Cervical Epidural Versus Cevical Facet Injection for Patients With Chronic Cervical Pain
Condition: Intervention; Cervical; Epidural; Injection
MeSH terms: Neck Pain
Study type: Interventional

Summary: 
      After approval of the institutional review board and the Ethics Committee of Al Fayoum
      University number (D228) , and written informed consent from all patientṣ Pilot study will be
      done to confirm this sample size .The patients are classified in two groups group P for
      cervical epidural and group F for facet injection To compare effectivness of cervical
      epidural versus cervical facet injection under fluroscopic guidance in patients sufferring
      from chronic neck pain.
    

Detailed description: 
      After the approval of the institutional review board and the Ethics Committee of Al Fayoum
      University number (D228) , and written informed consent from all patientṣ Pilot study will be
      done to confirm this sample size .The patients are classified in two groups group P for
      cervical epidural and group F for facet injection. Patients Inclusion criteria of chronic
      cervical pain syndromes will be made from their history, symptoms, and imaging diagnosis.
      Patients will be lying down on the prone position. In group( F) Under the C-arm fluoroscopic
      guidance targeted zygapophyseal joints will be identified. The mixture of 2 mL of 2%
      lidocaine with 2 ml of beta methasone (6 mg/ml) will be injected in the joints unilaterally
      or bilaterally according to complaints of patients. Another group ( P) patients will undergo
      translaminar or interspinous cervical epidural block (CEBs). The translaminar or interlaminar
      approach is considered the safest and most effective technique for cervical epidural
      placement.The patient will be in a prone position. This procedure will be performed with
      fluoroscopic guidance. The patient will be placed in an optimal flexed cervical spine posture
      stabilized with enough resistance to prevent movement of the head during the procedure. The
      skin will be prepared with an antiseptic solution. The midline of the selected interspace
      will be identified under fluroscopic guidance. LA, such as lidocaine, will be used, to mark
      the intended site of skin entry. As much as 1 mL of lidocaine will be used to infiltrate the
      skin and subcutaneous tissues. We will insert a 25-gauge, 2-inch needle exactly into the
      targeted midline. After the LA has been given time to anesthetize the area,we will hold the
      needle firmly at the hub with the left thumb and index finger. Then the palm of the left hand
      will be placed firmly against the patient's neck, so that the left hand acts as a unit to
      stabilize, protect, and control the needle's trajectory and its metered ingress from any
      unexpected patient activity. The needle will be then advanced with the left hand, which is
      braced against the neck with the needle hub held tightly between the left thumb and
      forefinger. We will use the right hand to monitor resistance through a syringe containing
      air. With constant pressure applied to the plunger of the syringe through light pressure
      applied by the right thumb, the needle and syringe will be advanced in a slow and deliberate
      manner. As the bevel passes through the ligament flavum and enters the epidural space, a
      sudden loss of resistance that we will appreciate also we can appreciate the entrence the
      epidural space under fluroscopic guidance in condition that not to cross J line (a line
      appear under flouroscopy imaging facet joint articulation if crossing this line we will
      puncture the dura).

      Needle position within the epidural space will be checked by using fluoroscopic verification
      and by repeating the loss of resistance maneuver. The cervical epidural space should accept
      0.5-1 mL of air or sterile preservative free saline without significant resistance. The force
      required to depress the plunger should not exceed that which is necessary to overcome the
      resistance of the needle. Any significant pain or sudden increase in resistance during the
      injection suggests incorrect needle placement, so the injection will be stopped and we will
      assess the position of the needle using fluoroscopy. If the needle remains satisfactorily
      placed and loss of resistance within the epidural space is confirmed without additional
      patient report of pain, gentle aspiration will be checked to assure that the needle is not
      positioned in the subarachnoid space or that it's not intravascular. If cerebrospinal fluid
      (CSF) is aspirated, we will repeat the block attempt at a different interspace. If aspiration
      of blood occurs, the needle will be tightly rotated and the aspiration test will be repeated.
      If the aspiration of blood continues, the procedure will be aborted due to the danger of
      developing an epidural hematoma and possibly neurological compromise. when the needle is
      correctly placed in the midline of the epidural space, then injection of the mixture of 2 mL
      of 2% lidocaine with 2 ml of beta methasone (6 mg/ml) will be done .
    

Intervention name(s): Flouroscopic guidance cervical epidural versus cervical facet injection
Intervention type(s): Other
Intervention description(s): The patients are classified in two groups group P for cervical epidural and group F for facet injection. The skin will be prepared with an antiseptic solution. The midline of the selected interspace will be identified under fluroscopic guidance.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Group P will receive cervical epidural Group F will receive cervical facet injection Both under fluroscopic guidance
Masking: Single (Investigator)
Primary purpose: Supportive Care
Keywords: Flouroscopy; Cervical epidural; Facet injection; Neck pain