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2. Cervical radicular pain
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DOI: 10.1111/papr.13252
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DOI: 10.1111/papr.13252
E V I D E N C E -B A S E D R E V I E W
Update of evidence-based interventional pain medicine according to clinical diagnoses
2. Cervical radicular pain
Laurens Peene MD1 | Steven P. Cohen MD2 | Brigitte Brouwer MD, PhD3 |
Rathmell James MD4 | Andre Wolff MD, PhD5 | Koen Van Boxem MD, PhD1,3 |
Jan Van Zundert MD, PhD1,3
1
Department of Anesthesiology, Abstract
Intensive Care, Emergency Medicine and
Multidisciplinary Pain Center, Ziekenhuis
Introduction: Cervical radicular pain is pain perceived in the upper limb, caused by
Oost-Limburg, Belgium irritation or compression of a cervical spine nerve, the roots of the nerve, or both.
2
Pain Medicine Division, Department of Methods: The literature on the diagnosis and treatment of cervical radicular pain
Anesthesiology, Johns Hopkins School of was retrieved and summarized.
Medicine, Baltimore, USA
3
Results: The diagnosis is made by combining elements from the patient's history,
Department of Anesthesiology, Pain
Medicine and Neurology, Maastricht
physical examination, and supplementary tests. The Spurling and shoulder
University Medical Center, Maastricht, abduction tests are the two most common examinations used to identify cervical
The Netherlands radicular pain. MRI without contrast, CT scanning, and in some cases plain
4
Department of Anesthesiology, radiography can all be appropriate imaging techniques for nontraumatic cervical
Perioperative and Pain Medicine, Brigham
and Women's Hospital, Leroy D. Vandam
radiculopathy. MRI is recommended prior to interventional treatments. Exercise
Professor of Anesthesia, Harvard Medical with or without other treatments can be beneficial. There is scant evidence for
School, Boston, Massachusetts, USA the use of paracetamol, nonsteroidal anti-inflammatory drugs, and neuropathic
5
Department of Anesthesiology, UMCG pain medications such as gabapentin, pregabalin, tricyclic antidepressants, and
Pain Center, University Medical Center
Groningen, University of Groningen,
anticonvulsants for the treatment of radicular pain. Acute and subacute cervical
Groningen, The Netherlands radicular pain may respond well to epidural corticosteroid administration,
preferentially using an interlaminar approach. By contrast, for chronic cervical
Correspondence
Jan Van Zundert, Department of
radicular pain, the efficacy of epidural corticosteroid administration is limited.
Anesthesiology, Intensive Care, Emergency In these patients, pulsed radiofrequency treatment adjacent to the dorsal root
Medicine and Multidisciplinary Pain ganglion may be considered.
Center, Ziekenhuis Oost-Limburg,
Bessemersstraat, 478 3620 Genk/Lanaken,
Conclusions: There is currently no gold standard for the diagnosis of cervical
Belgium. radicular pain. There is scant evidence for the use of medication. Epidural
Email: jan.vanzundert@zol.be corticosteroid radicular pain pulsed radiofrequency adjacent to the dorsal root
ganglion may be considered.
K EY WOR DS
cervical radicular pain, diagnostic process, epidural corticosteroids, evidence-based medicine,
pulsed radiofrequency treatment
I N T RODUC T ION Cervical radicular pain is defined as radiating pain

perceived in the upper limb, which is caused by irrita-
This narrative review on cervical radicular pain is an up- tion or compression of a cervical spine nerve, the roots
date of the 2009 article published in the series “Evidence- of the nerve, or both.2,3 C7, followed by C6 are the two
based Interventional Pain Medicine According to most commonly affected nerve roots, and typically in-
Clinical Diagnoses.”1 nervate the lateral arm and hand.4,5 In less frequent cases
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2023 The Authors. Pain Practice published by Wiley Periodicals LLC on behalf of World Institute of Pain.
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2 | CERVICAL RADICULAR PAIN
of upper cervical nerve root involvement, the pain can be per 1000 persons based on four medium-to high-quality
perceived in the shoulder, isolated to the neck area, or ra- studies.4,15
diate to the occiput for high cervical nerve root (C2, C3)
involvement. In the literature, the terms radicular pain
and radiculopathy are sometimes used interchangeably, al- M ET HOD OL OGY
though they are not synonymous. In the case of radicular
pain, only pain radiating in a dermatomal distribution is This narrative review is based on the article “cervical
present, while in the case of radiculopathy, objective sen- radicular pain” published in 2009.1 In 2015, an inde-
sory, motor, and/or reflex loss are usually present.6 The pendent company, Kleijnen Systematic Reviews (KSR),
word radiculopathy derives from the Latin term “radix,” performed a systematic review of the literature for the
meaning root, and the Greek term “patheia,” which means period 2009–2015, based on existing systematic reviews
“suffering” and is the basis for the term “pathology,” so (SRs) and randomized controlled trials (RCTs).16 For the
technically a person may have pathology of a nerve root current article, an updated search was conducted for the
that spares motor and sensory fibers.7 In clinical prac- period 2015–2022, using “cervical” and “radicular” and
tice, radicular pain presents in a dermatome related to “pain” associated with the interventional pain manage-
a particular radix or segmental spinal nerve.8 Cervical ment techniques, in this case “epidural” and “steroid” or
radicular pain and cervical radiculopathy frequently “corticosteroid”; “radiofrequency” or “pulsed radiofre-
occur simultaneously, and cervical radicular pain may quency”; “spinal cord stimulation.” Additional, authors
evolve into radiculopathy when the underlying disorder could select relevant missing articles.
progresses. A clear distinction between these two syn-
dromes is important for the sake of clarity as well for
correct interpretation of the available evidence. DI AGNO SI S
The three most common causes of cervical spinal nerve
compression or irritation are a posterolateral herniation There is currently no gold standard for the diagnosis of
of the intervertebral disc, disc degeneration causing de- cervical radicular pain. The diagnosis is made by com-
creased neuroforaminal height, and cervical spondylo- bining elements from the patient's history, physical ex-
sis.9 In contrast to lumbar radicular pain, herniation of amination, and supplementary tests.
the nucleus pulposus is reported to be responsible for
only 20%–25% of cases of cervical radicular pain.4 The
natural course of cervical radicular pain appears to be History
benign in most patients. A systematic review reported
substantial improvements in 83% of patients with cervi- Patients suffering from cervical radicular pain typically
cal radicular pain due to disc herniation 4–6 months after experience a shooting or electric-like sensation, which
onset.10,11 The time to complete recovery was reported typically radiates from the neck into the arm.17 Although
to be 24–36 months in most patients. Seventy to 95% of pain is perceived along the distribution of the affected
patients with cervical radicular pain will significantly nerve, the clinical diagnosis of cervical radicular pain
improve with conservative treatment, including exercise can be ambiguous.18 This can be elucidated by the dyna-
therapy, anti-inflammatory drugs, and/or epidural cor- tomal distribution of radicular pain, which may resem-
ticosteroid injections.12 A recent study demonstrated a ble the distribution of classic dermatomal maps but not
favorable outcome in most patients with acute cervical infrequently will be experienced outside of these maps.19
radicular pain, with no significant difference between A more recent retrospective study compared the stand-
having a disk herniation or degenerative changes (osteo- ard radiation pattern of single level pathology in patients
phyte complex) as the cause of radiculopathy.13 Similar undergoing discectomy and found that the observed pat-
to radicular symptoms, radiological studies have shown terns of cervical radiculopathy only followed the stand-
that about half of cervical disc herniations decrease ard pattern in 54% of patients and did not differ by the
within half a year and about three quarters will decrease cervical level involved.20 In addition, multilevel radicu-
by more than 50% within 2 years.14 lopathy may occur, with one study finding a prevalence
rate of 13.4%.21 Nonetheless, the pattern of pain radiation
can still provide an indication of the level of the involved
Incidence nerves and should be evaluated in the patient history.22
Paresthesia, subjective segmental numbness, and loss of
Currently, little data are available on the incidence of muscle power can support a clinical diagnosis of cervi-
cervical radicular pain. A systematic review on the cal radicular pain, but they may not always be present. A
epidemiology of cervical radiculopathy reported an in- recent study demonstrated a sensitivity of 0.83 for pares-
cidence between 0.832 and 1.79 per 1000 person-years thesia alone and 0.88 for the combination of paresthesia
based on two high-quality and one low-quality study. and numbness in patients with cervical radicular pain,
Incidence and prevalence values ranged from 1.21 to 5.8 which supports its relevance in history taking.23
PEENE et al. | 3
Physical examination instability, but the correlation with magnetic resonance

