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pISSN 2005-9159
eISSN 2093-0569

Editorial

Korean J Pain 2024; 37(3): 185-187

Published online July 1, 2024 https://doi.org/10.3344/kjp.24186

Copyright © The Korean Pain Society.

Complications and safety of cervical interlaminar epidural block

Jae Hun Kim

Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine, Seoul, Korea

Correspondence to:Jae Hun Kim
Department of Anesthesiology and Pain Medicine, Konkuk University School of Medicine, 120-1 Neungdong-ro, Gwangjin-gu, Seoul 05030, Korea
Tel: +82-2-2030-5749, Fax: +82-2-2030-5449, E-mail: painfree@kuh.ac.kr

Handling Editor: Francis S. Nahm

Received: June 5, 2024; Revised: June 22, 2024; Accepted: June 23, 2024

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cervical interlaminar epidural block (CIEB) can be effective for the treatment of neck or upper extremity pain [1]. It can also be effective in cervical post-surgery syndromes [2]. In Korea, this procedure is widely used for the treatment of pain. Although the frequency is low, cervical epidural blocks, including interlaminar and transforaminal epidural blocks, may cause several complications. These complications include neck pain, facial flushing, nausea, vomiting, transient hypotension, infection, respiratory insufficiency, subjective weakness in the arms, insomnia, dizziness, double vision, subdural block, dural puncture, headache, nerve injury, neuropathic pain, epidural hematoma, systemic toxicity of local anesthetics, syrinx formation, stroke, spinal cord/cerebellum/brainstem infarction, paralysis, or death [310].

There are published opinions on the safety of CIEBs. Recommendations include appropriate techniques, mandatory imaging guidance with multiple views, use of contrast media under real-time fluoroscopy or digital subtraction imaging, and performing the block at the C7-T1 spinal level (not higher than the C6-7 level) [2,1114]. After these recommendations were published, Manchikanti and Falco [15] pointed out a lack of evidence for some recommendations. They mentioned that mandatory fluoroscopy was necessary for all procedures, but multiple views were not. Many physicians use the loss-of-resistance (LOR) technique to confirm the epidural space. However, without C-arm fluoroscopy, 53% of the first LOR attempts resulted in inaccurate needle placement in the epidural space [16]. Therefore, C-arm fluoroscopy guidance is needed to ensure a safe and accurate CIEB. When performing CIEBs, physicians should not rely solely on the LOR technique for needle placement in the epidural space. At lower cervical levels, lateral views may be inappropriate for confirming the epidural space due to unclear images, while contralateral oblique views can be helpful for confirming needle placement in the epidural space and preventing dural puncture [17,18].

Manchikanti and Falco [15] did not agree with the approach at the C7-T1 level because the incidence of dural puncture at the C6-7 level and above was not higher than at the C7-T1 level. Many experienced pain physicians perform CIEBs at the C5-6 and C6-7 levels [15]. These levels are frequently associated with pathology and have minimal or similar complications compared with the C7-T1 level [6,15,19].

In a retrospective study of 12,168 CIEBs with particulate steroids, the complication rate was 1.1%, with only 0.06% encountering serious complications [6]. However, there were no cases of permanent disability, paralysis, or death, and most of the complications were minor. Serious complications (7 cases) included increased blood pressure (3 cases) during and after the procedure, substernal chest pain (1 case), dural puncture (1 case) with intrathecal air, and spinal cord penetration with the needle (2 cases). Although they used particulate steroids, there were no infarctions or other complications related to particulate steroids. In Korea, particulate steroids have been prohibited during epidural blocks since 2016 [20].

Although CIEBs may cause some complications, their incidence is low and most complications are transient. Serious complications associated with CIEBs are very rare. For safe CIEBs, physicians should perform the procedure with care and use imaging guidance techniques, such as C-arm fluoroscopy with contrast media. During and after the procedure, the patient's condition should be carefully monitored for abnormalities.

Data sharing is not applicable to this article as no datasets were generated or analyzed for this paper.

Jae Hun Kim is a section editor of the Korean Journal of Pain; however, he has not been involved in the peer reviewer selection, evaluation, or decision process of this article. No other potential conflict of interest relevant to this article were reported.

Jae Hun Kim: Writing/manuscript preparation.

