Cervical radicular pain is commonly treated with cervical epidural steroid injections. The transforaminal approach allows for direct treatment of the steroid at a particular nerve root or level. Still, it carries a significant risk of morbidity and mortality with thromboembolism or injury to cervical vasculature. The interlaminar approach is commonly utilized as it avoids vascular structures. However, the epidural space becomes narrower at higher levels, limiting the ability to perform this approach at higher cervical levels. Cervical epidural catheters can be used and advanced to target higher cervical pathology through the interlaminar approach. We present clinical images demonstrating the utility of a cervical catheter for treating higher cervical levels

Chen, Grant H

Hasoon, Jamal J

Robinson, Christopher L

Vu, Peter D

English

DigitalCommons@The Texas Medical Center

Review began 10/31/2023 Review ended 11/07/2023 Published 11/08/2023© Copyright 2023Vu et al. This is an open access articledistributed under the terms of the CreativeCommons Attribution License CC-BY 4.0.,which permits unrestricted use, distribution,and reproduction in any medium, providedthe original author and source are credited.Epidural Catheters for Cervical Epidural SteroidInjections to Target Higher Cervical Pathology:Clinical Images in PracticePeter D. Vu  , Christopher L. Robinson  , Grant H. Chen  , Jamal J. Hasoon 1. Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center at Houston, Houston,USA 2. Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, HarvardMedical School, Boston, USA 3. Department of Anesthesia and Pain Medicine, University of Texas Health ScienceCenter at Houston, Houston, USACorresponding author: Peter D. Vu, peter.d.vu@uth.tmc.eduAbstractCervical radicular pain is commonly treated with cervical epidural steroid injections. The transforaminalapproach allows for direct treatment of the steroid at a particular nerve root or level. Still, it carries asignificant risk of morbidity and mortality with thromboembolism or injury to cervical vasculature. Theinterlaminar approach is commonly utilized as it avoids vascular structures. However, the epidural spacebecomes narrower at higher levels, limiting the ability to perform this approach at higher cervical levels.Cervical epidural catheters can be used and advanced to target higher cervical pathology through theinterlaminar approach. We present clinical images demonstrating the utility of a cervical catheter fortreating higher cervical levels.Categories: Anesthesiology, Pain ManagementKeywords: interlaminar approach, educational images, epidural catheter, steroid epidural injections, cervicalradicular painIntroductionCervical radicular pain is commonly treated with cervical epidural steroid injections [1,2]. Thetransforaminal approach allows for direct treatment of the steroid at a particular nerve root or level. Still, itcarries a significant risk of morbidity and mortality with thromboembolism or injury to cervical vasculature[2]. The interlaminar approach is commonly utilized as it avoids vascular structures. However, the epiduralspace becomes narrower at higher levels, limiting the ability to perform this approach at higher cervicallevels [1,3]. Cervical epidural catheters can be used and advanced to target higher cervical pathology throughthe interlaminar approach. Novel studies report microcatheters targeting cervical pathology but do notprovide technique visualization [1]. We provide interlaminar cervical epidural steroid injection visualizationat the C7/T1 interspace with microcatheter advancement to treat C3/C4 radicular pain.Case PresentationWe present a female teacher in her early 50s with a history of hypertension, hyperlipidemia, andprevious C5/C6 cervical fusion five years prior who presents with a new onset of headaches and neck painwith radicular, electric-like pain radiating into her bilateral shoulders and upper arm for the last fourmonths. She denies any new trauma or inciting factors. Her pain is considered a constant 7-8/10 that isexacerbated to 9-10/10 with neck flexion and extension. Prior to this new pain, she was active with dailywalks and weekly tennis matches. She also reported difficulty in neck range of motion, especially withstraining her neck to teach effectively with school equipment. This included extending and bending her neckto use the chalkboard, lifting school supplies from shelves, and monitoring the children. Before her referralto the pain clinic by her primary care provider, the patient reported her previously prescribed gabapentin 300mg three times a day and over-the-counter acetaminophen 1,000 mg three times a day had not been helpful.Her primary care provider had also obtained further cervical spine