ARRS 2022 Abstracts


E1837. CT-Guided Indirect Cervical Epidural Steroid Injection: Influence of Contrast Dispersion Pattern on Clinical Outcome
  1. Amy O'Brien; Buckinghamshire Healthcare NHS Trust
  2. Marta Rinaldi; Buckinghamshire Healthcare NHS Trust
  3. Zoe Teh; Cardiff University, School of Medicine
  4. Philip Vickers; Royal Berkshire NHS Foundation Trust
  5. Rory Fairhead; University of Oxford
  6. Richard Hughes; Buckinghamshire Healthcare NHS Trust
  7. David McKean; Buckinghamshire Healthcare NHS Trust
Imaged-guided cervical epidural steroid injections (ICESIs) play an important role in the treatment of cervical radicular pain. Numerous publications have reported rare but potentially significant complications using the conventional anterolateral approach. The intravascular injection rate from CT-guided injections using an anterolateral approach has been reported to be 24% overall and 45% with a foraminal needle position. Recent studies have described an indirect dorsal approach, which may be inherently safer. However, foraminal contrast flow may be more difficult to reliably achieve from a dorsal approach. The objective of our study is to investigate the impact of contrast dispersion patterns during CT-guided indirect cervical epidural steroid injections (ICESI), performed from a dorsal approach, on therapeutic outcome.

Materials and Methods:
In this single-centre retrospective cohort study, we analyzed contrast dispersion during CT-guided indirect cervical epidural steroid injections performed on 139 patients (mean age 55.9 years, SD 13.8 years, range 28–116) with cervical radiculopathy between January 2011 and December 2020. The contrast dispersion pattern was classified as "extraforaminal,’ “junctional zone,” or “foraminal.” Patient global impression of change (PGIC) was assessed. ICESIs were performed by experienced consultant musculoskeletal radiologists. The contrast pattern was compared between "good responder" (> 50% pain reduction) and "poor responder" (< 50%) groups. A p-value < 0.05 was considered to be statistically significant. Data were recorded on time taken to complete injections, vascular flow, significant complications, and adverse events.

Perineural extraforaminal contrast was identified in 34.5% (n = 48) of cases. Junctional zone contrast was evident in 27% (38) of injections. Foraminal zone contrast flow was identified in 38% (53) of cases. Follow up data at 4–8 weeks post CT-guided ICESI was obtained in 108 patients. Overall, CT-guided ICESI resulted in a substantial pain reduction (> 50% pain reduction) in 65.6% of patients with cervical radiculopathy. Contrast dispersion pattern had no effect on patient response (p = 0.72) after ICESI. Venous vascular flow was identified in 1.4% (2). No cases of carotid or vertebral artery penetration were identified. No adverse outcomes or significant complications were reported.

Indirect CT-guided cervical nerve root injection from a dorsal approach is associated with excellent pain response rates and very low risk of vascular penetration. No difference in clinical response was demonstrated with extra-foraminal, junction, or foraminal patterns of contrast dispersion. Dorsal indirect CT guided cervical nerve root injections may offer a safe and effective alternative to direct cervical transforaminal nerve root injections.