Steroid injection can be considered for patients whose symptoms persist after four to six weeks of conservative management. A 2007 Cochrane review found low-quality evidence to support the use of epidural steroid injections in patients with chronic cervical radiculopathy. 35 A more recent systematic review found good-quality evidence to support steroid injections for cervical radiculopathy caused by disk herniation, but only fair evidence for radiculopathy caused by spondylosis. 36 An RCT showed significant benefit in pain and function with epidural steroid injections for at least one year in patients who had not improved with physical therapy and nonsteroidal anti-inflammatory drugs. 37 Several cohort studies showed significant improvements in recalcitrant radicular pain with epidural steroid injections, in most cases for at least one year. 9 , 35 , 38 – 40 Patients should be counseled about the risk of potential complications, including dural puncture, meningitis, epidural abscess, and nerve root injury.
Contrast is used to verify epidural location and to indicate the distribution of injectate. Some physicians use contrast as a volume expander while others prefer saline for this use. The contrast is typically nonionic and lowosmolar. In patients with contrast allergies gadolinium can be safely used in most lumbar procedures. 30,31,52,53 If using gadolinium, the amount should be just enough to document epidural injection. Gadolinium should not be used as a substitute for volume expander. The typical amount of contrast or contrastsaline mixture used for either cervical or lumbar interlaminar epidurography is 4 cc to 5 cc (less in nerve blocks; see below). A smaller amount will not provide sufficient contrast for an epidurogram to evaluate for adhesions or distribution of injectate. For coding purposes, an epidurogram is considered to have been performed when approximately 4 cc to 5 cc of contrast is injected regardless of the route (transforaminal or interlaminar). The report, CPT code, and amount billed must be adjusted if an epidurogram is not performed. The amount of contrast injected may be reduced in spinal stenosis. Many patients will feel pressure or leg cramping from almost any volume, no matter how small. Patients undergoing first-time injections may confuse this with pain. Careful questioning and reassurance that pressure is normal will be adequate in most cases. The injectate volume should be reduced if significant pain is experienced.