kashmir
India
Abstract
Cervical radicular pain is often due to a combination of factors including intervertebral disc prolapse or herniation, narrowing of the intervertebral foramen, osteoarthritis of facet joints, and spondylolisthesis. Cervical Epidural with local anesthetics along with steroids is used for evaluation and management of radicular pain in patients with pathology that exists at multiple vertebral levels. Medial branch block is given for facet joint arthropathy both for diagnostic and therapeutic purposes. Therefore, the aim of performing this procedure was to provide an interlaminar epidural steroid injection at C7-T1 vertebral level along with a diagnostic right medial branch block under fluoroscopic guidance to 86 years old hypertensive female, with complaints of pain in the neck lower portion, upper part of back and shoulder on the right side, radiating down the arm up to medial two fingers and thumb for 2 years. An interlaminar epidural steroid injection was planned on the right side at the C7-T1 vertebral level under C-arm guidance. A diagnostic right medial branch block was also planned to be given on the same day at 2 levels C5/C6 and C6/C7 facet joint each using 2 mg dexamethasone (0.5 ml) and 1.5 ml of 1% lignocaine. A repeat epidural injection was given using a combination of 1 ml of steroid dexamethasone (4 mg) and 3 ml of 1% lignocaine along with facet medial branch block injection at the same levels using 0.5% bupivacaine 1.5 ml and 2 mg dexamethasone (0.5 ml) on her follow-up visit after 6 weeks. Following the block patient on her first visit, she had considerable pain relief with a visual analog scale (VAS) of 3. She was prescribed gabapentin, methyl-cobalamine and clonazepam. After 6 weeks, the patient had VAS score of 6. She looked comfortable and her paresthesia had grossly improved. At the end of the procedure, patient had good pain relief with no deficit. She was advised to continue gabapentin. On her third follow-up after 3 months, the patient presented with >70% relief in her initial pain with a VAS of <3 and minimal paresthesia along the distribution of the ulnar nerve and hence required no intervention. Cervical epidural steroid injections under fluoroscopy guidance are being used for the conservative management of neck pain or cervical radiculopathy. Facet joint injections and medial branch blocks aim to diagnose and treat the pain arising from facet joints in the spine. It is also important to prescribe drugs to manage the neuropathic component of the pain.
How to cite this article:
Mehta N, Jandial R, Tu Nisa Qazi SA. Epidural steroid and facet joint injection neck in elderly patient: A combined approach.J Recent Adv Pain 2020;6:41-44
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How to cite this URL:
Mehta N, Jandial R, Tu Nisa Qazi SA. Epidural steroid and facet joint injection neck in elderly patient: A combined approach. J Recent Adv Pain [serial online] 2020 [cited 2023 May 29 ];6:41-44
Available from: http://www.jorapain.com/text.asp?2020/6/3/41/329013 |
Full Text
Introduction
Cervical radicular pain is often due to a combination of factors including intervertebral disc prolapse or herniation, narrowing of the intervertebral foramen, osteoarthritis of facet joints, and spondylolisthesis. Any of these conditions may be the cause of radicular pain and in fact, could co-exist.[1]
Cervical epidural with local anesthetic is used for the evaluation of radicular pain in patients with pathology that exists at multiple vertebral levels. When a therapeutic benefit is desired, corticosteroids are included with a similar approach and they are regarded as cervical epidural steroid injections. Medial branch block is given for facet joint arthropathy both for diagnostic and therapeutic purposes.
Case Report
An 86-year-old hypertensive female, presented to our pain clinic with complaints of pain in the neck lower portion, the upper part of the back and shoulder on the right side, radiating down the arm up to medial two fingers and thumb for 2 years. The intensity of patient's pain had increased over the last 3–4 months, with a visual analog scale (VAS) score of 10. The pain started in the lower part of the neck and extended to the medial side of the arm up to the fingers. She also complained of tingling sensation with a feeling of pins and needles in that area with some numbness. She had been prescribed a number of analgesics but there was no relief. In fact, the patient was unwilling to take the painkillers. She was highly anxious because of her continuous and increasing pain and was even unable to sleep at night.
On local examination, the medial side of her hand was erythematous with wasting of hypothenar muscles. The local temperature was normal and the patient had a loss of light touch on the ulnar border of the hand. There was mild hyper-algesia on the medial side of the arm but no allodynia. On palpation of the neck, there was marked tenderness over the lower part of the neck in the right paramedian region and over the right upper region of the back near the shoulder as shown in [Figure 1]. Various special tests such as Spurling test, Jackson test, and Relief test were positive on the right side with a negative Tinel sign at the elbow and wrist. The Deep-tendon reflexes like Biceps and Triceps were normal and motor power was Grade 3 in the right hand.{Figure 1}
Investigations
X-ray of the neck was unremarkable with no spondylolisthesis or any fracture. Magnetic resonance imaging cervical spine revealed marked degenerative changes of cervical spine with multiple disc buldge in C5–6, C6–7, and C7-T1 levels with impingement of both traversing (T1) and exiting (C8) nerve at C7-T1 vertebral level on the right side. The nerve conduction test showed markedly decreased conduction speed along the ulnar nerve on the right side.
