Therapeutic Injections for Cervical Radiculopathy

Ross A. Hauser, MD, Physiatrist

Even when faced with severe disabling pain, many patients desire a non-surgical approach to their problem. While anti-inflammatory medications and oral corticosteroids can decrease nerve inflammation, some cases of cervical radiculopathy necessitate injecting steroids directly into or around the inflamed nerve. Studies have shown that even patients who have not responded to physical therapy, oral medications, and other conservative treatments, or those whose cervical radiculopathy symptoms and radiographic findings make them surgical candidates, can still experience significant benefits with cervical epidural and periradicular steroid injections and not need surgical intervention.^1,2 An Orthopedic Surgery Task Force on Neck Pain that appraised the scientific literature from 1980 to 2006 on surgical interventions for neck pain alone or with radicular pain concluded, “it is not clear from the evidence that long-term outcomes improved with the surgical treatment of cervical radiculopathy compared to nonoperative measures.”³ The Cervical Spine Research Society did a prospective, multicenter investigation of patients who presented with symptomatic cervical radiculopathy from cervical spondylosis and/or disc disease. They found that 26% of patients who underwent surgery reported persistent excruciating or horrible pain on follow-up.⁴ For these reasons, a nonoperative conservative approach, which may include cervical injections, is prudent for most patients with cervical radiculopathy.

Cervical radiculopathy is, by definition, a disease of the cervical spinal root in which the nerve root is either impinged upon, inflamed or both.⁵ Steroid and/or Prolotherapy injection therapy is utilized to help the patient (1) maintain an ambulatory or outpatient treatment status; (2) maintain participation in a physical therapy or rehabilitation program; (3) continue to work (4) decrease the need for analgesics; and (5) in some cases, avoid or delay surgical intervention.^6,7

Steroid injection therapy for cervical radiculopathy is utilized to directly decrease the inflammation in a specific nerve root. Each cervical nerve can be injected (or blocked) paravertebrally by approaching the nerve in a lateral or posterior direction. Cervical nerve roots (C1- C8) pass laterally through their respective foramina with the sulcus of each transverse process and exit at the level above the vertebral segment for which they are numbered (See Figure 1.) Since these transforaminal or periradicular corticosteroid injections are given onto a specific nerve root, they are typically done under fluoroscopic guidance. Studies have shown statistically significant neck and radicular pain relief with these types of injections.^8,9

Figure 1. Anterior view of neck showing cervical nerve roots. Cervical radiculopathy occurs when one of these nerve roots is irritated or pinched.

When it is not clear which cervical nerve root is involved or if several nerve roots are irritated, a cervical epidural injection can be utilized. The procedure can be performed in an outpatient setting using fluoroscopy (Xray guidance) where a needle can be directed, in most cases under local anesthesia alone, to the target site. (See Figures 2a & 2b.) The membrane covering the spine and nerve roots is called the dura. The space surrounding the dura is the epidural space. An epidural injection places anti-inflammatory medicine into the epidural space to decrease inflammation of the nerve roots, reducing pain and hopefully aiding the healing process. It may provide permanent relief or pain relief for several months while the injury/cause is healing. Improvement may occur immediately or within two weeks. Some patients will respond with one injection, but some may require up to three, interspersed over the course of a recovery period of one to three months. It is still unclear which factors or conditions, including herniated discs or spinal canal stenosis, optimize pain relief with cervical epidural steroid injections.^10,11

Figure 2a. C7 nerve root block under fluoroscopy. While the patient is in a supine position with the neck turned to contra-lateral side, a 25 gauge 2 inch needle is advanced under fluoroscopy into the right C6/7 neural foramen.

Figure 2b. C7 nerve root block under fluoroscopy. After confirmation of accurate needle placement with flow of contrast along the right C7 nerve root in both the AP and oblique views, injection of a local anesthetic and steroid is performed.

