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Introduction

This leaflet has been produced to give you general information about your treatment.  Most of your questions should be answered by this leaflet. It is not intended to replace the discussion between you and the healthcare team, but may act as a starting point for discussion.  If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team.

What is a cervical nerve root block / transforaminal epidural steroid injection?

Nerves carrying pain sensations from the arm and shoulder arise from the spinal cord at the neck level. Cervical nerve root block / transforaminal epidural steroid injection may be used to determine the source of your pain to relieve your pain in your shoulder, arm and hand.

A nerve root block is not a cure, but aims to alleviate your symptoms by reducing the inflammation caused by the mechanical irritation of the nerve.

Why do I need cervical nerve root block / transforaminal epidural steroid injection?

A cervical nerve root block / transforaminal epidural steroid injection could be offered to you to either diagnose your pain or to relieve your pain.

Diagnose your pain

If the cervical nerve root block / transforaminal epidural steroid injection relieves your pain, the doctor could better understand the source of your pain and how to treat it. If not relieved, then there may be a different cause of your pain which may require alternative treatment.

Relieve your pain

A cervical nerve root block / transforaminal epidural steroid injection may be used to relieve your pain, reduce swelling, or improve mobility.  Steroid medication, with or without local anaesthetic, is injected directly into the place the pain comes from. Depending on the medicine injected, you may feel pain relief right away, or it may take a few days or more to take effect. Pain relief may be temporary (lasting several weeks or months) or could be longer lasting.

Can there be any complications or risks?

Common risks

·  local tenderness, bleeding and bruising at the site of the injection

·  Weakness, tingling or numbness in limbs for a few hours to days

·  Vasovagal episode (fainting)

·  A temporary increase in pain for few days.

Rare risks

·  No improvement in pain.

·  Blood in the epidural space (the space around the spinal cord).

·  Infection.

·  Very rarely damage to the nerve or spinal cord or paralysis may happen. Damage can occur from direct trauma from the needle, secondarily from infection or bleeding resulting in compression, or injection into an artery causing blockage.

·  Damage to surrounding blood vessels

·  Spinal headache

·  Convulsions.

·  Allergic reaction.

·  Stroke and paralysis 

·  Death

Patients who develop unusual symptoms such as severe neck pain, new numbness or weakness in the arms or legs, fever or difficulty with urinating after a spinal procedure are requested to attend the Emergency department immediately for assessment.

How long will the pain relief last?

This is highly variable between each individual.  Some patients may notice immediate pain relief, whereas in others it may take anything up to one to two weeks.  Similarly, the pain relief may last from a few days to several months, which again is variable between patients.  Some patients do not experience any pain relief from nerve blocks.

Advice to be read before having a pain relief procedure

The following information has been produced to ensure that you are able to have your pain relief procedure.  It is essential that you read and follow the advice given below before you come to the hospital. If you do not follow the advice you may not be able to have your treatment.

Please contact the Pain Service if any of the following apply to you:

·  You are diabetic and take medication to control your diabetes.

(Please see below for further advice)

·  You have recently been admission to hospital.

·  You have tested positive for MRSA.

·  You have an infection and are currently taking antibiotics.

·  If there is any possibility that you may be pregnant.

Continue your other regular medications including your pain relief.  However, If you take any anticoagulants or blood thinning medications (examples are listed below but may not include some of the newest drugs introduced since the publication of this leaflet), please notify the Pain Service at least 10 days before your appointment for advice.  You may need to stop taking these drugs about 1 week prior to the procedure unless your doctor has advised against this.

·  Warfarin (Marevan)

·  Clopidogrel (Plavix)

·  Dabigatran (Pradaxa)

·  Rivaroxaban (Xarelto)

·  Apixaban (Eliquis)

·  Edoxaban(Lixiana)

·  Prasugrel (Effient)

·  Ticagrelor (Brilique)

·  Dalteparin (Fragmin) injections

·  Enoxaparin (Clexane) injections

·  Tinzaparin (Innohep) injections

·  Dipyridamole (Persantin Retard)

·  Phenindione

·  Acenocoumerol (Sinthrome)

·  Asasantin Retard

You may have to wait a while before your procedure, so please bring something to read or do to keep yourself occupied. Please bring a dressing gown and slippers to wear.

