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j.wneu.2017.09.123

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Original Article
Effect of Interlaminar Epidural Steroid Injection in Patients with Central Cervical
Spinal Stenosis
Dong Gyu Lee and Min Cheol Chang
OBJECTIVE: To investigate the effect of interlaminar
epidural steroid injection (ESI) for management of central
cervical spinal stenosiseinduced posterior neck pain.
-
METHODS: This retrospective study recruited 45 patients
with posterior neck pain caused by central cervical spinal
stenosis. For the ESI procedure, a 21-gauge Touhy needle
was inserted into the epidural space between C7 and T1,
and 20 mg (40 mg/mL) of dexamethasone with 4 mL of normal
saline was injected. The effect of the procedure was evaluated using a numerical rating scale at 1, 2, and 3 months
after the procedure. Successful pain relief was defined as
reduction in numerical rating scale score of ‡50% compared
with before treatment. At 3 months after treatment, patient
satisfaction levels were examined; patients who reported
very good (score [ 7) or good results (score [ 6) were
considered to be satisfied with the procedure.
-
RESULTS: Posterior neck pain was significantly reduced
at follow-up evaluation 1, 2, and 3 months after ESI (P <
0.001, repeated measures 1-factor analysis). At 3 months
after the procedure, 58% of the patients achieved a successful response (‡50% pain reduction), and 56% were
satisfied with treatment results.
-
CONCLUSIONS: Cervical interlaminar ESI appears to be
a good treatment method for managing chronic posterior
neck pain induced by central cervical spinal stenosis,
especially when pain is refractory to oral medication.
-
Key words
Central spinal stenosis
- Cervical spine
- Chronic pain
- Epidural steroid injection
- Neck pain
-
Abbreviations and Acronyms
ESI: Epidural steroid injection
MRI: Magnetic resonance imaging
NRS: Numerical rating scale
WORLD NEUROSURGERY -: ---, - 2017
INTRODUCTION
C
entral cervical spinal stenosis is defined as narrowing of
the central spinal canal in the neck. It is usually caused by
age-related central spinal degenerative changes, including
herniation or bulging of intervertebral disks, osteophytes, and
ossification of the posterior longitudinal ligament.1,2 Although
central cervical spinal stenosis is found in 26% of asymptomatic
older individuals, it frequently causes pain in the posterior neck
and upper extremities.3 Patients with pain induced by central
cervical spinal stenosis may experience reduced functional ability
and quality of life.4
Surgery and other modalities have been used for the management of pain induced by central cervical spinal stenosis.4-8
However, noninvasive management should be considered
before surgery. Cervical interlaminar epidural steroid injection
(ESI) is one of the most commonly applied nonsurgical interventions for controlling neck and upper extremity pain secondary to central cervical spinal stenosis.4 Corticosteroids
inhibit the synthesis of various proinflammatory mediators.9
Therefore, interlaminar ESI can reduce inflammation induced
by mechanical compression in the narrowed central cervical
spinal canal. A previous study demonstrated the positive
therapeutic effects of interlaminar ESI in patients with central
spinal stenosis including central cervical spinal stenosis and
cervical foraminal stenosis.4 However, to the best of our
knowledge, there have been no studies on the effects of
interlaminar ESI on central cervical spinal stenosis alone. We
evaluated the effect of cervical interlaminar ESI in patients
with chronic posterior neck pain resulting from central
cervical spinal stenosis that was unresponsive to oral
medications.
Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam
University, Taegu, Republic of Korea
To whom correspondence should be addressed: Min Cheol Chang, M.D.
[E-mail: wheel633@ynu.ac.kr]
Citation: World Neurosurg. (2017).
https://doi.org/10.1016/j.wneu.2017.09.123
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2017 Elsevier Inc. All rights reserved.
www.WORLDNEUROSURGERY.org
E1
ORIGINAL ARTICLE
DONG GYU LEE AND MIN CHEOL CHANG
ESI IN CENTRAL CERVICAL SPINAL STENOSIS
MATERIALS AND METHODS
Patients
The institutional review board of our university hospital approved
the study protocol. This study was conducted retrospectively. We
recruited 50 patients who visited the spine center of a university
hospital for chronic neck pain resulting from central cervical
spinal stenosis and received cervical interlaminar ESI during the
period March 2015 to February 2017. The inclusion criteria were as
follows: 1) age 20e79 years; 2) >6-month history of neck pain with
or without upper extremity pain (in cases with neck pain combined with upper extremity pain, only patients whose pain was
mainly in the neck were recruited); 3) posterior neck pain rated 3
on a numerical rating scale (NRS) (0 ¼ no pain, 10 ¼ worst
possible pain) despite oral medications (meloxicam and tramadol/
acetaminophen); and 4) magnetic resonance imaging (MRI)
findings of grade 2 (complete obliteration of the anterior or posterior subarachnoid space) or grade 3 (cervical cord compression
or displacement) central cervical spinal stenosis using the classification system of Muhle et al.10 (Table 1). Exclusion criteria were
as follows: 1) the presence of signal change in the cervical spinal
cord (cervical myelopathy) on sagittal MRI, cervical foraminal
stenosis on axial MRI, or infection in the spine; 2) previous
history of surgery on the cervical spine; and 3) coagulation
disorders. After chart review, 5 patients were excluded owing to
incomplete data. There were 45 patients (mean age 57.1 years 11.2; range, 32e79 years, male-to-female ratio 20:25, pain duration, 18.1 months 25.1) finally included in our study.