imaging (MRI) is poor and therefore its usefulness is
Clinical examination limited.29,30 MRI is the preferred imaging technique in
patients with cervical radicular pain, particularly if un-
A physical examination is important not only to de- derlying pathology must be excluded.31 However, ana-
termine the level of compression but also to rule out tomical abnormalities on MRI are frequently observed
myelopathy and exclude other conditions in the differ- in asymptomatic patients.32,33 There is currently no
ential diagnosis such as polyradiculopathy, plexopathy, consensus or high-quality evidence regarding the opti-
mononeuropathy, and primary shoulder disorders. It is mal timing of medical imaging in patients with cervical
recommended that physicians assess the motor strength radicular pain, with one randomized surgical study re-
of all muscles in the upper limb as well as reflexes in quiring a concordant MRI within 18 weeks of surgery.34
upper and lower limbs.24 Hypo- esthesia or allodynia In the absence of red flags, it is appropriate to limit the
can be demonstrated using light touch or skin pinprick. use of MRI to patients who remain symptomatic after
Radicular pain is often provoked by maneuvers that 4–6 weeks of conservative treatment. This proposed
stretch or compress the involved nerve root such as the time window is a pragmatic recommendation based on
Spurling test. For the Spurling test, the patient's neck is the natural course of the disease and the recommenda-
extended with the head rotated to the affected shoulder tions available for lumbosacral radicular pain in clinical
while axially loaded. The reproduction of shoulder or practice guidelines.27,35 Although MRI provides the best
arm pain is indicative for spinal nerve root compression. visualization of soft tissues, computed tomography (CT)
With the shoulder abduction test, patients with C4-6 can provide better images of the osseous structures. CT
radicular pain may experience pain relief with active or in combination with intrathecal administration of a con-
passive shoulder abduction. Most of these tests have a trast dye (CT-myelography) can help with the diagnosis
higher specificity than sensitivity.23,25 The upper limb of cervical radicular pain when an MRI is contraindi-
tension test has the highest sensitivity, in the range of cated.36 In contrast to those for lumbar radiculopathy,
70%–90%, but the lowest specificity (15%–30%) using guidelines on the safe use of epidural steroid injections
clinical presentation with supplemental testing as the (ESI)in the cervical region recommend advanced medi-
reference standard.5 The accuracy of clinical diagnosis cal imaging for procedural planning to reduce the risk of
increases when the findings of these tests are combined complications.37–39
rather than when each test is evaluated in isolation.24
Electrophysiological tests
Additional tests
Needle electromyography (EMG) and nerve-conduction
Medical imaging tests (NCT) can be useful when patient history and phys-
ical examination do not allow differentiation between
In the acute phase of cervical radicular pain (4 weeks cervical radicular pain and other neurologic causes of
after onset), medical imaging is indicated only if there neck and arm pain.1 Typically, abnormal insertional ac-
are symptoms or signs indicative of severe underlying pa- tivity, including positive sharp-wave potentials and fi-
thology or cervical myelomalacia—so-called “red flags”. brillation potentials, is present in the limb muscles of the
(See Table 1) With evolution to subacute or chronic radic- involved myotome within 3 weeks of the onset of nerve
ular pain, medical imaging can identify27 recommended compression.40 Large-scale studies evaluating the sen-
plain radiography, MRI without contrast, and CT scan- sitivity and specificity of electrophysiological tests are
ning as appropriate imaging techniques for nontrau- lacking, with one prospective study performed in 101
matic cervical radiculopathy.28 Plain radiography can patients reporting sensitivities > 90% with at least five
provide information on sagittal alignment and potential muscle screens including the paraspinals.41,42
TA BL E 1 Red flags adapted from Childress et al.26
Patient history Examination Condition
Fever, history of cancer, night pain, and Variable; dependent on the localization of the tumor/metastases, Malignancy
weight loss unilateral neurologic findings more common than bilateral
Decreased dexterity, urinary urgency, loss of Hypertonia clonus, hyperreflexia Myelopathy
strength legs, and muscle stiffness
Fever, history of intravenous drug use, and Hypertonia clonus, hyperreflexia Spinal abscess
immunocompromised
Selective segmental nerve blocks behavioral therapy. The addition of manual or mechani-
cal traction to physical therapy was evaluated in a meta-
Selective segmental spinal nerve blocks are used to iden- analysis.48 The authors found that while there seems to
tify the level where the radicular pain originates and can be short-term pain relief, there was no clear effect on
help confirm a relationship between the clinical picture function and disability. Another systematic review found
and radiological findings.43 A small amount of local an- manual therapy to be effective in reducing pain and im-
esthetic is administered adjacent to the spinal nerve sus- proving functional outcomes, though most evidence was
pected of causing the radicular pain. Patient pain scores of moderate-to-low quality.49 One of the RCT's of high
are evaluated during a follow-up period of 30–180 min quality found that the addition of mechanical cervical
depending on the local anesthetic used. If the patient traction to a multimodal treatment program of manual
reports pain reduction (global perceived effect, GPE) therapy and exercise yielded no significant additional
of more than 50% to account for spread to other non- benefit for pain, function, or disability in patients with
neural structures, further interventional treatment may cervical radiculopathy.50 In one study that randomized
be indicated at the same level. Studies have found that 81 patients with cervical radiculopathy to surgery, physi-
lower volumes (0.5–1 mL) are more specific for identify- otherapy or a neck collar, the surgical patients reported
ing a painful spinal nerve than larger volumes, and that faster reduction of pain, but there were no significant dif-
diagnostic spinal nerve blocks can provide valuable in- ferences between groups at 1 year, leading the authors to
formation even with multilevel cervical degeneration.44 recommend multidisciplinary management.51
To identify different affected levels, one single nerve root
level is targeted with a selective segmental diagnostic
block per session, if indicated this should be repeated at Pharmacological therapy
an adjacent level in separate sessions.
Paracetamol and nonsteroidal anti-inflammatory drugs
(NSAIDs) are often prescribed in the acute and subacute
Differential diagnosis settings, but the evidence for benefit of these drugs in pa-
tients with cervical radicular pain is lacking. Meloxicam
It is important to distinguish between conditions that was found in one preclinical study to prevent the onset of
may mimic cervical radicular compression syndromes.45 cervical radicular pain following spinal nerve compres-
These include neurological syndromes such as infectious sion by suppressing inflammation and oxidative stress
polyradiculitis, plexopathy (malignancy such as pan- both centrally in the spinal cord and peripherally in the
coast tumor, neuralgic amyotrophy), mononeuropathies DRG, but most guidelines recommend against NSAIDs
(eg, carpal and cubital tunnel syndromes), as well as re- for neuropathic pain.52,53 Scant evidence exists for the
ferred mechanical pain from neck pathology (eg, cervi- use of neuropathic pain medications such as gabapen-
