The Use of Epidural Corticosteroids for Cervical Radiculopathy: An Interlaminar Versus Transforaminal Approach

A 43-year-old right-handed man presents with left shoulder pain and left arm pain and numbness.His symptoms began 6 weeks previously while weightlifting, performing repetitive shoulder abductions with a 10-pound dumbbell in each hand.He noticed a sudden cramp in his neck and left shoulder and immediately stopped his workout.While driving home from the gym, he noticed a temporary jolting pain into his left arm to the hand and fingers.He awoke the following morning with sharply increased pain.His primary care physician initially prescribed ibuprofen, cyclobenzaprine, and hydrocodone, and later gabapentin.Ibuprofen was helpful, and each of the remaining medications ameliorated a portion of his pain but caused either somnolence or vertigo.Within the first week, the patient developed numbness in left hand and thumb whereas the overall severity of his pain decreased.Cervical magnetic resonance imaging (MRI) was ordered, and physical therapy prescribed including 12 sessions of traction, mobilization, and stretching, resulting in temporary improvement only.He attempted a few home exercises but was limited by increased pain while performing sit-ups and weakness of his left arm while performing push-ups and pull-ups.He denied problems with walking or balance and had no changes in his bladder or bowel function except for some constipation associated with use of hydrocodone.The patient works for the phone company, installing and repairing phone lines.The job involves phone line work from a bucket as well as ground work for building installations.Aside from his tools, there is no heavy lifting.During installations, he is required to maintain awkward neck and arm positions that significantly aggravate his arm pain and numbness more than neck pain.He has missed 4 of the last 6 weeks of work and has exhausted his paid sick leave and is concerned about losing his job.He is cooperative and pleasant during the examination.He has a positive Spurling maneuver to the left, a diminished left brachioradialis tendon reflex, subtle weakness of the left biceps, and reduced pin-prick sensation in the left lateral hand and thumb.The remainder of the neurologic examination is normal.His MRI taken 2 weeks previously demonstrates a left paracentral disc herniation at C5-C6 (Figs. 1 and 2).While the physician discusses these findings with the patient, the patient states that he is "willing to have surgery or do whatever it takes to get better quickly.