ESI Procedures
All injections were performed by a single interventional physiatrist
(CMC) who specialized in central spinal injections. Strict aseptic
technique was used in the performance of the interlaminar ESI
procedures. Patients were placed in prone position with a towel or
blanket under the chest to ensure sufficient flexion of the cervical
spine. C-arm fluoroscopy (Siemens Healthcare, Erlangen, Germany) was used for level identification and needle guidance.
Lidocaine 1% was administered at the needle insertion site, and a
21-gauge Touhy needle was inserted and placed into the epidural
space between C7 and T1 using the loss-of-resistance technique.
Adequate placement of the needle tip into the epidural space was
confirmed with radiopaque contrast medium. After confirmation,
20 mg (40 mg/mL) of dexamethasone with 4 mL of normal saline
was injected.
Outcome Measures
Assessments at pretreatment and during follow-up were performed by 1 investigator (DGL) who was blinded to the group
allocation and did not participate in any treatments. Neck pain
intensity was assessed using an NRS. The NRS scores were
measured before and 1, 2, and 3 months after cervical interlaminar
ESI. Successful treatment was defined as >50% reduction in the
NRS score at 3 months compared with the pretreatment NRS
score. To validate the change in pain reduction, NRS scores were
evaluated by assessing the difference between the pretreatment
scores and the 3-month posttreatment scores (change in NRS
[%] ¼ [pretreatment score score at 3 months after treatment]/
pretreatment score 100). After 3 months, the global perceived
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effect was assessed using a 7-point Likert scale (Table 2).11,12 Patients reporting very good (score ¼ 7) or good results (score ¼ 6)
were considered to be satisfied with the procedure.
Statistical Analysis
Data were analyzed using IBM SPSS Version 22.0 (IBM Corp.,
Armonk, New York, USA). Summary of characteristic variables
was performed using descriptive analysis with mean SD for
quantitative variables and frequency (percent) for qualitative variables. Changes in NRS scores over time were evaluated using
repeated measures 1-factor analysis. Multiple comparison results
were obtained following Bonferroni correction. P values < 0.05
were considered statistically significant.
RESULTS
No adverse effects were observed after interlaminar ESI. Average
NRS scores for neck pain declined from 4.4 1.3 at baseline to 2.4
1.5 at 1 month, 2.3 1.5 at 2 months, and 2.2 1.5 at 3 months
after ESI. NRS scores changed significantly over time (P < 0.001)
(Figure 1). More specifically, NRS scores at 1, 2, and 3 months
after ESI were significantly lower than at baseline (P < 0.001)
(Figure 1). Of 45 patients, 26 (57.8%) reported successful pain
relief (50%) at 3 months after ESI.
Patient satisfaction with treatment, as determined using the 7point Likert scale, were as follows: very good (score ¼ 7) in 10
patients (22.2%), good (score ¼ 6) in 15 patients (33.3%), and
fairly good (score ¼ 5) in 6 patients (13.3%). No change (score ¼
4) was reported by 14 patients (31.1%). No patient returned a
satisfaction score of <4. Therefore, 25 patients (55.6%) were
satisfied with their results at 3 months after ESI.
DISCUSSION
In this study, we evaluated the effect of cervical interlaminar ESI in
patients with chronic posterior neck pain that was refractory to
oral medications. After ESI, neck pain was significantly reduced,
and the effect was sustained for at least 3 months. Furthermore,
58% of the patients reported successful pain relief, and 56% reported satisfaction with the results after ESI.
ESI mainly acts by reducing production and release of
inflammation-related mediators.13,14 Although the mechanisms
responsible remain unclear, compression of the central spinal
cord or meninges is thought to induce cytokines and
inflammation-mediated cells, which appear to cause neck pain in
central cervical spinal stenosis.15 The anti-inflammatory properties
of steroids reduce production of inflammation-related mediators,
consequently inhibiting the processes leading to the development
of pain.16,17 Furthermore, decreased inflammation can reduce
edema in the cervical spinal canal. Reduction of edema can increase space in the spinal canal, reducing the degree of
compression in the cervical spinal cord and relieving spinal cord
ischemia.18,19 In addition to an anti-inflammatory effect, corticosteroids inhibit neural transmission within the nociceptive C fibers.20,21 These actions of corticosteroids are thought to reduce
pain after ESI.
