Posted on September 29, 2024
Often, patients are referred to our office for neck pain that radiates down the arm. Sometimes it only goes as far as the shoulder, but often goes past the elbow into the fingers. It can be associated with severe shooting electric pain, or can be dull, aching and constant.
This is often due to pressure on the exiting nerves within the cervical spinal canal. Such pain can originate from a cervical disc herniation, disc protru-sion, or bony nerve root narrowing (a pinched nerve).
It is important to differentiate neck and arm pain coming directly from nerve root pressure (radicular pain) from pain coming from the shoulder itself, or from carpal tunnel nerve compression. The latter two types of pain must be addressed separately.
Physical therapy is designed to help achieve better range of motion of the neck, correct poor neck and shoulder posture and to correct any associated weakness down the arm. Physical therapists may also add cervical traction to create more room and take pressure off the exiting nerve roots.
When physical therapy does not provide adequate pain relief, an injection of an anti-inflammatory steroid may be advised. The purpose of the injection is to place the medication adjacent to the inflamed nerve that is firing. By decreasing inflammation around the nerve and perhaps coupled with cervical traction to create additional space, surgery may be avoided.
There are two main approaches to providing epidural injections in the neck. The first (Interlaminar Cervical Epidural) is done with the patient face down to approach from the back of the neck. After sterile preparation, the skin is anesthetized with local anesthetic.
Under x-ray guidance, a narrow needle is placed just at the entrance into the outer spinal canal. Once we have excellent spread of contrast material under live x-ray, then the local anesthetic and steroid are placed into the targeted area of the cervical epidural space.
This steroid solution bathes the inflamed nerves, minimizing inflammation and suppressing the pain.
If patients are on blood thinners, it is necessary to stop them, because there is increased potential bleeding within the spinal canal. This includes baby aspirin, high dose fish oil (Lovaza) and any blood thinners you may be on for AFIB, DVT, or pulmonary emboli. So, please let us know if you’re on blood thinners, or have any bleeding tendencies.
The other approach is Transforaminal Cervical Epidural injections. In this procedure the patient is face up and we approach from the side of the neck directly into the nerve root canal. Under x-ray guidance, the contrast ensures that we are spreading along the correct nerve segments.
When good nerve root spread is obtained, then local anesthetic and steroid are injected directly along the affected spinal nerves to suppress the pain. (This approach may be used if patients are on blood thinners.)
The local anesthetic works immediately, but may take 3 to 5 days for the steroid to create the anti-inflammatory effect.
Once the inflammation is suppressed, the pain should resolve. These injections can be repeated every 2 to 3 weeks initially. If repeated injections are needed (which occurs in rare instances), they can be given every 3 to 4 months.
For severe radiating arm pain that is unresponsive to injections, surgery may be needed as a last resort, especially if there is associated arm weakness. This would be the case for large disc herniations or severe bony pressure on the exiting nerve roots.
However, the majority of neck and arm pain can be safely treated with epidural injections and physical therapy.