Procedure
An interlaminar epidural steroid injection was planned on the right side at the C7-T1 vertebral level. The patient was positioned prone on the table with flexion of the neck. C7-T1 epidural space was identified under C-ARM in anteroposterior view. After hitting the point on the posterior half of the lamina of T1 vertebrae on the right side with an 18 G Tuohy's needle under fluoroscopic guidance the needle was advanced upwards and anteriorly till the upper border of the lamina. Then the C-Arm was rotated obliquely till tear drop view was seen. The needle was then advanced over the teardrop till loss of resistance to saline was elicited. 1–2 ml of Omnipac dye was injected and after checking the depth of needle in lateral view on fluoroscopy, a combination of 1 ml of steroid dexamethasone (4 mg) and 3 ml of 1% lignocaine were injected. The patient was then observed for pain relief and any side effects for the next 2 h. Although the patient had some pain relief postprocedure but was still complaining of discomfort and pain (VAS 6). Considering that she was an elderly patient who had come from a very far-flung area, a diagnostic right medial branch block was planned to be given on the same day. Under fluoroscopic guidance, a Medial branch block was given at 2 levels C5/C6 and C6/C7 facet joint each using 2 mg dexamethasone (0.5 ml) and 1.5 ml of 1% lignocaine. Following the block, patient had considerable pain relief with a VAS of 3. She was discharged on the same day and prescribed 100 mg gabapentin at bedtime to be increased to twice daily doses after 2 weeks, methylcobalamin 1500 microgram and clonazepam 0.25 mg for 6 weeks.
On subsequent follow-up after 6 weeks, the patient was feeling comfortable but and still had some pain with VAS score of 6 as compared to 10 at the time of the first presentation. She revealed that she had good relief of up to 90% for the 10 days after the injection, after which the pain gradually increased to the present level. Despite the pain, she looked comfortable and the pain in her thumb and thenar muscle areas had completely resolved. Her paresthesia had grossly improved and she could sleep better at night. A repeat epidural injection was given using a combination of 1 ml of steroid dexamethasone (4 mg) and 3 ml of 1% lignocaine along with facet medial branch block injection at the same levels using 0.5% bupivacaine 1.5 ml and 2 mg dexamethasone (0.5 ml). At the end of the procedure, the patient had good pain relief with no deficit. She was discharged with the advice to continue same doses of gabapentin for 6 months.
On her third follow-up after 3 months after the second visit, the patient presented with more than 70% relief in her initial pain with a VAS of <3 and minimal paresthesia along the distribution of the ulnar nerve. She did not feel the requirement of any intervention and she was very comfortable on her oral medications. She was advised to report back in case the pain increases and was explained about the radiofrequency ablation of the medial nerve in case the need arises.
Discussion
Cervical epidural steroid injections are being used for the conservative management of neck pain or cervical radiculopathy.[2] These injections were often performed in a “blind” manner, i.e., without fluoroscopic guidance. Since fluoroscopy can improve the accuracy of needle placement and medication delivery to targeted areas and reduce procedure-related complications, it is being routinely used for all procedures on the spine.[3]
Cervical Epidural Steroid Injection, though not a procedure without complications can be a good treatment modality in patients who suffer from chronic radiculopathy not relieved by medical intervention and who are not candidates for surgical intervention. Cervical epidural steroid injections reduce inflammation around the nerve root, thus alleviating radicular pain.[4]
Complications occur when needle comes in contact with the spinal cord, blood vessels, spinal nerves, contamination, intra-arterial injection of particulate steroids, and local anesthetics.[5],[6] Serious complications are infrequent from epidural corticosteroid injections when nonparticulate steroid given, whereas particulate steroids should not be given in the head and neck.[7] Hemorrhage or infarction can occur during a cervical epidural corticosteroid injection; cases have resulted in fatalities, particularly during a transforaminal approach.[8],[9] The mechanism of complications again is unknown, but it has been said to be secondary to emboli and thrombus formation, aortic dissection leading to hemorrhage, arterial vasospasm, as well as a dural puncture.[10],[11] Epidural hematomas, spinal abscess, and cerebral vascular accidents can occur after injection.
