Cervical Transforaminal Epidural Steroid Injection

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Pre-Procedure0/2

Perform time-out: verify patient identity, procedure, level, laterality, allergies, and anticoagulation status.

Cervical TFESI carries higher risk than lumbar due to proximity to the vertebral artery and spinal cord. Ensure informed consent specifically addresses stroke and spinal cord injury risk.

The vertebral artery enters the transverse foramen at C6 and ascends through C2. Radiculomedullary arteries supplying the anterior spinal artery may traverse the cervical foramen.

Review MRI/CT to confirm target level. Evaluate foraminal anatomy and vertebral artery position.

Identify any anomalous vertebral artery course or foraminal stenosis that may preclude safe needle placement.

Pre-procedure CT angiography may be considered in high-risk cases. An anteriorly positioned vertebral artery increases procedural risk at that level.

Setup0/3

Position patient supine with slight neck extension, or lateral decubitus. Place shoulder roll if needed for access.

Supine positioning allows patient to communicate and reduces risk of vasovagal events. Ensure IV access for emergency medication.

Many practitioners prefer the oblique/lateral approach with the patient supine for cervical TFESI. This provides an anterior-to-posterior trajectory toward the posterior foramen.

Position C-arm for AP view. Identify target level by counting from C2 (axis). Rotate to ipsilateral oblique to open the foramen.

Accurate level identification is critical. Count from the occiput or C2 dens as a landmark.

An oblique angle of 45-60 degrees typically opens the cervical foramen. The target is the posterior aspect of the foramen to avoid the vertebral artery anteriorly.

Select a 25-gauge, 2.5- or 3.5-inch spinal needle. Prepare contrast and non-particulate steroid (dexamethasone only).

ONLY non-particulate steroid (dexamethasone) should be used for cervical transforaminal injections. Particulate steroids are absolutely contraindicated.

Multiple case reports document catastrophic outcomes (cerebellar and spinal cord infarction) from particulate steroids in cervical TFESI via radiculomedullary artery embolization.

Procedure0/5

In the oblique view, advance the needle toward the posterior-superior aspect of the target foramen using an anterolateral approach.

The target is the posterior foramen only. Never advance into the anterior foramen where the vertebral artery lies.

The posterior approach targets the space between the superior articular process posteriorly and the uncinate process anteriorly, staying posterior to the exiting nerve root.

Check AP and lateral views to confirm needle position: tip should be at the lateral aspect of the foramen, not past the midline of the articular pillars.

On AP view, the needle tip should not cross the midpoint of the articular pillar. On lateral, it should remain in the posterior foramen.

Multi-planar confirmation is essential for safe cervical TFESI. The lateral view distinguishes posterior from anterior foraminal position.

Perform digital subtraction angiography (DSA) or real-time fluoroscopy during 0.3-0.5 mL contrast injection.

DSA is strongly recommended for cervical TFESI to detect vascular uptake. If vascular pattern is seen, reposition before injecting steroid.

DSA subtracts the bony background and highlights vascular patterns that may be missed on standard fluoroscopy. A positive DSA showing arterial uptake mandates needle repositioning.

Confirm epidural contrast pattern: nerve root sleeve outline with medial epidural spread.

Abort the procedure if adequate epidural spread cannot be confirmed or if the patient develops new neurological symptoms.

Proper cervical epidural spread shows contrast along the nerve root and into the ventral epidural space. A periosteal pattern suggests subperiosteal placement requiring repositioning.

Inject 0.5-1 mL dexamethasone (10 mg/mL). Total injectate volume should not exceed 1-1.5 mL.

Inject slowly with continuous patient communication. Stop immediately if the patient reports any new symptoms (dizziness, visual changes, weakness).

Small volumes are critical in cervical TFESI to avoid compressive effects on the spinal cord. Dexamethasone 10 mg/mL provides therapeutic effect with lower risk.

Post-Procedure0/2

Remove needle and monitor patient for at least 30 minutes. Perform focused neurological exam before discharge.

Assess grip strength, upper extremity sensation, and gait before discharge. Any new deficit requires immediate evaluation.

Delayed onset of neurological deficits (minutes to hours) may indicate epidural hematoma or vascular injury requiring emergent MRI and possible surgical decompression.

Document procedure details including DSA findings, contrast pattern, injectate, fluoroscopy time, and neurological exam.

Document the use of non-particulate steroid and DSA to demonstrate adherence to safety standards.

Documentation of safety measures (DSA, non-particulate steroid, multi-view confirmation) is essential for medicolegal protection in cervical TFESI.