78 yo male with neck pain who previously underwent two sets of diagnostic C4-5-6 mbb with 80+% pain relief. Subsequently underwent RF. Pain better for 3 months or so. Tried some oral meds, facet joint injection. Repeated the medial branch blocks, now 6-7 months after RF. No real benefit. Lots of cervical degeneration. ?discogenic pain. Patient does not want surgical intervention as he's had a few lumbar surgeries. Suggestions? thanks
neck pain treatment suggestions?
- Thread starter Pain_doc
- Start date
no real myofascial component
pain is posteriolateral neck, mostly posterior. No pain in traps/arms
mild multilevel alignment issues due to degen, but lordosis still present (not "straightened")
pain with neck movement, with loss of ROM
pain is posteriolateral neck, mostly posterior. No pain in traps/arms
mild multilevel alignment issues due to degen, but lordosis still present (not "straightened")
pain with neck movement, with loss of ROM
- Joined
- May 30, 2005
- Messages
- 21,231
- Reaction score
- 12,342
Our clinics apoproach would have been to include C4-7 as a motion segment and if double diagnostic paradigm positiv eper ISIS guidelines then we would RF. If either MBB failed, we would proceed to C3, C4, TON MBB. Failing this the options include CESI (worth trying but of low clinical utility for pain described), manipulation under anesthesia (no good peer reviewed literature, but very little downside), AA/AO blocks.
Cervical discogram and possible perc disc procedures could be entertained. I do not care for either, but when PAZ reads this he'll ref Slipman's C-disc article, and others that support C-disc and interventions to the C-disc. My bias is go watch a NS do an ACDF and then it would be fairly easy to convince a patient that this may be the best course of treatment. They work well and are not that complicated. (Unless I got stuck watching great NS on easy necks- I think it is a reasonable thing to do before intradiscal procedures in the C-spine).
Cervical discogram and possible perc disc procedures could be entertained. I do not care for either, but when PAZ reads this he'll ref Slipman's C-disc article, and others that support C-disc and interventions to the C-disc. My bias is go watch a NS do an ACDF and then it would be fairly easy to convince a patient that this may be the best course of treatment. They work well and are not that complicated. (Unless I got stuck watching great NS on easy necks- I think it is a reasonable thing to do before intradiscal procedures in the C-spine).
- Joined
- May 27, 2006
- Messages
- 73
- Reaction score
- 0
Pain doc: from what you said, he has true facet mediated pain at C4-C7 w/ greater than 80% relief the first round and also effective pain relief after RF but short-lived. Is your hypothesis that his medial branch continues to regenerate and thus bring back the pain? what was his pain response to the second round of MBBs? What about repeating RF?
Did he have a hx of trauma to the neck? or just DDD?
If you belief that the facets are the source of pain, I wouldn't recommend an ACDF, that ( -- spine surgeon's please weigh in) is for discogenic pain. ACDF works best for arm pain > neck pain and many patients are left w/ axial neck pain after ACDF. I would worry that surgery in this patient:
1. Might not help at all bc it is not targeting the correct pain generator
2. Might make the pain worse.
3. Might leave him with a new and exciting type of axial neck pain in addition to his familiar neck pain.
ACDF has the poorest outcomes for pure axial neck pain; and what is the # of patient's left w/ persistent axial neck pain? 25%. (Anyone have these literature #'s at their computer tips).
Just out of curiousity -- what lumbar surgeries did he have and why? Why doesn't he want the surgeon's help again. Were his facets/SI joints evaluated before surgery?
- Joined
- Oct 18, 2004
- Messages
- 2,959
- Reaction score
- 584
Personally, I would have a proper course of PT performed (where the biomechanical derangements have been correctly identified prior to treatment including the T-spine, ribs and scapulae), unless the patient has already burned up all his sessions.
If the patient is adamantly against further surgery, I'm not sure what the value of a cervical disco would be. From what I understand, the posterior annulus is extremely thin and poorly innervated in the c-spine, so unless there is a focal portrusion, I can't see being able to perform perc disc decompression. Additonally, I haven't heard of anyone performing a thermal annuloplasty on the the anterior annulus.