Complications reported with transforaminal cervical epidural corticosteroid injections include transient increased radicular pain, vasovagal reaction, dural puncture, temporary lightheadedness, transient global amnesia, paralysis, vertebral artery injury, cerebellar infarction, and death.[12],[13]
Complications reported with an interlaminar cervical epidural corticosteroid injection include dural puncture, vasovagal reaction, nerve root injury, epidural hematoma, subdural hematoma, transient paraesthesias, transient blindness, epidural abscess, cord injury, paralysis, and death.[14]
Absolute contraindications to epidural corticosteroid injection include active infections, worsening and progressing neurological deterioration. Furthermore, uncontrolled coagulopathy or bleeding disorders are also considered contra-indications. Relative contraindications include uncontrolled medical conditions such as hypertension or diabetes and pregnancy.
The inflammatory pathway has been suggested to be the main mechanism for radicular pain. Cervical herniated disk specimens have demonstrated increased levels of matrix metalloproteinase activity, nitric oxide, prostaglandin E2, and interleukin-6.[15] Phospholipase A2 also plays a role in the inflammation of the nerve root and can be neurotoxic. Dexamethasone being a corticosteroid with moderate-to-strong efficacy inhibits both cyclo-oxygenase and lipo-oxygenase pathways of arachidonic acid metabolism, thus helping to reduce inflammation and in turn pain.[16] Several studies have demonstrated a favorable effect of injection of corticosteroid in cervical radiculopathy.[17],[18]
Local anesthetic mixed with the corticosteroid may have additional benefits beyond the direct anesthetic affects. Lidocaine has been shown to have anti-inflammatory effect on nucleus pulposus induced nerve injury.[12] Lidocaine has been demonstrated to increase intra-radicular blood flow in an animal compressed nerve root model.[19] This may improve intra-neural metabolism and reduce inflammatory mediators. Furthermore, the local anesthetic drug is used in any diagnostic procedure in which ideally two different local anesthetic drugs with different duration of action at two occasions.
As simple as the procedure may seem, it is not without complications. Only specialists who are trained in this procedure should perform it. Adequate needle positioning under the C-arm and the use of contrast medium are necessary.
Facet joints are surrounded by a joint capsule made up of synovial membrane tissue. This joint capsule contains a rich innervation of nerves and its upper pad is typically fused with the fatty sheath of the spinal nerve.[19] Each facet joint has a dual nerve supply being supplied by the medial branch of the same level and the level above.
Facet joint injections and medial branch blocks aim to treat pain arising from facet joints in the spine. While facet joint injections are given directly into the facet joint medial branch blocks target the medial branch nerves that carry pain signals from the facet joints to the brain. Both facet joint injections and medial branch blocks are used to diagnose and treat pain arising from facet joints. In fact facet joint arthropathy cannot be picked by any radiological investigation and performing two blocks of the facet joint on two different occasions help to confirm the diagnosis. The blocks are performed using a low volume of two different local anesthetic drugs and more than 50% pain relief on each occasion is indicative of positive test. To have a therapeutic effect for treating pain, steroids mixed with anesthetics are used. Radiofrequency ablation of the medial nerve supplying the involved facet joint is being done to achieve good pain relief in patients with confirmed facet joint arthropathy.
Injecting steroids near the medial branch nerves may:
Suppress the nerve from sending pain signals to the brainBlock specific fibers (C fibers) within the nerve that results in a decrease in pain transmitted to the brainDecreases the permeability of nerve fibers to receive blood, decreasing pain transmission.
Fluoroscopy or ultrasound guidance is done to guide the needle to the accurate treatment region. A contrast dye may be used to enhance the visualization of the joint and/or nerves.
Risk and complications include Allergic reaction, spinal cord damage, phrenic nerve damage, chemical meningitis, septic arthritis, infection and bleeding.
It is also important to prescribe drugs to manage the neuropathic component of the pain. Various drugs such as anticonvulsants, tri-cyclic antidepressants and Serotonin-norepinephrine reuptake inhibitor (SSNRI) can be used for the management of neuropathic pain.
Conclusion
Cervical epidural steroid injections are being used for the conservative management of neck pain or cervical radiculopathy. Fluoroscopy and epidurography can improve the accuracy of needle placement and medication delivery to targeted areas and reduce procedure-related complications. Initially, many people were using the Trans Foraminal Epidural Steroid Injection approach but due to serious side effects, this approach is nowadays avoided in favour of intra-laminar being comparatively safer.[13],[14],[20],[21] In case the offending disc bulge is central with bilateral impingement of nerve roots then inter-spinous approach for injection of steroids and local anesthetics can be used.[22]
Facet joint injections and medial branch blocks aim to diagnose and treat the pain arising from facet joints in the spine.
Considering her age, cervical epidural steroid injection and right median nerve branch block were thought to be a safe approach both for diagnosis and achieving therapeutic effect.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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