radiographs, which reported no changesto her anatomical features or previous cervical fusion. Before the referral, physical therapy and cervicalspine magnetic resonance imaging (MRI) were ordered by the primary care provider.At the pain clinic, the cervical spine MRI was reviewed and showed new-onset disc bulges at C3/C4 andC4/C5. After further discussion with the patient, she opted to trial an intralaminar cervical epidural steroidinjection at the C7/T1 interspace in the clinic procedure room. The patient was placed in a prone position,and the target area was cleaned with chlorhexidine and alcohol wipes. Lidocaine (5 mm) was injected toprovide local anesthetic into the target area before a spine needle was introduced. A contralateral obliqueimage was utilized for safety and reliability [4,5]. After obtaining a loss of resistance with approximately 3cm of needle insertion, iohexol contrast without additives was injected and demonstrated minimal cephalicspread (Figure 1).1 2 3 3 Open Access CaseReport  DOI: 10.7759/cureus.48528How to cite this articleVu P D, Robinson C L, Chen G H, et al. (November 08, 2023) Epidural Catheters for Cervical Epidural Steroid Injections to Target Higher CervicalPathology: Clinical Images in Practice. Cureus 15(11): e48528. DOI 10.7759/cureus.48528FIGURE 1: Contralateral oblique view of an interlaminar cervicalepidural steroid injection at the C7/T1 interspace (arrow) demonstratingminimal cephalic spread of contrast (white circle).Given that the patient’s pathology was more cephalic, a microcatheter (Perifix Epidural Catheter (20 Ga),Braun B, Melsungen, Germany) was advanced through the Tuohy needle to the C3/C4 level withapproximately 5 cm of microcatheter. Contrast was again injected and demonstrated diffuse spread aroundthe C3/C4 and C4/C5 levels (Figure 2).2023 Vu et al. Cureus 15(11): e48528. DOI 10.7759/cureus.48528 2 of 4FIGURE 2: Contralateral oblique view after advancement of amicrocatheter at C3 (orange arrow) demonstrating significantly morecontrast spread around the C3/C4, C4/C5, and C5/C6 levels (whitecircle).Once confirmation of the level was obtained, 3 mL of dexamethasone and bupivacaine (1:4 ratio) mixturewere injected, which the patient tolerated well. The catheter needle was immediately removed, and thepatient was observed for 10 minutes in the clinic procedure room. She reported 50% relief immediately afterthe procedure and was discharged home from the clinic. At her three-month follow-up, the patient reported90% relief of radicular symptoms (at worst a 1/10) and improved teaching involvement with her students.DiscussionCervical epidural steroid injections are medical procedures commonly used to alleviate pain andinflammation in the neck and upper spine region [1]. These injections involve the administration of a localanesthetic (i.e., lidocaine, bupivacaine, or ropivacaine) and a corticosteroid (i.e., particulate (triamcinoloneand methylprednisolone) and nonparticulate (dexamethasone and betamethasone)) medication into theepidural space surrounding the spinal cord and nerve roots. There are two primary approaches foradministering cervical epidural steroid injections: the transforaminal approach and the interlaminarapproach [2]. The transforaminal approach involves injecting the medication directly into the neuralforamen, a narrow opening through which spinal nerves exit the spinal cord. This method specificallytargets the affected nerve root and provides localized relief. On the other hand, the interlaminar approachinvolves injecting the medication into the epidural space between the vertebrae. While the interlaminarapproach covers a broader area, it may disperse the medication less precisely.Safety considerations between the two approaches revolve around the risk of complications [3]. Thetransforaminal approach is more targeted but may carry a slightly higher risk of neurovascular injury, whilethe interlaminar approach is generally considered safer, but it might require higher medication doses toachieve the desired effect. Epidural catheters, as in this case, can be employed to treat conditions that arechallenging to access directly through injections [5,6]. Currently, a variety of microcatheters arecommercially available for catheterizing intricate brain arteries. These microcatheters exhibit the necessaryflexibility to navigate through remote vascular locations and the strength required for propelling themeffectively. Furthermore, these catheters can be used off-label to thread into the epidural space using readilyavailable live fluoroscopic equipment [7].Despite the benefits, the use of epidural catheters involves careful monitoring and carries specific risks;2023 Vu et al. Cureus 15(11): e48528. DOI 10.7759/cureus.48528 3 of 4considerations