As the pain is in same general region as his pain prior to the 2 sets of mbbs and subsequent RF, I did repeat mbbs and actually did include C7. Unfortunately, he did not obtain any pain relief from the diagnostic blocks the last time. That's my I posted my question. He's been through PT for both his neck and lower back. As he's 78, he's just not interested in any more surgery. He also doesn't tolerate most medications very well. His last lumbar surgery was a multi-level laminectomy and fusion. He is a motivated and very pleasant gentleman who I'd like to help. Thanks.
- Joined
- May 30, 2005
- Messages
- 21,231
- Reaction score
- 12,342
If the facets are adequately denervated, then they no longer are causing the pain. Look at another source of neck pain, e.g. the discs. A CESI at C7-T1 would be my next procedure.
Don't get hung up on the location of the pain as posterolateral to mean facet mediated. Recall the drawings of referred cervical discs and that of referred cervical facets. Lots of overlap.
Don't get hung up on the location of the pain as posterolateral to mean facet mediated. Recall the drawings of referred cervical discs and that of referred cervical facets. Lots of overlap.
- Joined
- Jun 12, 2002
- Messages
- 5,332
- Reaction score
- 138
the most common reason for short-lived RF???
POOR TECHNIQUE.... why do you think more and more people are extending their burn zones. Hell, the first paper by susan lord their methodology was 3 HOURS of procedure time for correct positioning!!! now of course none of us would spend that much time... but it means something
POOR TECHNIQUE.... why do you think more and more people are extending their burn zones. Hell, the first paper by susan lord their methodology was 3 HOURS of procedure time for correct positioning!!! now of course none of us would spend that much time... but it means something
- Joined
- May 30, 2005
- Messages
- 21,231
- Reaction score
- 12,342
I was going to post this as as well. But I thought it would be unfair to critique a physician I did not train with or viewed their technique first hand. I've learned to keep my ego one step behind my skills, for patient safety.
One of the biggest problems in PM is ego. I see so many people who have such a strong desire to get better or docs so biased against other providers that they just redo everything that was done before when a "new" patient gets worked up.
We take pictures of our RF placement during the burning for the chart. I recommend everybody else do the same, that way if your patient ever winds up in front of me, I can see that you did the procedure correctly (I hope). I'm a big proponent of reigning in health care costs. But I'll gladly take your money if you want me to.
I print pictures of the needle placements for the chart, and was generally happy with placement by fluoro (as with sensory stim, but that can be argued since its voltage based, etc.). Certainly I recognize that perhaps it was my technique as I am relatively new in practice and performed less than 100 cervical Rfs, and that's why I repeated the medial branch blocks 7 months after the initial RF. The pain present now is not responsive to diagnostic mmb, versus 80+% relief with the two prior sets of blocks (0.5ml local).
- Joined
- May 9, 2005
- Messages
- 162
- Reaction score
- 3
Poor technique? If using a 14 gauge probe and 3 hours of lesioning constitute good technique, you are better off sending the patient to a spine surgeon who can make an incision overlying the lower facetal pillars and use electocautery to burn 'away', under an operating microscope...it would probably take less time and be better tolerated by the patient.
Also, the placebo effect of having a neurosurgeon do a procedure probably is greater than the placebo effect from an interventional 'what-do you do'?
- Joined
- Apr 10, 2003
- Messages
- 282
- Reaction score
- 14
- Joined
- Jun 12, 2002
- Messages
- 5,332
- Reaction score
- 138
well if we are going to be obsessed by evidence based pain medicine then we need to look at the literature a bit closer...
needle placement is not everything - while it can be argued that your fluoro film looks PERFECT, it doesn't mean the needles were overlying the nerves as nicely as you would have hoped for... you have no control of somebody's anatomy....
in my experience, if i get great results w/ MBB (i use between 0.1 and 0.2ml of lidocaine) repeated twice and i get a few months w/ RFL, then i go for a repeat RFL and try to create a larger burn area - some people are using bipolar approach and i am thinking about it.
needle placement is not everything - while it can be argued that your fluoro film looks PERFECT, it doesn't mean the needles were overlying the nerves as nicely as you would have hoped for... you have no control of somebody's anatomy....
in my experience, if i get great results w/ MBB (i use between 0.1 and 0.2ml of lidocaine) repeated twice and i get a few months w/ RFL, then i go for a repeat RFL and try to create a larger burn area - some people are using bipolar approach and i am thinking about it.
