The principles of management of pain arising from the cervical spine are essentially the same as those described above for the lumbar spine. The increased mobility of this part of the spine and the greater use of paraspinal muscles for stabilization, however, place a greater emphasis on functional treatments in the management of chronic cervical spine pain. Although, theoretically, the approach to nerve root compression and irritation is the same as that for the lumbar spine, the use of invasive therapies such as epidural injections is more limited. This is at least partly because the technique of epidural injection in the cervical spine is more difficult and the potential risks (para- or quadri-paresis, secondary to epidural hemorrhage or infection) are more severe. They may be considered for the treatment of cancer-related cervical spine pain and radicular-type pain. The procedure is carried out using an 18-gauge Tuohy needle and a loss-of-resistance technique to locate the epidural space. Local anesthetic and steroid may be injected. Much smaller volumes of local anesthetic (5 ml or less) than in the lumbar region should be used because of the disastrous consequences of uncontrolled spread. Careful patient observation is required following the procedure, to detect any untoward respiratory, cardiovascular or neurological events. The combination deters all but the enthusiast.
Cervical Facet Joint Injections Injection of the cervical facets can be a useful tool in the management of patients with degenerative disease. Patients complain of pain radiating to the occiput, shoulder, arm or scapula, depending on the site of pathology, with the pain being exacerbated by rotation and hyperextension. Local anesthetic and steroid can be placed into the joint capsule in a similar fashion to lumbar facet joint injection, under X-ray control from C3 to C7. Careful aspiration is required prior to injection, as the epidural space lies immediately medial to the joint, with the vertebral artery lying lateral. Again, as with lumbar facet joint injections, if good pain relief is obtained following joint injections, consideration should be given to facet joint denervation for more permanent relief. The C3-C4 facet joints to C7-T1 are supplied by the medial branch of the posterior cervical rami, both from the corresponding level and the level above. The C2-C3 facet is supplied by the posterior ramus of C2 and the third occipital nerve from C3.
Cervical facet joint injections are more difficult than in the lumbar spine and, frequently, injections are directed at the nerve supply to the joint at the point where the nerve winds backwards around the lateral mass. Results, as in the lumbar spine, are equivocal but the technique is low-risk and worth trying in those patients with a mechanical pain of a non-radicular nature.
As in the lumbar spine, the use of the multi-disciplinary approach to chronic cervical pain has become established, although there is little objective evidence for education-based techniques or muscular relaxation in these patients [19,20].
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