Bilateral cervical transforaminal epidural steroid injection

 

  • anatomy of neck nodes , more anatomy , node levels , node levels from NCCN
  • risk of spread to nodes ,   more neck anatomy ,  location of neck nodes
  • mets to nodes from an unknown source (occult primary)
  • treatment and outcome of neck node metastases
  • more neck node data
The treatment of metastatic cancer in the lymph nodes is related to the type of cancer and the size of the nodes. Some node cancers (. lymphoma) are very sensitive to radiation (or chemotherapy) and surgery is not indicated. Most head and neck cancers are squamous cell carcinomas and for large nodes surgery is necessary (except nasopharynx cancer where surgery is less often used.) For patients with multiple nodes chemotherapy probably plays an increasing role. In  general  a small single node up to 2-3 cm (so called N1) can be treated adequately with surgery (usually a radical neck dissection) or radiation. Larger nodes or  multiple nodes (N2 or N3) usually require combined surgery and radiation. In the past surgery was always a radical neck dissection but there has been increasing use of more limited resections. Also some nodes (. retropharyngeal nodes) cannot be resected and radiation is always indicated. The risk of   spread to these nodes is noted below:
Retropharyngeal Node Metastases (McLaughlin Head and Neck 1995;17:190) Primary Site Risk of Node Spread nasopharynx 74% pharyngeal wall 19% soft palate 13% tonsillar region 9% pyriform/ postcricoid 5% base of tongue 4% supraglottic larynx 2%

The patient presents with a deteriorating neurologic exam in the presence of a bilateral C5-6 facet dislocation. Because the patient is alert, cooperative, and sober, the next step in management is closed reduction with cranial traction while the patient is awake.

An ASIA Impairment Scale of E is a normal exam. An ASIA Impairment Scale of D shows preserved motor function below the neurological level, but with more than half of key muscles below the neurological level showing weakness but with a muscle grade greater than 3. Therefore his exam is worsening. You know it is a bilateral facet dislocation as there is 50% subluxation of the vertebral bodies. Because the patient is alert, cooperative, and sober, the next step in management is closed reduction with cranial traction while the patient is awake. Because of his rapid decline in neurologic function you would not want to delay reduction by obtaining an MRI. All facet dislocations need to be stabilized surgically following reduction. Following closed reduction an MRI should be obtained to look for a cervical disc herniation, as the presence of one will determine the approach for stabilization.

The cited reference by Star et al is a case series (LOE4) of 53 patients who underwent closed reduction. They found that contrary to prior beliefs, adding weights of > 50 lbs and up to 100 lbs was safe and effective. In their series, 39 patients required greater than 50 lbs to obtain reductions and there was no associated complications with this additional weight.

Vaccaro et al performed prereduction and postreduction magnetic resonance imaging in eleven consecutive patients with cervical spine dislocations. They found the process of closed traction reduction appears to increase the incidence of intervertebral disc herniations. The relation of these findings, however, to the neurologic safety of awake closed traction reduction remain unclear.

Illustration A shows a simple algorithm to determine the ASIA Impairment Score (AIS).

The diagnosis was never conclusive to me, since there was no verified bilateral nerve compression, although it is possible that some of the cauda equina is affected by a large central herniation at L5/S1. Now, I feel that my later discovered cervical herniations are more probable as the source of most of my suffering, at least structurally. One intervertebral bulge, in particular, really displaces the spinal cord severely and this may explain the incredible diversity of symptoms I endure. I place far more credence in this theory than in the lumbar disc-enactment suspicions.

Bilateral cervical transforaminal epidural steroid injection

bilateral cervical transforaminal epidural steroid injection

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