Cervical Transforaminal Epidural Steroid Injections Diagnostic and Therapeutic Value Shrif J. Costandi, MD,*† Gerges Azer, MD,† Yashar Eshraghi, MD,* Yosaf Zeyed, MD,‡ Jasmyn E. Atalla,§ Michael E. Looka,|| and Nagy A. Mekhail, MD, PhD*† Background: Cervical transforaminal epidural steroid injections (CTFESIs) may help decrease pain and restore function in patients with cervical radiculopathy. Evidence of the injections' effectiveness, however, remains controversial, and multiple case reports have identified potential complica- tions. Such reports have led to diminished interest in including the proce- dure in patient care algorithms. Objectives: Our retrospective analysis aims to evaluate the CTFESI- associated pain relief and possible decreased need for spine surgery, along with its potential predictive role in determining cervical surgical outcomes. Finally, our study intends to estimate associated complications. Methods: A pain management database registry was used to identify pa- tients who were referred by spine surgeons for diagnostic CTFESIs in prep- aration for possible surgery between January 2001 and December 2009. Outcomes were defined as the incidence of cervical surgery after diagnos- tic injection and the associated pain relief. A Poisson distribution was used to obtain a 95% confidence interval for the incidence of complications. Results: Sixty-four patients met the inclusion and exclusion criteria. After diagnostic CTFESIs, 45 (70.3%) of the observed 64 patients did not require cervical spine surgery whereas 19 (29.7%) still did. The mean pain reduction was 4.4 units on the numeric rating scale, with no observed complications. Conclusions: This retrospective analysis further demonstrates the safety, diagnostic value, and possible therapeutic role of CTFESIs. A larger, con- trolled, randomized study is needed to assess definitively the procedure's efficacy and safety. (Reg Anesth Pain Med 2015;40: 674–680) C ervical radicular pain is a common problem that affects ap- proximately 1:1000 population per year, with a higher in- cidence in men. 1 Irritation of the cervical spinal nerve roots is typically caused by lateral disc herniation or foraminal steno- sis. Because of its favorable natural history, conservative mea- sures are initially implemented. 2 Conservative therapy includes oral anti-inflammatory drugs whether steroids or nonsteroids and/or oral analgesics, along with gradated physical therapy. Ob- servational studies have noted resolution of symptoms in 80% of cases. 3 Failure to achieve success with such regimen is usually en- countered in approximately 20% to 25% of patients 1,3–5 who are often offered surgical decompression. In our study, we focused on this subset of patients who failed conservative measures and were deemed candidates for surgery. Based on multiple observational studies, surgery constitutes the main line of management, yet it carries risks that many patients are unwilling to undertake. 6 Lack of long-term efficacy of conser- vative therapy, failure of response in a subset of patients, in addi- tion to the risks involved with the surgery led to the evolvement of cervical epidural steroid injections (CESIs), as a minimally inva- sive option, where the steroids are deposited directly in the epidu- ral space whether through an interlaminar or a transforaminal approach. In addition to its therapeutic role, the latter has the ad- vantage of diagnosing the culprit cervical nerve root level. A com- mon practice in our institution is to perform interlaminar approach in cases of central or paracentral disc herniation or in cases where more than 2 levels are involved. The transforaminal approach is performed in single-level foraminal disc herniation or when symp- toms are limited to a specific nerve root. Since its inception, cervical transforaminal epidural ste- roid injections (CTFESIs) have been labeled with rare cata- strophic complications. Many physicians have drifted away from incorporating such intervention in their practice espe- cially in light of the lack of strong evidence data supporting its efficacy. Only case reports and case series of complications have been reported in the literature. Thus, there is a great need to evaluate the potential risks/benefits ratio of this procedure. The present study is an attempt to evaluate the CTFESI-associated pain relief and possible decreased need for spine surgery, along with its potential predictive role in determining cervical surgical outcomes. Furthermore, our study intends to provide a real-life es- timate of the associated complications. METHODS After obtaining institutional review board approval (IRB 12-086), patients' records were retrieved with the CTFESI CPT code between January 2001 and December 2009 for retrospective data analysis. Investigators involved in the data collection and analysis were not involved in direct patient care. Subjects who were involved in worker's compensation claims or pending litiga- tions were excluded. Records were reviewed to confirm that all patients had a clin- ical presentation of cervical radiculopathy confirmed by radiolog- ical imaging studies. All patients failed to respond to conservative therapeutic measures, including oral anti-inflammatory drugs whether steroids or nonsteroids, and/or analgesics, along with physical therapy, for a period that varied from 8 to 12 weeks. In addition, we verified that they were referred by spine surgeons for diagnostic CTFESI to identify the exact symptomatic spinal level before their decompressive surgery. None of the patients had prior interlaminar CESIs. The procedures were performed by an experienced physician (N.M.) of the Pain Management Department of Cleveland Clinic and took place in the procedures suite under fluoroscopic guid- ance with contrast enhancement. Patients were placed in supine position. Midazolam and fentanyl were administered in incre- ments by a registered nurse, under the supervision of the physi- cian performing the procedures (N.M.), to achieve a mild level of sedation that allowed the patient to converse throughout the From the *Pain Management Department, †Evidence-Based Pain Medicine Research, and ‡Outcomes Research Department, Cleveland Clinic, Cleveland; and §Ohio State University, Columbus, OH; and ||Oakland University, Rochester, MI. Accepted for publication August 6, 2015. Address correspondence to: Nagy A. Mekhail, MD, PhD, Carl E. Wasmuth Endowed Chair in Anesthesiology Director, Evidence-Based Pain Medicine Research, Pain Management Department, Cleveland Clinic, 9500 Euclid Ave, C25, Cleveland, OH 44195 (e‐mail: mekhain@ccf.org). The authors declare no conflict of interest. Copyright © 2015 by American Society of Regional Anesthesia and Pain Medicine ISSN: 1098-7339 DOI: 10.1097/AAP.0000000000000323 ORIGINAL ARTICLE 674 Regional Anesthesia and Pain Medicine • Volume 40, Number 6, November-December 2015 Copyright © 2015 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.