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, 7 (2), 137-143

Cervical Epidural Steroid Injection: Parasagittal Versus Midline Approach in Patients With Unilateral Cervical Radicular Pain; A Randomized Clinical Trial


Cervical Epidural Steroid Injection: Parasagittal Versus Midline Approach in Patients With Unilateral Cervical Radicular Pain; A Randomized Clinical Trial

Masoud Hashemi et al. Bull Emerg Trauma.


Objective: To compare parasagittal interlaminar cervical epidural steroid injection (PSIL-CESI) and the classic midline interlaminar cervical epidural steroid injection (MIL-CESI) in terms of pain relief and functional improvement in patients with unilateral upper extremity radicular pain.

Methods: This was a randomized clinical trial being conducted in a single pain center in Tehran. Twenty-six patients were allocated into two groups of 13, undergoing either PSIL-CESI or MIL-CESI. After confirmation of radiocontrast spread in the epidural space by fluoroscopic guidance, dexamethasone 8 mg and bupivacaine 0.125% in a volume of 5 ml were delivered to the epidural space. Evaluation of functional state and pain intensity before and 1 month after the procedure was accomplished using the neck disability index (NDI) and the numeric rating scale (NRS) respectively.

Results: Demographic and baseline characteristics of the cases showed no significant statistical difference. Improvements in the NDI and the NRS were observed in both groups; meanwhile, improvements were more pronounced in the PSIL-CESI group as compared to the MIL-CESI group (P<0.001). With the PSIL approach the ventral spread of radiocontrast was significantly higher (38%) than with the MIL approach (0.7%) (P<0.001). All patients in PSIL group showed radiocontrast spread ipsilateral to the painful side and all patients in the MIL group showed a midline distribution of radiocontrast.

Conclusion: PSIL-CESI provides superior pain relief and improvement of functional disability in patients with unilateral upper extremity radicular pain in comparison to the classic MIL-CESI.

Clinical trial registry: IRCT20180524039816N1.

Keywords: Epidural; Injections; Intervertebral disc disease; Pain management; Radiculopathy; Treatment outcome; Upper extremity.

Conflict of interest statement

The authors declared that there was no conflict of interest in this study.


Fig. 1
Fig. 1
Parasagittal needle trajectory at C5-C6 interspace
Fig. 2
Fig. 2
Parasagittal needle trajectory at C7-T1 interspace
Fig. 3
Fig. 3
Confirmatory contralateral oblique (45○) view of radiocontrast distribution. Solid white arrow pointing to an ipsilateral fine crescent of radiocontrast
Fig. 4
Fig. 4
Lateral (A) and contralateral oblique (B) views of contrast spread of the same patient as in figure 3 (needle advanced through C7-T1 interspace)
Fig. 5
Fig. 5
CONSORT flow diagram of the study

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