  1. Choi JW, Lim HW, Lee JY, Lee WI, Lee EK, Chang CH, et al. Effect of cervical interlaminar epidural steroid injection: analysis according to the neck pain patterns and MRI findings. Korean J Pain 2016; 29: 96-102.
    Pubmed KoreaMed CrossRef
  2. Kim CS, Kwon HJ, Nam S, Jang H, Kim YD, Choi SS. Current practices of cervical epidural block for cervical radicular pain: a multicenter survey conducted by the Korean Pain Society. Korean J Pain 2024; 37: 256-63.
    Pubmed CrossRef
  3. Manchikanti L, Malla Y, Cash KA, Pampati V, Hirsch JA. Comparison of effectiveness for fluoroscopic cervical interlaminar epidural injections with or without steroid in cervical post-surgery syndrome. Korean J Pain 2018; 31: 277-88.
    Pubmed KoreaMed CrossRef
  4. Van Zundert J, Huntoon M, Patijn J, Lataster A, Mekhail N, van Kleef M. 4. Cervical radicular pain. Pain Pract 2010; 10: 1-17.
    Pubmed CrossRef
  5. Peene L, Cohen SP, Brouwer B, James R, Wolff A, Van Boxem K, et al. 2. Cervical radicular pain. Pain Pract 2023; 23: 800-17.
    Pubmed CrossRef
  6. Chang A, Wang D. Complications of fluoroscopically guided cervical interlaminar epidural steroid injections. Curr Pain Headache Rep 2020; 24: 63.
    Pubmed CrossRef
  7. Schultz DM, Hagedorn JM, Abd-Elsayed A, Stayner S. Safety of interlaminar cervical epidural injections: experience with 12,168 procedures in a single pain clinic. Pain Physician 2022; 25: 49-58.
  8. Epstein NE. Neurological complications of lumbar and cervical dural punctures with a focus on epidural injections. Surg Neurol Int 2017; 8: 60.
    Pubmed KoreaMed CrossRef
  9. Kang HY, Kim JE, Kim YJ, Park SW, Kim Y. An unusual delayed onset of systemic toxicity after fluoroscopy-guided cervical epidural steroid injection with levobupivacaine: a case report. Pain Pract 2019; 19: 762-6.
    Pubmed CrossRef
  10. Scanlon GC, Moeller-Bertram T, Romanowsky SM, Wallace MS. Cervical transforaminal epidural steroid injections: more dangerous than we think? Spine (Phila Pa 1976) 2007; 32: 1249-56.
    Pubmed CrossRef
  11. Khan S, Pioro EP. Cervical epidural injection complicated by syrinx formation: a case report. Spine (Phila Pa 1976) 2010; 35: E614-6.
    Pubmed CrossRef
  12. Manchikanti L, Knezevic NN, Navani A, Christo PJ, Limerick G, Calodney AK, et al. Epidural interventions in the management of chronic spinal pain: American Society of Interventional Pain Physicians (ASIPP) comprehensive evidence-based guidelines. Pain Physician 2021; 24(S1): S27-S208.
    CrossRef
  13. Benzon HT, Huntoon MA, Rathmell JP. Improving the safety of epidural steroid injections. JAMA 2015; 313: 1713-4.
    Pubmed CrossRef
  14. Rathmell JP, Benzon HT, Dreyfuss P, Huntoon M, Wallace M, Baker R, et al. Safeguards to prevent neurologic complications after epidural steroid injections: consensus opinions from a multidisciplinary working group and national organizations. Anesthesiology 2015; 122: 974-84.
    Pubmed CrossRef
  15. Manchikanti L, Falco FJ. Safeguards to prevent neurologic complications after epidural steroid injections: analysis of evidence and lack of applicability of controversial policies. Pain Physician 2015; 18: E129-38.
    CrossRef
  16. Stojanovic MP, Vu TN, Caneris O, Slezak J, Cohen SP, Sang CN. The role of fluoroscopy in cervical epidural steroid injections: an analysis of contrast dispersal patterns. Spine (Phila Pa 1976) 2002; 27: 509-14.
    Pubmed CrossRef
  17. Park SY, Leem JG, Jung SH, Kim YK, Koh WU. An alternative approach to needle placement in cervicothoracic epidural injections. Korean J Pain 2012; 25: 183-7.
    Pubmed KoreaMed CrossRef
  18. Kwon HJ, Kim CS, Kim J, Kim S, Shin JY, Choi SS, et al. Contralateral oblique view can prevent dural puncture in fluoroscopy-guided cervical epidural access: a prospective observational study. Reg Anesth Pain Med 2023; 48: 588-93.
    Pubmed CrossRef
  19. Manchikanti L, Malla Y, Cash KA, Pampati V. Do the gaps in the ligamentum flavum in the cervical spine translate into dural punctures? An analysis of 4,396 fluoroscopic interlaminar epidural injections. Pain Physician 2015; 18: 259-66.
    Pubmed CrossRef
  20. Notification No. 2016-49. Detailed information on the application standards and methods of medical care benefits [Internet]. Health Insurance Review and Assessment Service. Available at: https://www.hira.or.kr/bbsDummy.do?pgmid=HIRAA020002000100&brdScnBltNo=4&brdBltNo=5980.