cal facet joint pain, cervical discogenic pain), primary tin, pregabalin, and antidepressants for the treatment
shoulder pathology and ischemic cardiac disease. It is of radicular pain. Two uncontrolled prospective trials
often difficult to differentiate between radicular and re- involving 369 and 50 patients reported improvement
ferred mechanical pain due to the significant overlap in of pain scores with pregabalin in patients with chronic
radiation patterns in the upper limb. Other pathologies cervical radicular pain.54,55 A large, randomized study
should therefore be excluded when evaluating a patient performed in 169 patients found that epidural steroid
with cervical radicular pain. injections plus physical therapy and pharmacotherapy
with nortriptyline and/or gabapentin resulted in better
outcomes than epidural steroids or conservative treat-
T R E AT M E N T S ment as stand-alone therapies.56 One RCT conducted in
59 patients demonstrated short-term benefit for oral cor-
The goals of treatment are to reduce radicular pain, ticosteroids.57 Another prospective, observational study
improve patient quality of life (QoL), and to prevent found no difference in cervical ESI outcomes between
recurrence. 49 patients who responded to oral steroids and 22 pa-
tients who failed to respond.58 Therefore, patients can be
reassured that they may experience pain reduction after
Conservative treatment a cervical epidural steroid injection even if oral corticos-
teroid therapy fails to provide relief.
A recent systematic review found that exercise with or
without other treatments can be beneficial in patients with
cervical radicular pain.46 A randomized controlled trial Interventional pain management
reported that neck-specific training and prescribed phys-
ical activity both reduced radicular pain in patients with Acute and subacute cervical radicular pain respond well
cervical radiculopathy.47 Both groups included cognitive to epidural corticosteroid administration. In contrast, for
PEENE et al. | 5
chronic cervical radicular pain the efficacy of epidural different approaches to reach the epidural space have
corticosteroid administration is limited. In these pa- been described such as the paramedian (parasagittal)
tients, pulsed radiofrequency (PRF) treatment adjacent or modified paramedian approach.68,69 The rationale for
to the dorsal root ganglion (DRG) may be considered.1,59 this approach is to obtain more target-specific adminis-
tration of the medication—and thus closer proximity to
the inflamed spinal nerve—compared to the dorsal de-
Epidural corticosteroid administration livery of medication in the epidural space with a conven-
tional interlaminar approach.70 One very small (n = 26)
The aim of epidural steroid administration is to de- RCT reported superior pain relief and improvement
posit medication close to the inflamed neural tissues of functional disability with the parasagittal approach
that are responsible for the generation of radicular pain. compared to the interlaminar approach in patients with
Corticosteroids produce anti-inflammatory effects due unilateral cervical radicular pain, with non-particulate
to the inhibition of phospholipase A-2 initiated arachi- steroids being used in both groups.71 In contrast, a ret-
donic cascade and possess the ability to suppress ectopic rospective study that included 182 patients failed to
discharges from injured nerves. Cervical epidural corti- demonstrate a significant difference between the two
costeroid injections (CESI) are routinely performed in pa- approaches.72 Another RCT that used dexamethasone
tients with subacute radicular pain in whom conservative demonstrated non- inferiority for the parasagittal ap-
therapy has failed. In one prospective study performed in proach compared to the transforaminal approach in 80
98 patients considered to be surgical candidates, in 80% patients with cervical radicular pain and concluded that
of cases surgical intervention was avoided with epidural this technique might be recommended over transforami-
corticosteroid administration.60 Nonetheless, it is not a nal CESI, which carry significantly higher risks.73
surrogate for conversative therapy, and an interdiscipli- Medication can also be delivered to the epidural space
nary approach seems advisable in this patient group.56 through an epidural catheter. The rationale for this tech-
Different routes of epidural access are described for nique is also to obtain a more ventral and target-specific
corticosteroid administration. The interlaminar route is administration of medication.74 With this approach, a soft
most frequently used due to the risk of catastrophic neu- radiopaque catheter is advanced through an introducer
rologic complications associated with the transforaminal needle to the level and side of pathology with the final
approach.61 In one study evaluating cervical interlaminar position of the catheter tip located in either the posterior
steroid injections for cervical radicular pain, the presence epidural space or in the lateral recess close to the site of
of non-herniated disk pathology, higher baseline disabil- the inflamed spinal nerve. One RCT demonstrated that
ity, and nonorganic signs were associated with negative a catheter-directed interlaminar CESI was as effective as
outcome. Medical imaging such as fluoroscopy is recom- a transforaminal CESI in reducing pain and disability in
mended for all techniques to improve accuracy of needle patients with refractory unilateral cervical radicular pain
placement in the epidural space.62,63 for up to 1 year.75 The preferred level for an interlaminar
CESI is C7–T1 and no higher than C6–C7, since at these
levels the epidural space is widest with an average di-
Interlaminar epidural corticosteroid mension of 3 mm (and variations of 1–4 mm).37 A critical
administration review of the available evidence asserts that there is mod-
erate evidence that interlaminar epidural corticosteroid
The use of interlaminar epidural corticosteroid injec- administration could be used in addition to conservative
tions (CESI) for cervical radicular pain was evaluated treatment in patients with cervical radicular pain, with
in a systematic review, which demonstrated Level II the strength of the recommendation being weak.59
evidence for the effectiveness of interlaminar CESI with
local anesthetic with or without steroids based on multi-
ple RCTs.64 A meta-analysis failed to demonstrate ben- Transforaminal epidural corticosteroid
efit for the addition of corticosteroids to local anesthetic administration
in interlaminar CESI but this conclusion was based on
few available studies and a lack of homogeneity in the in- The efficacy of transforaminal CESI was evaluated in a
cluded RCTs.65 The American Society of Interventional recent systematic review, which reported evidence sup-
Pain Physicians (ASIPP) reported level I evidence for porting efficacy.76 However, the available evidence was
interlaminar CESI with a strong recommendation for very low quality (GRADE rating) due to the lack of
long-term effectiveness with repeated injections.66 The placebo/sham-controlled studies or studies using active
effectiveness of interlaminar CESI was compared to standard of care as a comparator, similar to that reported
transforaminal CESI in 108 patients with axial pain in another recent systematic review and meta-analysis.77
due to cervical disk herniation.67 No significant differ- Although the transforaminal approach for CESI permits
ence for pain or functionality was observed between the more accurate delivery of medication at the affected spinal
two groups after 2-and 8-week follow-ups. Recently, nerve, serious concerns exist due to reports of calamitous
side effects and complications—including death—which Pulsed radiofrequency