The average duration from symptom onset to ESI was 18.1
months, and all patients were recruited at least 6 months after
pain onset. Therefore, the pain was in a plateau state, and reduced
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2017.09.123
ORIGINAL ARTICLE
DONG GYU LEE AND MIN CHEOL CHANG
ESI IN CENTRAL CERVICAL SPINAL STENOSIS
Table 1. Central Cervical Spinal Stenosis Level in Each Patient
Table 1. Continued
Stenosis Level
Stenosis Level
Patient
1
Grade 2
C4-5
2
C5-6
3
C4-5, C5-6
4
C4-5
5
C5-6
6
C7-T1
7
C4-5
8
C6-7
9
C5-6
10
C5-6
11
C6-7
12
C5-6
13
14
Grade 3
C5-6
C5-6
C3-4, C4-5
15
C5-6
C5-6
16
C7-T1
17
C6-7
18
C5-6
19
C5-6
20
C4-5, C5-6, C6-7
C5-6
C4-5
21
C5-6
22
C5-6
23
C5-6
24
C4-5
25
C6-7
26
C6-7
27
C4-5
28
C5-6
29
C6-7
Patient
Grade 2
38
C5-6
39
C4-5, C5-6
40
C6-7
41
C5-6, C6-7
42
C5-6, C6-7
43
C4-5, C5-6
44
C5-6
45
C5-6
Grade 3
pain after ESI was not the result of spontaneous recovery. Thus,
although we conducted this study without control subjects, we
think our results demonstrate the positive effect of ESI in patients
with chronic neck pain induced by central cervical spinal stenosis,
especially patients with pain that has an inadequate response to
oral medication.
In addition, we included patients with grade 2 or 3 cervical
stenosis according to the classification by Muhle et al.,10
indicating complete obliteration of the anterior or posterior
subarachnoid space or the presence of cervical cord
compression or displacement. We excluded patients with grade
1 stenosis (partial obliteration of subarachnoid space) because
compression of the spinal cord or meninges may not be present
in such cases. In addition, neuropathic pain caused by
myelopathy would not show good pain reduction with ESI;
accordingly, we did not recruit patients with cord signal changes
on sagittal MRI.
Thus far, only 1 previous study evaluated the effect of interlaminar ESI in patients with central cervical spinal stenosis. In
2012, Manchikanti et al.4 prospectively performed interlaminar ESI
in 30 patients with neck and upper extremity pain induced by
central cervical spinal stenosis with or without cervical foraminal
stenosis. They performed additional injections when the
previous ESI did not significantly reduce the pain. At 1 year after
30
C4-5
31
C5-6
32
C4-5, C5-6
33
C7-T1
7
75% improvement
34
C5-6
6
50%e74% improvement
Good
35
C5-6, C6-7
5
25%e49% improvement
Fairly good
36
C5-6
4
0%e24% improvement or worse
Same as before
C5-6, C6-7
3
25%e49% worse
Fairly bad
2
50%e74% worse
Bad
1
75% worse
Very bad
37
Table 2. Global Perceived Effect Using a Likert Scale
Score
Continues
WORLD NEUROSURGERY -: ---, - 2017
Change
Description
Very good
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E3
ORIGINAL ARTICLE
DONG GYU LEE AND MIN CHEOL CHANG
ESI IN CENTRAL CERVICAL SPINAL STENOSIS
Figure 1. Changes in numeric rating scale (NRS) scores
for posterior neck pain during follow-up. NRS scores
reduced significantly from 4.4 1.3 before treatment
the first ESI procedure, 70% of the recruited patients reported
>50% pain reduction. However, the authors also recruited
patients with cervical foraminal stenosis combined with central
cervical spinal stenosis. Thus, our study is the first to evaluate
the effect of ESI in patients with central cervical spinal stenosis
without cervical foraminal stenosis.
This study has some limitations. First, the study was conducted
retrospectively. Second, the study did not include a control group.
Third, the long-term effect of cervical interlaminar ESI was not
evaluated. Fourth, various possible causes of neck pain other than
central cervical spinal stenosis were not considered. Lastly,
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www.SCIENCEDIRECT.com
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WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2017.09.123
ORIGINAL ARTICLE
DONG GYU LEE AND MIN CHEOL CHANG
ESI IN CENTRAL CERVICAL SPINAL STENOSIS
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WORLD NEUROSURGERY -: ---, - 2017
Received 16 July 2017; accepted 19 September 2017
Citation: World Neurosurg. (2017).
https://doi.org/10.1016/j.wneu.2017.09.123
Journal homepage: www.WORLDNEUROSURGERY.org
21. Li JY, Xie W, Strong JA, Guo QL, Zhang JM. Mechanical hypersensitivity, sympathetic sprouting,
and glial activation are attenuated by local injection of corticosteroid near the lumbar ganglion in
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2017 Elsevier Inc. All
rights reserved.
www.WORLDNEUROSURGERY.org
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