Spinal Steroid injection for Neck and Arm pain

It is a small procedure that is very useful to control neck and arm pain performed under local or intravenous sedation. This nerve root injection helps to reduce the pain and inflammation due to the nerve root compression. The nerve roots that come out of the spinal cord exits through small holes (foramen) in your spine. These nerve roots can be pinched by a herniated disc, narrowing of the holes (foramen)due to wear and tear of the spine.

Nerve root injection is recommended for control of your neck and arm pain. Inflammation caused by the wear and tear of your spine produces chemicals around your spinal nerves that irritates these nerves. This is the cause of neck and arm pain.

The spinal column is made of bones and the soft cushion between these bones. It has a central canal (passage) that contains and protects the solid spinal cord. There are branches coming out of the spinal cord at regular intervals on each side. These are called nerve roots. These nerve roots come out of the spinal cord exits through small holes (foramen) in your spine. These nerve roots can be pinched by either a herniated disc or by the narrowing of the small exit holes (foramen)due to wear and tear of the spine.

The nerve root injection is given close to the trapped or pinched nerve.

Cervical nerve root Injection contains a mixture of:

• Kenalog 40 mgs (Steroid)
• Marcaine 0.25% (Local anaesthetic)

Kenalog is a Steroid commonly used in Spine Injections. It has a 40 mgs of steroid in a sterile solution. This steroid works on the spinal nerves in your neck and reduces pain and inflammation around them.

It blocks the release of chemicals that your body releases from ruptured or damaged discs, injured soft tissues around the spinal nerves. Steroid limits the production of proteins needed for these chemicals and blocks the painful nerve signals coming from these injured tissues.

Due to the pain relief, there is more movement in the small (facet) joints in the spine and the soft tissues. This increase in movement will further reduce the stiffness around the bones, ligaments and muscles of your neck.

Marcaine 0.25% is a local anaesthetic (numbing solution) used by your dentist. This is also used in Cervical Nerve root Injection. This solution works on the tissues around the spinal nerves and reduces pain. This works very well with the steroid.

It blocks the pain signals released by your irritated and inflamed spinal nerves as the steroid works to control the inflammation. Due to the pain relief, there is more movement in the small (facet) joints and the soft tissues of your neck.

This increase in movement will further reduce the stiffness around the bones, ligaments and muscles of your neck. The strength of the muscles around neck and improves after the pain relief from these injections.

Nerve root injection contains a mixture of numbing solution (local anaesthetic) and corticosteroid (steroid). The local anaesthetic will improve the pain immediately and the steroid in the solution will act on the inflammation around the nerve roots and control the pain in the long term. This improvement in the pain will help you move around better and mobilise your neck. This increase in the movement of the small joints of your spine will further reduce the stiffness around the bones, ligaments and muscles.

You will be admitted for Day Case surgery just for a day. You will need to come in starved for at least 6 hours. This is because we have to give you a sedative in your arm to make you sleep for a short duration. It will help you cope with the anxiety and pain from the procedure.

This procedure is done under the guidance of a CT scanner. You will be in the CT scanner and the radiologist trained in this procedure will give the injection. The CT scanner ensure accurate placement of the needle and delivery of the injection to the right spot.

You will be admitted for Day Case surgery just for a day. You will arrive in the morning with a member of your family. It will be safe for you to return home after a short period of sedation. The pain relief is instant as the local anaesthetic works on the inflamed tissues of the neck immediately.

You need to come in starved for at least 6 hours so that it is safe to give you sedation in an empty stomach. You will be required to lie on your tummy. After the sedation, with the help of Xray guidance, the cervical nerve root  injection will be performed safely and accurately.

After you are sedated, a tiny needle for the injection of the steroid and anaesthetic solution close to the trapped spinal nerve. CT scan will ensure that the needle placement is accurate before the procedure. You will recover from the procedure and sedation very quickly. You will be free of the pain almost immediately.

After the injection, you will be taken to the recovery room from theatre and monitored for an hour. It takes 24 to 48 hours before the steroid takes effect on the inflamed and trapped spinal nerve and soft tissues around it. You will be able to leave hospital once you are safe.

You must be aware that the local anaesthetic may cause a temporary numbness or weakness of the arm for a few hours. But this will settle with time. Once the effect of the anaesthetic wears off, your neck and arm pain may return, occasionally slightly worse than before for a short period until the steroid in the solution takes effect. It takes a few days or even weeks for the steroid to take effect on your pain.

You must continue to take your usual pain relief medication that your doctor had prescribed for you till you begin to feel benefit. Some medications like morphine, gabapentin, pregabalin or amitriptyline need to be continued and not stopped abruptly.

After discharge from the hospital you will be given a discharge summary and a booklet. This will contain all the details of:

1) Cervical Nerve Root Injection procedure

2) How and when to move around

3) Physiotherapy exercises

4) Driving – when and how to drive

5) When and how to return to your work

70% of patient will have significant benefit from a cervical nerve root injection for low back pain. But the duration of this pain control varies between a few weeks to a few months. Sometimes the pain relief can last for a year. The inflammation and soft tissue swelling will reduce naturally due to your increase in mobility and activity. However, there is an increased risk of having a further episode of neck and arm pain.

Repeat Injections: If the initial injection was helpful in controlling your neck and arm pain, you will be offered a repeat injection.

Most experts recommend not more than 2-3 injections over a 12-month period. There are concerns about the adverse side effects of repeated steroid injections on the trapped spinal nerve and on your metabolism. There is a very small risk of diabetes, raised blood pressure, decreased immunity, recurrent infections and weight gain.

My secretary will arrange a follow-up appointment in about two weeks’ time for a review with me – either Face to Face or over the telephone. I will be keen to know the control of your pain over the last 2 weeks.

Most patients will not need physiotherapy but if you need physiotherapy, after my assessment, I will make arrangements. The physiotherapist will educate you on gentle stretching, strengthening, and conditioning exercises for your neck and arm.

Steroid injections in combination with physiotherapy will offer you longer period of pain control.

There are risks and complications associated with any procedure:

This is rare but there is an increased risk in skin conditions like psoriasis or eczema. The rate is less than 1 in 1000 injections.

There is very little chance that you will bleed from a tiny puncture wound with a needle. But there is an increased risk of bleeding if you are taking medications to ‘thin your blood’ like warfarin, rivaroxaban or clopidogrel. You will be advised to stop these medications at least a week in advance of the procedure for safety.

This is a temporary side effect from the steroid injection  – like a prolonged ‘blush’  – it settles down very quickly.

This can be due to the stress of the procedure and is not life threatening. 1 in 100 patients do have such episodes and it settles very quickly.

You are advised to take the next day off work as you had an intravenous sedation. If your back pain persists or is worse, you may need a few days off work. Usually, it can take several weeks before you feel the full benefit of the injection. There are no limitations for work if your pain settles after a day.

This is booked in 4 weeks after the injection. It allows you to explain the progress of you neck and arm pain to Mr Rajesh and he may arrange physiotherapy to build on the gains from the injection. Repeat injections or possible the need for surgery only if necessary, can be discussed.