are discussed below—no definitive evidence that trans-
foraminal CESI result in better clinical outcomes com- A systematic review reported significant pain reduction
pared to interlaminar CESI. The increasing number of with pulsed radiofrequency (PRF) treatment adjacent
reports of serious adverse events has stimulated a call for to the cervical dorsal root ganglion (DRG) in patients
safety and routinely avoiding the transforaminal route. In with refractory cervical radicular pain unresponsive
the international literature. there in no consensus on this to analgesics, physical therapy, or epidural steroid in-
topic. In general, it is recommended that the interlami- jections.85 The results of this systematic review were
nar route be tried first before considering transforami- based on one RCT, two prospective observational
nal CESI. It is similarly recommended that practitioners studies, and one retrospective study that contained
perform transforaminal CESI with the injection of con- a total of 67 patients. Similar effectiveness was dem-
trast under real-time fluoroscopy or digital subtraction onstrated for PRF compared to transforaminal CESI
angiography, if available, and use only a preservative in a small (n = 38) comparative-effectiveness study.86
free non-particulate corticosteroid such as dexametha- PRF treatment adjacent to the cervical DRG is usu-
sone.38,39 In one nonrandomized study performed in 159 ally performed under fluoroscopic guidance. Recently,
patients, there was no significant difference in effective- an ultrasound (US)-g uided approach reported good
ness between transforaminal CESI with particulate corti- outcomes in 49 patients with chronic cervical radicular
costeroids compared to dexamethasone.78 In a systematic pain.87 Overall, the strength of recommendation that
review involving nine trials (three in cervical region) that PRF treatment adjacent to the cervical DRG should
compared particulate and non- particulate steroids for be used for the treatment of patients with cervical
cervical and lumbar epidural injections (four studies and radicular pain is moderate, with a moderate level of
300 participants were included in a meta-analysis), Freely evidence.59
et al. reported no significant difference between particu-
late and non- particulate steroids in the meta- analysis
(0.31 in favor of particulates, 95% CI - 0.68 to 1.30), Spinal cord stimulation
though in their qualitative synthesis they found a trend
toward superiority for epidural injections performed with No systematic reviews or RCTs regarding the use of spi-
particulate steroids.79 The collaboration between the U.S. nal cord stimulation (SCS) for the management of cer-
Food and Drug Administration and 13 specialty stake- vical radicular pain were identified. One observational
holder associations issued a unanimous recommendation study reported improved function and decreased pain
that “Particulate steroids should not be used in thera- scores with cervical burst SCS in 15 patients with axial
peutic cervical TF injections.”38 It should be noted that neck pain with or without radicular pain.88 Another pro-
preservative-free dexamethasone is not routinely avail- spective study reported long-term pain relief with cervi-
able as pharmaceutical product in many countries. Some cal SCS in 24 patients, though not all of these patients
advocate using digital subtraction angiography (DSA) in- had cervical radiculopathy.89 One prospective, multi-
stead of real-time fluoroscopy for better detection of in- center, international registry demonstrated significant
travascular injection, with studies showing that real-time effectiveness for cervical spinal cord stimulation but
fluoroscopy may miss over 25% of cases of intravascular found only nine patients with failed neck surgery syn-
uptake detected with DSA.80 However, a narrative review drome or cervical radicular pain who had a cervical SCS
reported that existing studies do not support the hypoth- implanted.90 Overall, there is a weak recommendation
esis that DSA can reliably predict arterial spread, and based on low-quality evidence that spinal cord stimula-
postulated that DSA exposes the practitioner and patient tion should be considered for the treatment of cervical
to higher levels of radiation without objective evidence of radicular pain.59
improved safety parameters.81,82 Recently, an ultrasound-
guided approach for transforaminal CESI has been pro-
posed.83 The available evidence suggests non-inferiority SI DE E F F EC T S A N D
to fluoroscopy- g uided techniques, but there is still a COM PL ICAT ION S OF
paucity of adequately powered clinical studies evaluating I N T E RV E N T IONA L PA I N
the accuracy and effectiveness of using ultrasound guid- M A NAGE M E N T
ance.84 This technique has important limitations in terms
of visualization of anatomy, with the evidence available Interlaminar epidural corticosteroid
at this time suggesting it is best used in combination with administration
fluoroscopy. A 2018 evidence-based update of the lit-
erature concluded that there is very weak evidence that Cervical interlaminar epidural corticosteroid adminis-
transforaminal epidural preservative- free dexametha- tration is considered relatively safe when performed prop-
sone should be considered for the treatment of subacute erly. Reported complication rates vary between less than
cervical radicular pain.59 1%–16.8% depending on the timing of assessment.1,91,92
PEENE et al. | 7
Minor complications include but are not limited to axial Transforaminal epidural corticosteroid
neck pain and sensitivity at the injection site, flushing in administration
the face, nausea, vomiting, fever during the night after
the intervention, transient hypotension, respiratory in- Various reports of catastrophic complications after
sufficiency, subjective weakness in the arms for less than transforaminal CESI have been published. Most of these
24 h, and insomnia.37 neurological complications were evaluated in detail in
Nonetheless, major complications have been reported a systematic review and meta-analysis.103 Nonetheless,
in the literature. Dural puncture can lead to postdural more recent case reports with severe neurological compli-
puncture headache (PDPH), pneumocephalus, spinal cations such as brainstem infarction, and transient and
cord injury, and if unrecognized, to apnea and cardio- permanent blindness have since been published.104–107
vascular collapse after inadvertent intrathecal injection. The exact mechanism(s) behind these complications are
An inadvertent subdural injection, which leads to hy- not yet fully understood, but in broad lines, we can dis-
poventilation and hypotension, must be distinguished tinguish between direct lesions of the spinal cord caused
from an intrathecal injection. The incidence of dural by anterior spinal artery syndrome and effects on the
puncture after interlaminar CESI is reported to be central nervous system involving brain stem and cerebel-
0.8%–1.8%, depending on the level of the procedure.93 lum related to inadvertent injection into the vertebral
A higher risk for dural puncture is described in the cer- artery.1 For the cases of transient blindness, revers-
vical region due to the smaller space and incomplete ible posterior leukoencephalopathy syndrome, perhaps
fusion of the cervical ligamentum flavum.94 These gaps secondary to vasospasm or embolization of vascular
in the ligamentum flavum occur in the lower cervical structures, has been implicated. In a 2003 case report,
spine at high rates, with the highest prevalence of full the procedure was aborted after initial aspiration, then
thickness ligamentum flavum gaps exceeding 70% and nonionic contrast injection revealed possible vertebral
occurring at C7–T1.95 Tactile feedback is essential for artery puncture, suggesting a mechanism other than
safe and effective cervical epidural needle placement particulate steroid embolization.108 Multiple anatomi-
when using the loss of resistance (LOR) or hanging drop cal as well as pharmacological considerations must be
technique, but these gaps could compromise the safety acknowledged to link the technique of a transforami-
of the procedure and caution must be employed during nal CESI to these complications. Using non-particulate
the procedure. Preprocedural evaluation of medical im- corticosteroid (dexamethasone) is considered to be safer
aging of the cervical spine—preferably MRI—may pre- because of the probable absence of embolus formation,
vent serious complications and is therefore advisable. as described below. There are, however, two case reports
Some advocate measuring the approximate dermal-to- of serious complications after transforaminal epidural
