title: Directional preference following epidural steroid injection in three patients with acute cervical radiculopathy.
abstract: Cervical radiculopathy is typically characterized by neurologic symptoms that are traced to disturbances of discrete spinal nerve root(s) due to inflammatory or mechanical etiologies. Here we present three patients diagnosed with cervical radiculopathy, whose directional preference only surfaced after either a cervical transforaminal or intralaminar nerve root epidural steroid injection. This retrospective observational case series describes three men who presented with cervical radiculopathy with 7-9/10 neck pain, neck disability index (NDI) ranging between 44% and 90%, and an irreducible derangement upon McKenzie mechanical diagnosis and therapy (MMDT) evaluation. These patients demonstrated weaknesses, sensory changes, and/or decreased reflexes in the C5, C6, or C7 distributions. They each underwent a cervical transforaminal or intralaminar epidural injections at one or two levels, which uncovered their directional preference and facilitated further conservative treatment. These three patients experienced drastic improvements with each postinjection physical therapy session. They demonstrated decreased pain scores, centralization of pain, and a decreasing NDI trends throughout their treatments. They were all discharged with stable 0-3/10 pain severity after four physical therapy sessions and NDI scores of 0%. These cases suggest an interplay between inflammatory and mechanical contributors to spine-mediated pain and the treatment challenge this presents. Dissecting the components of spine pain can be challenging; however, delivery of skilled multidisciplinary care in an algorithmic fashion may be beneficial and provide the future framework for the management of cervical radiculopathy and other spine-related conditions.
authors.affiliation: The George Washington University Medical Center, Washington, District of Columbia 20037, USA. mdesai@mfa.gwu.edu
authors.forename: Mehul J
authors.initials: MJ
authors.lastname: Desai
authors.forename: Girish
authors.initials: G
authors.lastname: Padmanabhan
authors.forename: Ajai
authors.initials: A
authors.lastname: Simbasivan
authors.forename: Gladys G
authors.initials: GG
authors.lastname: Kamanga-Sollo
authors.forename: Ajay
authors.initials: A
authors.lastname: Dharmappa
mesh_terms: D000208:Acute Disease; D000779:Anesthetics, Local / Q000008:administration & dosage; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage; D002045:Bupivacaine / Q000008:administration & dosage; D002574:Cervical Vertebrae; D003907:Dexamethasone / Q000008:administration & dosage; D006801:Humans; D007268:Injections, Epidural; D008297:Male; D008875:Middle Aged; D019547:Neck Pain / Q000188:drug therapy* / Q000209:etiology / Q000534:rehabilitation*; D026741:Physical Therapy Modalities; D011843:Radiculopathy / Q000150:complications / Q000188:drug therapy* / Q000534:rehabilitation*; D012189:Retrospective Studies
chemical_list: D000779:Anesthetics, Local; D000893:Anti-Inflammatory Agents; D003907:Dexamethasone; D002045:Bupivacaine
keywords: cervical pain; epidural; pain; radiating