Outcome of Cervical Radiculopathy Treated with Periradicular/Epidural Corticosteroid Injections

Dear Editor, We read the excellent article regarding response to transforaminal injection of steroids and correlation to MRI findings in patients with cervical radicular pain by Klessinger et al. with interest and we feel compelled to comment because their experience is so far removed from ours over the past 30 years. Specifically, they report that only just over a third of patients achieved at least 50% reduction of pain at one month after treatment with just under a quarter ultimately having to undergo an operation. Contrast this to our prospective, independently-assessed series of cervical radiculopathies treated with periradicular/epidural corticosteroid injections . Three quarters of our patients had 100% reduction of pain and the remaining quarter: 80%. No patients required an operation. How can this be? We have scrutinised Klessinger et al's paper very carefully and two key points arise: Accuracy of injection and content. In Figure 0001 “Transforaminal Injection C6/C7 level: antero-posterior fluoroscopy view after injection of contrast medium,” it is clear that the contrast flows only to the mid intervertebral foramen, appears to merely allow visualisation of the ventral ramus and may not be covering the targeted spinal nerve and DRGB. Conversely, they clearly illustrate in Figure 0002 that most postero-lateral disc protrusions lie medial to this and, thus, the injectate has not reached the pain source. Contrast this with Figure 0003 in our article, where contrast medium flows through the intervertebral foramen into the lateral recess covering the suspected pain generators. In any event: ISIS guidelines suggest that a sufficient volume of contrast should be injected to outline the spinal nerve in the intervertebral foramen and to enter the lateral epidural space.