epidural distance on an axial or sagittal cut on medi- injection with non-particulate steroids109,110 and multiple
cal imaging.96 However, estimates of needle depth made reports after lumbar TFESI.111 A 39-year-old man with
with MRI are consistently slightly deeper than the ac- no medical antecedents except for a car accident and
tual loss-of-resistance needle depth, indicating that cau- persistent neck pain received transforaminal CESI at
tion should be employed when measuring this distance C6-7 and C7-T1 with 5 mL dexamethasone and lidocaine
on MRI.97 and saline. Eleven hours after the injection the patient
Epidural hematomas have been reported in several developed segmental myoclonus.110 The second case was
case reports, along with epidural abscesses.91 A case a 50-year-old woman with acute cervical radicular pain
of pneumomyelia has been reported after cervical in- who after three interlaminar epidural steroid adminis-
terlaminar epidural steroid injection resulting in acute trations continued to experience tingling sensations ex-
quadriparesis.98 The patient's symptoms were caused tending from the left shoulder to the fingers. The patient
by an inadvertent puncture of the cervical cord and received a transforaminal CESI at C6-7 with 5 mg dexa-
injection of air present in the needle or syringe via an methasone and 1500 IU hyaluronidase. After injection of
interlaminar approach. The procedure was performed 1 mL of the medication, the patient reported a shock-like
under fluoroscopy with the patient in prone position. pain radiating in the left hand. As no further complaints
Spinal cord injury is likely to be more severe with in- were expressed, the injection was continued. At the end
jection into the spinal cord than with penetration with- of the injection, the patient complained of sudden pain in
out injection.99 Hence, both closed claims analyses and the posterior neck and the lateral part of the ipsilateral
guidelines recommend the avoidance of deep sedation, upper limb, which spread to the fingers and the bilat-
which may prevent patient feedback during spinal cord eral lower limbs. MRI was performed, which revealed
violation.100 An intracranial subdural hematoma after intramedullary high- signal intensity at the left-sided
a cervical epidural steroid injection is also a potential spinal cord from C4–T4, with ill-defined edema.109 The
complication.101,102 Interlaminar CESI should always addition of hyaluronidase to the injectate in the second
be performed under image guidance, preferably using case is questionable, and the etiological role of dexa-
fluoroscopy. methasone is unclear. However, strict safety measures
and a proper indication are mandatory even when dexa- were instances of: (1) Several deep cervical arteries aris-
methasone is used. ing from the subclavian artery either directly or from a
An overview of the reported complications after CESI very short costocervical trunk that entered the interver-
is given in Table 2. tebral foramen in its posterior aspect near sites of recom-
mended transforaminal needle placement; (2) A single
ascending cervical artery was noted to enter the poste-
Anatomical considerations rior foramen at C4 and eventually supply the ASA; (3)
A large segmental medullary artery was noted to be the
Several vital vascular structures may be encountered main supplier to the ASA when the ipsilateral vertebral
in the cervical intervertebral foramen during a trans- artery entered the transverse foramen at C5-6 instead
foraminal CESI.112 The vertebral artery is implicated of C6-7; (4) Several anastomoses were noted between all
in many reported complications, since embolization three main supply arteries in several cadavers, suggest-
within this vascular structure can lead to impairment of ing the potential for communication; and (5) If the deep
the blood supply to the brain stem and cerebellum. The cervical artery entered the intervertebral foramina, it
vertebral artery can be subdivided into three segments: was usually at either C7-T1 or C6-C7, in which case the
V1, V2, and V3.1 The V1 segment represents the distance ascending cervical artery tended to enter the foramina
from the origin of the vertebral artery at the subclavian at C5-C6 or higher. Special attention should be paid
artery to its entry in the cervical transverse foramen at to patients with carotid stenosis. A retrospective study
the C6 or C7 vertebral level. The V2 segment represents demonstrated that collateral arteries were present in the
the area from entrance in the transverse foramen to its majority of patients with significant (> 70%) stenosis on
exit out of the C2-3 transverse foramen. The V3 segment carotid CT angiogram and were within 10 mm of the op-
represents its course through the C1-2 transverse fora- timal needle tip position for transforaminal CESI.118 All
men, after which it turns medially and dorsally through these findings establish that there is no specific “safe
the groove on the upper surface of the C1 vertebral zone” for needle placement in the posterior cervical fo-
body to penetrate the posterior atlanto-occipital mem- ramina during transforaminal CESI. It is still unclear
brane and dura, and then passes through the foramen whether these vascular anatomic variants or anomalies
magnum into the cranial cavity. The vertebral arteries increase the risk of complications, but due to the poten-
eventually fuse to form the basilar artery on the ventral tial for this to be the case, caution should be exercised
surface of the medulla oblongata, but prior to this each during this procedure.
artery gives rise to other branches. These branches fuse
to form the anterior spinal artery (ASA) which runs in
the ventral median fissure of the spinal cord. The longi- Pharmacological considerations
tudinal anterior spinal artery must be reinforced by seg-
mental medullary arteries (radicular arteries) that arise The choice of corticosteroid plays an important role in
primarily from the V2 segment of the vertebral artery the risk of transforaminal CESI. In case of intra-arterial
but may also come from the ascending and deep cervi- injection, particulate corticosteroids may act as an em-
cal arteries. The V2 and V3 segments of the vertebral bolus and cause spinal cord infarction and permanent
artery are particularly prone to significant variability impairment. Animal studies have confirmed that injec-
in their course, which has been illustrated in several tion of particulate corticosteroids into the vertebral or
medical imaging studies.113 Figure 1 illustrates possible carotid artery results in permanent neurologic damage
variations of the vertebral artery. A retrospective study due to ischemia.119 Dexamethasone has been postulated
in which 2207 CT angiograms were evaluated reported to be safer. However, in one case report, an acute cer-
that an unusual V2 entrance into the transverse fora- vical myelopathy with quadriparesis developed after a
men was observed in 11.4% of cases, which is slightly transforaminal CESI with dexamethasone.109 In another
higher than earlier reports.114 An uneven transverse fo- case report, segmental spinal myoclonus occurred after
ramen on medical imaging was correlated with the oc- a transforaminal CESI with dexamethasone.110 Several
currence of an unusual V2 entrance.115 Furthermore, a authors have also reported catastrophic neurologic com-
significant correlation between the severity of cervical plications after lumbar transforaminal epidural admin-
neuroforaminal narrowing and the occurrence of an ab- istration of dexamethasone.111 These cases demonstrate
errant vertebral artery position has been reported, with that the use of preservative-free dexamethasone does not
displacement of the artery into the neuroforamen being guarantee the absence of neurologic complications and
common.116 Several other anatomical variations of nor- again, that caution should always be exercised when this
mal cervical vascular anatomy are possible. A cadaveric procedure is considered.
study found that in a significant number of interverte- Other complications have also been reported.120 One
bral foramina (21/95), an artery was located proximal case report describes a cervical epidural hematoma after
to the posterior aspect of the foraminal opening with transforaminal CESI with Brown-Sequard syndrome as
different anatomical variations.117 To summarize, there a consequence.121 Chemical meningitis occurred after a
PEENE et al. | 9
TA BL E 2 Overview of the reported complications after CESI.
Author year Year Type of complication Type Nr Classification
Waldman 1991 Epidural abscess NS 1 Infection