One of the most useful techniques in experienced hands for the treatment of cervical radiculopathy is Prolotherapy. Prolotherapy has a long history of being used in neck pain with and without arm and hand pain.^12-17 The mechanisms by which Prolotherapy can decrease pain and expedite healing time can be seen in Figure 3. Since many people with neck pain with concomitant shoulder, arm or hand pain come with the diagnosis of cervical radiculopathy, the first order of business for the treating physician is to investigate whether or not the diagnoses are correct. What most doctors and patients don’t realize is that ligament injuries in the neck can refer pain down the arm. (See Figure 4.) In my experience the most common reason for referral pain or pins-and-needles sensation down the arm is not a pinched nerve, but ligament laxity in the neck or upper thoracic region. Clearly if someone does not have a somatic (voluntary) nerve getting pinched (one of the cervical nerves discussed above) then having the person get a transforaminal or cervical epidural steroid injection(s) would be futile. If such a person had cervical ligament injury as the cause of their neck pain with referral symptoms down the arm then Prolotherapy or other conservative treatments would be warranted.

Figure 3. Mechanisms by which Prolotherapy can decrease pain and expedite healing time.

Figure 4. Ligament injuries to the neck can refer pain to the arm and hand as depicted in this referral diagram outlined by Dr. Hackett.

Ligaments are taut structures that prevent excessive movement of bones. The cervical ligaments prevent excessive movement of the neck vertebrae. When these cervical vertebrae rotate excessively to one side the condition is called cervical subluxation. This excessive movement of cervical vertebrae can lead to the irritation of autonomic nerves (nerves not under our voluntary control) which can lead to a host of symptoms including Barré-Lieou syndrome. (See Figures 5, 6, & 7.) Whether a person has had a forceful whiplash injury or side flexion injury, or they simply just sit at a computer terminal with forward head posture, ligament laxity or injury can result. (See Figure 8.)

Figure 5. Whiplash injury in sports can lead to Barré-Lieou syndrome. Injury to the ligaments in the neck can cause the vertebrae to move (subluxation) pinching on the autonomic sympathetic nerves.

Figure 6. Relationship of the sympathetic nerves to the neck vertebrae. The sympathetic nerves and ganglion sit just in front of the cervical vertabrae, and their proper functioning depends on proper vertebral alignment.

Figure 7. Symptoms that characterize Barré-Lieou syndrome.

Figure 8. A forceful side flexion injury results in asymmetric injury to the facet joints, vertebrae, and associated ligaments. Pain can then develop in the head and arm because of the referral patterns of the neck ligaments.

If the ligament weakness condition persists, not only can cervical subluxation occur, but the body will induce muscle spasm and eventually bone overgrowth or spur formation to stabilize the unstable segments. Dr. Liyand Dai from Changzheng Hospital in Shanghai, China found a direct correlation between cervical instability and the development of disc degeneration (arthritis of the neck).¹⁸ Prolotherapy has been found to be effective for the treatment of cervical instability.¹⁹ Prolotherapy will treat the underlying cause of the person’s cervical instability or cervical degeneration by stimulating ligament repair. It can be used alone or in combination with the treatments discussed in this article. The following is a case history to show how Prolotherapy was used in the treatment of cervical radiculopathy.

CASE STUDY #1. CERVICAL RADICULOPATHY IMPROVES WITH PROLOTHERAPY

A 38 year-old male, came to see Dr. Ross Hauser at Caring Medical in April 2008 with complaints of severe pain in his neck that radiated down his right arm with numbness of his right index finger and posterior wrist (C6 distribution). His pain began earlier that month after lifting a TV. Prior to this injury he was an active person who did not have pain. He stated that his pain was at its worst when lying down (a 10 out of 10 pain), but is helped by wearing a neck brace while sleeping. He was taking Norco two to three times per day for pain, a Medrol dose pack, and Daypro at the time of his first visit. An MRI ordered by his primary doctor revealed a right sided disc herniation at C5-C6 and C6-C7.

Upon initial exam, his right arm muscle strength was normal but had slightly diminished sensation in C6 dermatome. Upon extension of his neck and right lateral rotation he had shooting pains down his right arm. The patient received Prolotherapy at his first visit to his entire neck and right scapular region. He was taken off Norco and Daypro and given Ultram for pain and Ambien to help him sleep.

