Translaminar steroid injections safely address neck pain

Translaminar steroid injections are safer than the standard epidural injection approach in chronic neck pain, according to a multicenter study led by researchers at the University of Cincinnati. The technique avoids complications linked to the transforaminal approach and offers an alternative to surgery in some patients.

Though used primarily to detect the cause of neck pain, epidural injections through the foraminae are commonly used to apply high concentrations of pain medication close to the site of pathology. Serious complications have been reported, however, including paralysis and even death after the perforation of the vertebral artery. The largest patient sample to date shows that the translaminar approach is also effective but less risky, said principal investigator Dr. William M. Strub, an interventional radiologist at the Christ Hospital in Cincinnati.

The outpatient translaminar approach involves fluoroscopy-guided injection of a small dose of medication between the C7 and T1 vertebrae, the largest epidural space in the neck. The treatment comprises up to three injections every three to four weeks. This approach is indicated for patients with neck pain from bulging discs and arthritis and those with continuous pain even after cervical spine surgery, Strub said. Patients who are most responsive experience the greatest pain relief immediately.

"We expect this approach to become the gold standard for reducing patients' neck pain," he said.

Strub and five other interventional radiologists performed a total of 312 interlaminar epidural steroid injections on 172 patients at three separate institutions between December 2003 and April 2006. The investigators found that patients with multilevel degenerative changes had a greater percentage of pain relief compared with those who had localized, single-level degenerative changes (p = 0.0112). They released their findings at the 2007 Society of Interventional Radiology meeting.

Fifty percent of patients who did not benefit from the injection required surgery for pain relief. Most patients who received narcotics prior to the procedure and those who got injections at a level other than C7-T1 were less likely to benefit from the injection. Researchers found no statistically significant association between pain relief, number of procedures performed, patient age, and duration of symptoms. Only five patients reported side effects.

Patients with muscle weakness or loss of sensation from a herniated disc will probably still need surgery, but those with neck and radicular pain could get enough symptomatic relief from the translaminar injection approach to avoid surgery, said Dr. J. Kevin McGraw, codirector of interventional radiology at Riverside Methodist Hospital in Columbus.

McGraw suffered from a herniated cervical disc, which led to triceps muscle weakness and hand numbness. He had to undergo surgery to keep the nerve injury from becoming permanent and shortening his career. Under different circumstances, though, surgery might have not been an option, he said.

"Had I only had pain, then cervical epidural injections would have been right for me," McGraw said.

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