Siegfried 1997 Left upper extremity CRPS NS 1 Neurological
Hodges 1998 Spinal cord damage NS 2 Neurological
Benzon 1999 Epidural hematoma with paralysis NS 1 Hematoma—
neurological
Field 2000 Severe prolonged upper limb neuropathic IL 3 Neurological
pain, edema, and allodynia
Ghaly 2001 Epidural hematoma and Brown-Sequard NS 1 Hematoma—
neurological
Brouwers 2001 Cervical anterior artery syndrome TF 1 Neurological,
vascular
Rozin 2003 Perforation of left vertebral artery TF 1 Vascular
Stoll 2002 Epidural hematoma NS 1 Hematoma
Reitman 2002 Subdural hematoma and quadriparesis NS 1 Neurological
Bansal 2003 Subdural spread of injectate NS 1
McMillan 2003 Cortical blindness TF 1 Blindness
Huang 2004 Epidural abscess NS 1 Infection—
neurological
Tiso 2004 Cerebellar infarction TF 1 Neurological
Rosenkranz 2004 Anterior spinal artery syndrome TF 1 Neurological,
vascular
McMillan and 2003 Bilateral cortical blindness, seizures, and TF 1 Neurological
Crumpton cognitive impairment
Karasek 2004 Temporary neurologic deficit after TF 1 Neurological
transforaminal local anesthetic
Ludwig 2005 Spinal cord infarction TF 1 Neurological
Bose 2005 Quadriplegia NS 1 Neurological
Beckman 2006 Cerebellar herniation TF 1 Neurological
Wallace 2007 Unresponsive, requiring CPR. TF 1 Neurological
Suresh 2007 Cerebellar and brainstem infarction TF 1 Neurological
Muro 2007 Spinal cord infarction. TF 1 Neurological,
vascular
Lee 2007 Epidural hematoma causing paraplegia TF 1 Hematoma—
neurological
Lee 2008 Spinal cord injury due to injection of TF 1 Neurological
contrast and air
Ruppen 2008 Plegia of right leg TF 1 Neurological
Kim 2011 Bilateral visual impairment due to TF 1 Neurological
leukoencephalopathy
Maddela 2014 Hemiparesis and facial sensory loss IL 1 Neurological
Landers 2018 Contrast injection in the spinal cord IL 1 Neurological
Carter 2018 Convulsions and atrial fibrillation TF 1 Neurological,
cardiac
Yang 2019 Cervical myelopathy with quadriparesis TF (Dexa) 1 Neurological
Boudier-Revéret 2020 Segmental myoclonus TF (Dexa) 1 Neurological
Nowicki 2020 Pneumomyelia and transient IL 1 Neurological
quadriparesis with acute cord injury
Dehaene 2021 Subdural hematoma post-dural puncture IL 1 Hematoma
headache
F I G U R E 1 Possible variations of the arteries—adapted from Wang.113 (1A) Persistent first intersegmental artery variation. (2A, 2B)
Paracondylar process variation anatomical drawing and 3D reconstruction. (3A, 3B) Unusual Entrance Transverse Foramen of V2 Segment
anatomical drawing and 3D reconstruction. (4A, 4B) Midline migration variation anatomical drawing and 3D reconstruction.
transforaminal CESI where a mixture of lidocaine, hy- Pulsed radiofrequency

