Patients with Cervical Radiculopathy Should Try ESI Before Surgery
Pressure on the spinal cord or spinal nerves in the cervical (neck) region can cause painful disabling symptoms. This condition is called cervical radiculopathy. Usually, it's a herniated disc pressing on the nerve tissue that's causing all of the problems.
Painful symptoms can be managed with medication and physical therapy. But a loss of motor control of the arm and hand (progressing to paralysis) is a signal that it's time for surgery. For patients with pain but no other neurologic symptoms, epidural steroid injection (ESI) may be helpful and may also eliminate the need for surgery.
As the name implies, epidural steroid injection (ESI) is the injection of a numbing agent (like Novocain) and antiinflammatory (steroid). A long, thin needle is used to inject the medication into the space between the spinal cord and the lining around the spinal cord. The effect of the injection is to block pain messages. It also decreases swelling that is putting pressure on the nerve tissue.
Many studies have reported the effects of ESI for lumbar radiculopathy. There aren't as many reports on the use of ESI for cervical radiculopathy. This study comes from Korea where 98 patients with cervical radiculopathy were divided into two groups. Everyone in both groups had one or more (up to three total) injections. One group ended up having surgery, whereas the second group did not have surgery.
The differences between the two groups were the areas of interest. Seeing how many patients had surgery and how many did not was one important comparison. Analyzing the patient characteristics between the two groups was the second main focus of the study. Having this information might help surgeons predict who would benefit from ESI before surgery. The various factors they compared included patient age, sex (male versus female), duration of symptoms, number of spinal segments involved (one or more), measure of pain intensity, and neck disability.
They found that 80 per cent of the group did just fine with the steroid injection therapy and did not need surgery after all. Only 20 per cent of the group failed to get pain relief and ended up having follow-up surgery. In some cases, ESI was helpful but either the pain came back or some patients had pain relief but not total elimination of painful symptoms. In those cases, conservative care was prescribed including rest, change in activities, medications, and physical therapy.
There weren't a lot of differences between the two groups. But two things did stand out: 1) return of radiculopathy pain and 2) severe intensity of pain. Patients with these two factors were most likely to need surgery. None of the other factors (including imaging studies) gave any clues as to who would respond well to ESI therapy and who would need surgery.
Surgery to remove the disc and fuse the spine or replace the disc with an artificial implant was done on average six weeks after the last injection. For some patients, surgery was elected within two weeks of the start of injection therapy. For others, it was six months before surgery was performed. In all cases, the severity of pain and progression of neurologic symptoms were the deciding factors to have surgery.
The authors reported that right now there is no consensus or consistent evidence that ESI is effective for cervical radiculopathy. Their study showed that the majority of patients with cervical radiculopathy who were considered good candidates for surgery actually got much better with a less invasive form of treatment (i.e., epidural steroid injection). Unless there is paralysis or a worsening of pain and/or other neurologic symptoms, patients with cervical radiculopathy should consider ESI therapy before surgery.
Sang-Hun Lee, MD, et al. Clinical Outcomes of Cervical Radiculopathy Following Epidural Steroid Injection. In Spine Journal. May 20, 2012. Vol. 37. No. 12. Pp. 1041-1047.