Cervical Epidural Steroid Injection: Levels, Contrast and Contraindications

A cervical epidural steroid injection places anti-inflammatory medication into the epidural space of the neck. The principle matches the lumbar procedure, but the anatomy is less forgiving and the contraindication list is longer.

What it treats

The core indication is radicular pain emanating from the cervical spine. Beyond that, Empire's curriculum lists:

• Cervical spondylosis
• Nonspecific radiculitis
• Spinal stenosis
• Post-laminectomy syndrome
• Post-traumatic pain
• Post-herpetic neuralgia — noted as less frequent in practice, though a recognised indication
• Pain from malignancy

That range is wider than most patients expect, and it is why the assessment rather than the diagnosis label determines whether the injection is appropriate.

The levels that herniate, and the one that does not

Cervical discs do not fail at random, and knowing the pattern is genuinely useful when reading a scan.

The most common levels are C5-C6 and C6-C7. The next most common is C4-C5.

And the exception worth remembering: C7-T1 rarely herniates. A reported herniation at that level is unusual enough to be worth a second look at both the imaging and the symptoms.

Two other conditions account for much of the rest. Cervical osteophytes — bone spurs — can grow anywhere from C1 to C7. And cervical foraminal stenosis may arise with or without disc herniation, usually producing nerve root compression whether or not a herniated nucleus is present.

That last point matters for expectations. A patient can have genuine nerve root compression with an unremarkable disc, and treating the disc would be treating the wrong thing.

Contrast, and what to do when it goes the wrong way

Contrast under fluoroscopy confirms needle placement before any medication is delivered. In the cervical spine this is not optional — the margin for error is smaller than in the lumbar region.

The curriculum is specific about the response when contrast shows intravascular uptake: stop the procedure, or perform it one level below, provided the C7-T1 level has not already been used.

That is a clean decision rule. Intravascular spread means the needle is somewhere it must not deliver medication, and adjusting and proceeding is not the answer — repositioning to a different level, or stopping, is.

Absolute contraindications

Longer than the lumbar list, and each is absolute rather than relative:

• Known hypersensitivity to any of the agents
• Local or systemic infection
• Local malignancy
• Bleeding disorders
• Congestive heart failure
• Uncontrolled diabetes mellitus

The diabetes entry carries an important qualifier. The contraindication is uncontrolled diabetes — as the teaching puts it, these injections are performed “all the time in patients with diabetes mellitus which are well controlled.”

That distinction matters clinically. A diabetic patient with good control is a candidate; one with poor control is not, until control improves. Reading the list without the qualifier excludes patients unnecessarily.

The governing instruction beyond the list is to use common sense and avoid the cervical epidural in any medically at-risk condition.

The pain diary and the visual analogue scale

Most practitioners give the patient a pain diary before a cervical epidural, using the visual analogue scale.

The scale is a one-centimetre horizontal line carrying no numbers. The patient marks a point along it, and the position is measured afterwards.

The absence of numbers is deliberate rather than incidental. A numbered scale invites the patient to reason about what they said last time and to anchor to it. An unnumbered line captures a more direct impression, and successive marks can be compared without the patient having constructed a running tally.

For a procedure assessed on change rather than on a single reading, that is the difference between a measurement and a recollection.

How it differs from the lumbar procedure

The lumbar procedure, including approach selection, steroid choice and complications, is covered in epidural steroid injections.

For clinicians

Cervical epidural technique is learned under supervision with fluoroscopy, on real anatomy. This guide carries no doses, volumes, angles or depths. Empire teaches the cervical approaches, contrast interpretation and complication management across the pain management academy.