aluronidase, placenta hydrolysate, and normal saline
was injected.122 A retrospective study demonstrated that Most publications on PRF treatment adjacent to the cer-
subdural injection of contrast medium (in the space of vical DRG have reported no complications.124,125 Only
Okada) is also possible during transforaminal CESI, transient neuritis in the dermatome of the treated spinal
which could lead to hypoventilation and hypotension if nerve, for a duration of less than 2 weeks, has been re-
unrecognized.123 ported after this treatment.126
PEENE et al. | 11
Spinal cord stimulation Exam.”128 Ultimately, physicians should use techniques

they feel most comfortable with.
The complications of spinal cord stimulation (SCS) are
described in other articles in this series.
The literature on cervical spinal cord stimulation is Interlaminar epidural corticosteroid
rather limited. It is logical to expect similar technical administration
problems as described in the lumbar spine to occur the
cervical region such as lead displacement, lead breakage, A review of medical imaging—preferably MRI—is rec-
and battery depletion. Certainly, during the trial period ommended before planning an interlaminar cervical epi-
with an external stimulator and during permanent im- dural corticosteroid infiltration (CESI) to reduce the risk
plantation, there is a risk of infection and bleeding. An of major complications. Special attention should be paid
analysis of inpatient records for the period 2002 through to the presence of large disk protrusions and significant
2011 showed 2053 discharges for cervical spinal cord spinal canal stenosis, with deformation and/or reduc-
stimulation, with a spinal cord injury rate of 0.5%. The tion in diameter of the posterior epidural space as these
rates of any neurological, medical, and general perioper- may pose additional challenges and risks during needle
ative complications were 1.1%, 1.4%, and 11.7%, respec- placement. The procedure should be performed under
tively. There were no reported deaths.127 fluoroscopy with standard monitoring (EKG, pulse oxi-
metry, and noninvasive blood pressure monitors). Before
starting the procedure, a safe surgery checklist should
SU M M A RY OF T H E I N FOR M AT ION be performed with verification of the correct procedure,
known allergies and anticoagulants. Interlaminar CESI
Currently, there is no gold standard for the diagnosis of can be carried out with the patient in sitting position or
cervical radicular pain. The diagnosis should be made in prone position, but the latter is strongly preferred. The
by combining elements from the patient's history, physi- cervical spinal column is slightly flexed with the shoul-
cal examination, and additional tests. Medical imag- ders relaxed and brought caudally. A fluoroscopic image
ing, preferably MRI, is indicated if serious symptoms or in the lateral view is obtained, where the target level is
signs of underlying pathology are present in the acute identified. The procedure is preferably performed on the
phase. Selective segmental nerve blocks can help con- C7-T1 level, though the C6-C7 and T1-T2 levels can also
firm the suspected level of the involved spinal nerve(s). be considered. After skin disinfection, sterile draping is
First and foremost, conservative treatment—preferably placed, and skin local anesthetic is applied at or just lat-
exercise therapy—should be started. In the case of re- eral to the midline between the spinous processes of the
fractory radicular pain, interventional management can target level (eg, a right paramedian can be considered for
be considered. In patients with subacute radicular pain right-sided pathology and symptoms). A 20-or 18-gauge
with a duration ranging from 4 weeks to 3–6 months, in- Tuohy needle is then introduced between the spinous
terlaminar cervical epidural corticosteroid administra- processes at the same level. This can be verified using
tion is recommended in well-selected patients. In chronic an AP view of the cervical spine. The needle can then be
refractory radicular pain (> 3–6 months), pulsed radi- slowly advanced under fluoroscopic guidance in lateral
ofrequency adjacent to the cervical dorsal root ganglion or contralateral oblique (which may provide better visu-
should be considered. Spinal cord stimulation can be alization and more precise needle placement) views,129
considered in specialized pain centers if more conserva- using either the loss-of-resistance (LOR) technique or
tive treatment modalities fail. alternatively the “hanging drop” technique, though the
The published evidence is summarized in Table 3. latter may be unreliable as studies have shown that epi-
The proposed algorithm derived from the available dural pressure in the prone position is usually positive.130
evidence is illustrated in Figure 2. When the epidural space is reached, aspiration for blood
or cerebrospinal fluid (CSF) should be performed fol-
lowed by injection of a small amount of nonionic water-
A L G OR I T H M soluble contrast medium under live imaging or digital
subtraction angiography. If contrast spread is appropri-
Techniques ate, an injectate consisting of a depo-steroid solution
mixed with saline, with or without a small amount of
Depending on the interventionalist's experience and local anesthetic, can slowly be injected. After the proce-
training, different techniques may be used when apply- dure, the patient should be observed for an appropriate
ing interventional pain management techniques. We de- time period to ensure no complications arise. Any seri-
scribe the techniques preferred by the authors. ous neurological deficits should warrant rapid medical
For alternative techniques, we refer readers to imaging to exclude the presence of treatable pathology
“Interventional Pain. A step-by-step guide for the FIPP such as an epidural hematoma or spinal cord injury.131
TA BL E 3 Overview of the published evidence for interventional treatment of cervical radicular pain.
Author –date ref Technique Quality of evidence Conclusion Recommendation
Mesregah 2020 Interlaminar Four RCTs of high quality No significant difference Caution with
Effectiveness of cervical between steroid injection regard to
CESI for chronic epidural with local anesthetic and cost-effectiveness
neck pain Included patients local anesthetic alone in
with non- patients with radicular or
radicular neck non-radicular pain
pain
Huygen 2019 Interlaminar Moderate quality of evidence Interlaminar epidural Weak
Update of EBM cervical (GRADE) corticosteroid administration recommendation
guidelines epidural can be considered in addition for use
to conservative treatment
in patient with cervical
radicular pain
Conger 2020 Fluoroscopically Six RCTs, 11 nonrandomized, non- Half of the patients with cervical Further research
Effectiveness of guided comparator studies. radicular pain experience at necessary
fluoroscopy- transforaminal In the RCTs, no study met least 50% pain reduction for
guided cervical steroid predefined comparator criteria up to 3 months
transforaminal injections (sham, placebo, active control,
epidural steroid and no treatment).
injection for GRADE rating very low quality
radicular pain
Borton 2022 Transforaminal Three RCTs and three Significant symptom relief Further research
Systematic review epidural nonrandomized trials. No catastrophic complications needed
efficacy and steroid No study compared CTFESI with noted
safety of injections other treatment options.
CTFESI Quality judged to be fair to good.
Huygen 2019 Transforaminal Very weak quality of evidence Transforaminal epidural Very low
Update of EBM epidural (GRADE) performed with preservative- recommendation
guidelines injections with free dexamethasone could be for use
preservative- considered for the treatment
free of subacute cervical radicular
dexamethasone pain
Kwak 2018 PRF adjacent to One RCT and two observational PRF on the DRG is effective in Effective
Effectiveness of the ganglion studies of high quality. alleviating cervical radicular
PRF on cervical spinale (DRG) RCT by Van Zundert 2007 not pain
radicular pain included.6
Huygen 2019 PRF adjacent to Moderate quality of evidence PRF treatment adjacent to the Moderate
Update of EBM the ganglion (GRADE) cervical DRG should be
guidelines spinale (DRG) considered for the treatment
of patients with cervical
radicular pain
Huygen 2019 Spinal cord Very weak quality of evidence SCS should be considered for Weak
Update of EBM stimulation (GRADE) the treatment of cervical
guidelines radicular pain
Diagnostic nerve root block if this improves visibility. The correct level is identified
in this view. The entry point of the needle is determined
The procedure should be performed under fluoroscopy by projection of a metal marker over the posterior and
with standard monitoring. Before starting the procedure, caudal part of the targeted intervertebral foramen.
a safety checklist should be performed with verification After skin disinfection, sterile draping is placed,
of correct patient and procedure, correct side, known al- and skin local anesthetic is applied at the entry point.
lergies, and anticoagulants. The patient is placed in su- A 60-m m small-bore needle with extension tubing is in-
pine position on a radiolucent table, with the head fixed. troduced parallel to the X-ray beam (ie, using a coaxial
The c-arm of the fluoroscope is positioned to ensure that view). The direction of the needle is corrected while the
the X-ray beam runs parallel to the axis of the interver- needle is still in the uppermost subcutaneous layers. The
tebral foramen. This view is obtained by starting from an aim was to have the needle project as a single point on
anterior–posterior (AP) view and then tilting the image the fluoroscopic image. This point should lie in the pos-
intensifier 25 to 50° ipsilaterally, with a slight caudal tilt terior part of the intervertebral foramen, at the transition
PEENE et al. | 13
FIGURE 2 Proposed algorithm for the management of cervical radicular pain.
between the middle and most caudal third of the neural Pulsed radiofrequency of the dorsal root ganglia
foramen. This position is chosen in order to minimize
the risk of damage to or embolization within vascular The procedure should be performed under fluoroscopy
structures.132 After checking a lateral view, an AP view with standard monitoring. Before starting the proce-
is obtained, whereby the needle can be slowly adjusted dure, a safe surgery checklist should be performed with
until the tip projects just laterally to the ipsilateral cer- verification of correct patient and procedure, correct
vical facet column. Following negative aspiration, the side, known allergies, and anticoagulants. The patient is
segmental nerve is identified by injecting a small amount placed in supine position on a radiolucent table, with the
(< 0.5 mL) of nonionic water-soluble contrast medium (eg, head fixed. The c-arm of the fluoroscope is positioned
iohexol). If nerve root spread without epidural spread is to ensure that the X-ray beams run parallel to the axis
appreciated, 0.5–0.7 mL of a local anesthetic solution is of the intervertebral foramen. This view is obtained by
administered. After 10–20 min, the effect of the diagnos- starting from an anterior–posterior (AP) view and then
tic nerve root block is evaluated. A positive diagnostic angling the image intensifier 25–50°, with a slight caudal
block is usually defined as > 50% pain reduction. tilt used if necessary to optimize the foraminal radio-
Although an ultrasound-g uided approach is possible lucency. The correct level is identified in this view. The
for a diagnostic nerve root block, utilization is limited entry point of the needle is determined by projection of
by an ability to directly visualize intravascular uptake a metal marker over the caudal and posterior part of the
(eg, with real-time fluoroscopy or digital subtraction an- targeted intervertebral foramen. In the cervical spine, be-
giography) and lower accuracy rates. In one small study cause a significant proportion (> 33%) of the dorsal root
using CT as the reference standard, an accuracy of 88.5% ganglia may be situated proximally, a more medial tra-
was reported in 26 cervical transforaminal injections.133 jectory and target point can be considered.134 After skin
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2. Cervical radicular pain