of neurovascular structures and the risk of epidural hematomas, as described by Palmer [8],should be made prior to pursuing this technique. The use of fluoroscopy and loss-of-resistance techniquesminimizes the risk of direct spinal cord contact and damage to the spinal cord. Further considerationincludes particulate versus nonparticulate steroids; in the case of cervical epidural steroid injections,nonparticulate steroids are safer and reduce the risk of ischemic damage to the cord that couldperpetuate diaphragmatic weakness or paralysis [9].ConclusionsThese clinical images demonstrate the utilization of a catheter to target higher cervical pathology whenusing the interlaminar approach for cervical epidural steroid injection. Consideration of risks betweentransforaminal, interlaminar, and catheter approaches should be paramount when pursuing cervicalepidural steroid injections.Additional InformationAuthor ContributionsAll authors have reviewed the final version to be published and agreed to be accountable for all aspects of thework.Concept and design:  Peter D. Vu, Christopher L. Robinson, Grant H. Chen, Jamal J. HasoonAcquisition, analysis, or interpretation of data:  Peter D. Vu, Christopher L. Robinson, Grant H. Chen,Jamal J. HasoonDrafting of the manuscript:  Peter D. Vu, Christopher L. Robinson, Grant H. Chen, Jamal J. HasoonCritical review of the manuscript for important intellectual content:  Peter D. Vu, Christopher L.Robinson, Grant H. Chen, Jamal J. HasoonSupervision:  Jamal J. HasoonDisclosuresHuman subjects: Consent was obtained or waived by all participants in this study. The University of TexasHealth Science Center at Houston issued approval N/A. The patient provided consent and approval to reportthis case for educational purposes. Institutional Review Board (IRB) approval was not required withdeidentification and anonymization of identifiable medical information, per our institution’s IRB protocol.Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare thefollowing: Payment/services info: All authors have declared that no financial support was received fromany organization for the submitted work. Financial relationships: All authors have declared that they haveno financial relationships at present or within the previous three years with any organizations that mighthave an interest in the submitted work. Other relationships: All authors have declared that there are noother relationships or activities that could appear to have influenced the submitted work.References1. Conger A, Kendall RW, Sperry BP, et al.: One-year results from a randomized comparative trial of targetedsteroid injection via epidural catheter versus standard transforaminal epidural injection for the treatment ofunilateral cervical radicular pain. Reg Anesth Pain Med. 2021, 46:813-9. 10.1136/rapm-2021-1025142. Schneider BJ, Maybin S, Sturos E: Safety and complications of cervical epidural steroid injections . Phys MedRehabil Clin N Am. 2018, 29:155-69. 10.1016/j.pmr.2017.08.0123. McHaourab AS: Cervical epidural steroid injection: impact of cervical epidural anatomy . Anesthesiology.2004, 101:1238-9. 10.1097/00000542-200411000-000304. Gill J, Kohan L, Hasoon J, et al.: Contralateral and lateral views: analysis of the technical aspects of spinalcord stimulator lead insertion. Anesth Pain Med. 2022, 12:e123357. 10.5812/aapm.1233575. Qureshi AI, Qureshi MH, Malik AA, Khan AA, Sohail A, Saed A, Jadhav V: Catheter-based transepiduralapproach to cervical and thoracic posterior and perineural epidural spaces: a cadaveric feasibility study. JVasc Interv Neurol. 2015, 8:43-9.6. Amar AP, Wang MY, Larsen DW, Teitelbaum GP: Microcatheterization of the cervical epidural space vialumbar puncture: technical note. Neurosurgery. 2001, 48:1183-7. 10.1097/00006123-200105000-000527. Abdihalim MM, Hassan AE, Qureshi AI: Off-label use of drugs and devices in the neuroendovascular suite .AJNR Am J Neuroradiol. 2013, 34:2054-63. 10.3174/ajnr.A34478. Palmer E: Management of cervical epidural hematoma after cervical epidural steroid injection using acatheter technique. Pain Med. 2020, 21:1301-2. 10.1093/pm/pnz2209. Munglani R, Knaggs R, Eyre G: Particulate steroids in axial spinal blockade and the increasing role of patientconsent: Les grains de sable dans l'engrenage. Br J Pain. 2020, 14:141-6. 10.1177/20494637209211992023 Vu et al. Cureus 15(11): e48528. DOI 10.7759/cureus.48528 4 of 4

Epidural Catheters for Cervical Epidural Steroid Injections to Target Higher Cervical Pathology: Clinical Images in Practice

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Epidural Catheters for Cervical Epidural Steroid Injections to Target Higher Cervical Pathology: Clinical Images in Practice

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