He returned every 2 weeks for the same treatment and at his 3rd visit he reported 50% improvement in pain. His pain was down to 5 out of 10. He still had numbness of his right index finger with lying down. He moved his appointments to every 3 to 4 weeks over the next few treatments and at his 5th visit he reported 70% improvement in pain and that he no longer had pain unless he was lying down. His finger was unchanged at this time.

The patient continued his Prolotherapy every 6 weeks or so over the next few treatments and, at what would have been treatment #9, he reported that his neck was doing “really good.” He did not receive treatment at this visit to his neck but wanted to get his knees and feet treated for unrelated injuries because Prolotherapy had worked so well on his neck. He was on no pain medication for his cervical radiculopathy after his 8th visit and the sensation to his right index finger and posterior wrist was back to normal. He was also back to full activities including exercise. Six months after his last Prolotherapy treatment he continues to do well.

CASE STUDY #2. THE DOCTOR'S CASE

While the last case study was treated with only Prolotherapy and medications, there are times where a variety of therapies are needed to resolve cervical radiculopathy. The following case I know very well because it is my own (R.H.). In January 2008, I had the best race of my life when I ran a 1:29:53 and placed 82nd out of over 12,000 people in the Disney Half Marathon. I made the podium for my age group (45 to 49). The next day I paced my wife, Marion, to a 5:11 marathon. Within a few weeks after this I noticed a severe pain by my right scapula after a swim workout. I was unable to do my planned workouts over the next few days as the pain grew worse. Eventually it was completely disabling, causing me to keep my neck flexed and often my right arm raised with my palm on the back of my head to provide relief. The pain was severe on the right side of my neck, right scapula and felt like a hot poker digging into the right back of my hand between my thumb and index finger. The pain was making work very difficult, and despite pain medication, the pain continued.

I eventually had an MRI and X-rays of my neck. The MRI showed no surgical lesions, but did show extension degeneration bilaterally especially at the C5-C6 region. (See Figure 9.) The neck radiograph showed a straight cervical spine with loss of cervical lordosis and a posterior, right, superior C6 vertebra. (See Figure 10.) Trying to choose the most conservative treatment, chiropractic, physiotherapy, including high velocity manipulation, and some physical therapy (including analysis by C.F.) was done. After several weeks and a 50% reduction of the pain, a video fluoroscopic analysis was done (by G.B.). This still showed a posterior right C6, but the alignment and motion of the upper cervical spine was improved. G.B. then started treating me with the Pierce Technique of chiropractic. This had me to 85% improvement, but after a bike accident (yes, I was still training), I regressed back to severe neck, scapular, and arm pain. At this point a series of Prolotherapy treatments were started using stronger solutions in the left lower cervical region to help with spinal alignment. The first Prolotherapy alone produced definite improvement. Within a couple of weeks after the first Prolotherapy treatment I was back on my bike and exercising almost daily. By early April, I was back to Ironman training.

Figure 9. MRI of Ross Hauser showing extensive degeneration at C5-C6. This overgrowth of bone was one of the causes of my cervical radiculopathy.

Figure 10. Lateral C-spine X-ray. The curved line shows the normal curve of the cervical spine. This X-ray demonstrates a straight cervical spine, indicative of a lot of muscle spasms which commonly occur with cervical radiculopathy.

In total, I needed four Prolotherapy visits but I am happy to say that in July 2008, I completed the Ironman in Lake Placid, despite it pouring rain the whole time. After swimming 2.4 miles and cycling 112 miles in the pouring rain I was still able to run a 4 hour 20 minute marathon. (See Figure 11.) It is now over 18 months after my cervical radiculopathy incident and I am completely pain free though on occasion I will get a very, very slight tingling in the back of right hand. My friends know that I am back to running, cycling and swimming with a vengeance. As there are many others out there who need to know that cervical radiculopathy can be treated conservatively, we decided to write this article for JOP!

Figure 11. Ross Hauser, MD during the 2008 Ironman Lake Placid. A 4:20 marathon in the pouring rain after swimming 2.4 miles and cycling 112 miles in a downpour is pretty good for a 45 year-old who just a few months prior to this had full blown cervical radiculopathy.