Please leave any valuables or jewellery at home.  It is essential that after the procedure you arrange for an adult friend or relative to collect you by car or taxi. You will not be able to use the bus or train to travel home.

Hospital transport may be available if there is a medical need. If you think you may be eligible, please contact the Pain Service.

Sometimes pain injections are done under sedation (a drug is given to make you drowsy and relaxed but still conscious). If you are having sedation for the procedure, then you should not have anything to eat on the morning of your treatment. However, you may have a drink (tea or coffee without milk) if you wish, up to 2 hours before your appointment time.

Advice for diabetic patients only

If you are diabetic and booked to attend treatment under sedation in the morning, you should not have breakfast or take your morning medication, but please bring the medication with you.

If you are booked for treatment under sedation in the afternoon, please have your breakfast and take regular medications before 7.00am. Thereafter only drink clear fluids (not milk) for up to 2 hours before the procedure.  Please inform the Pain Service staff as soon as you arrive that you are diabetic, the staff will then assess your diabetes and if necessary, take appropriate action to monitor and control your blood sugar whilst you are in our care.

Your blood sugar level may raise and remain raised for few days after the procedure due to steroid medications that might be used during the injection. It is advisable to monitor your sugar level regularly for one week following the procedure.  Any concerns please contact your doctor.

What happens before the procedure?

You will be admitted by the nursing staff who will ask for and record some information about you.  Your blood pressure will be checked and you will be given a gown to put on. The doctor will explain the procedure and ask you to sign a consent form.  Please make sure you have understood what has been said and feel free to ask any questions.

What to expect during the procedure

As a precautionary measure, a thin plastic tube (cannula) may be inserted into a vein in your arm/hand before the procedure itself.  This allows us to give medication if there are any complications during the procedure.

Regarding the procedure itself, after cleaning your neck with antiseptic solution, local anaesthetic will be injected into your skin to numb it first.  Under X-ray screening or ultrasound guidance, a fine needle is introduced into your neck towards the area to be treated.  A small dose of contrast (X-ray dye) may be used to confirm the exact location of the needle.  Once the optimal position is obtained, local anaesthetic with or without steroid will be injected close to the nerve.

What happens after the procedure?

You will be taken on a trolley into the recovery area where the nurse will check your blood pressure and pulse.  You will be asked to rest for about an hour, following which, your nurse will then advise when you are able to get up.

Once you are mobile, you will able to go home accompanied by an adult friend or relative.

Please ensure that you have arranged for someone to drive you home after this procedure.  Failure to do so will result in your procedure being cancelled.  If you have had sedation, we recommend that you arrange for someone to stay with you overnight and that you do not drive 

for 24 hours

What to expect when your return home

Take it gently for a few days but gradually build up your activities. You should continue to take all your usual medication / pain relief as the pain may be slightly worse until the nerve block starts to work.

During the reduced pain period you should try to gently increase your exercise. Simple activities like a daily walk, using an exercise bike or swimming on your back will help to improve your muscle tone and strengthen your back. The best way is to increase your activity slowly. Try not to overdo things on a good day, as this may result in you experiencing more pain the following day.

Follow-up appointment

A letter will be sent to your doctor and you will be reviewed either by telephone or seen at the Pain Service in due course.

Points to remember

You will need to have arranged for someone to drive you home after this procedure.

·  Please bring your glasses if you need them for reading.

·  Always bring a list of all current medication.

·  Continue taking all your usual medication on treatment day

(please see above advice if you are a diabetic patient)

·  If there is any possibility you may be pregnant please inform the doctor or nurse.

·  If you are planning to travel abroad or fly within two weeks after the injections, please let your doctor know as it may be best to change the date of the injections.

Additional information

If you experience unusual symptoms such as a marked increase in pain around an injection site, fever, severe headache, new symptoms of pins and needles, new muscle weakness in your arms and legs, or you are very concerned about how you feel after the procedure, please contact your doctor.