Article in Pain Practice · June 2023

Laurens Peene Steven P Cohen

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Brigitte Brouwer James P Rathmell

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2. Cervical radicular pain

I N T RODUC T ION Cervical radicular pain is defined as radiating pain

Pain Practice. 2023;00:1–18. ﻿ wileyonlinelibrary.com/journal/papr | 1

Physical examination instability, but the correlation with magnetic resonance

TA BL E 1 Red flags adapted from Childress et al.26

Patient history Examination Condition

side effects and complications—­including death—­which Pulsed radiofrequency

TA BL E 2 Overview of the reported complications after CESI.

Author year Year Type of complication Type Nr Classification

Waldman 1991 Epidural abscess NS 1 Infection

transforaminal CESI where a mixture of lidocaine, hy- Pulsed radiofrequency

Spinal cord stimulation Exam.”128 Ultimately, physicians should use techniques

Author –­date ref Technique Quality of evidence Conclusion Recommendation

FIGURE 2 Proposed algorithm for the management of cervical radicular pain.

2. Bogduk N. The anatomy and pathophysiology of neck pain. Phys

133. Wang Y, Zhu Y, Wang W, Shi Y, Yang J. New simple ultrasound-­

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Pain Practice. 2023;00:1–18. wileyonlinelibrary.com/journal/papr | 1

side effects and complications—including death—which Pulsed radiofrequency

Author –date ref Technique Quality of evidence Conclusion Recommendation

133. Wang Y, Zhu Y, Wang W, Shi Y, Yang J. New simple ultrasound-