Severe Occipital and Frontal Headache after Cervical Medial Branch Block

[PainMD23]

Interesting case for me today and the first time I've seen this issue. 25 yom, thin, healthy, 6'3 200#. Referred by another pain management doc for cervical mb rfa. Neck pain for many years, axial; "burning" pain in axial neck, radiates from cervical area to occipital and frontal areas. He does have radiation from axial neck to supraspinous area to shoulder in C5-6 distribution with occasional muscle spasm. Pain is constant, but exacerbated by any type movement especially after long workday as lawn maintenance contractor. Pain level 5-9/10 varies with activity. Heat helps, PT no benefit. NSAID helping. Patient attributes onset of neck pain to working with horses and various falls while working, but no definitive injury. Neuro exam normal, non-focal. MRI shows small central osteophyte and focal disc protrusion with "borderline central canal stenosis," C7-T1 small right paracentral disc extrusion behind inferior endplate of C7 but no nerve root compression, small left T1-2 paracentral disc extrusion. Cervical Myelogram shows spur at T1-2 with symmetric filling of nerve root sleeves throughout cervical spine, a shallow right C7-T1 disc protusions without foraminal compromise; and left T1-2 disc/spur flattening the left anterior cord. The other pain doc has performed 3 cervical esi's at C7-T1 and C6-7 with benefit for 2-3 days each. He had right then left C3-4 and C4-5 facet injections with benefit for two weeks 60-70%. Bone scan Cspine normal. No RA, lupus, spondyloarthropathies in family, and patient's sed rate, ANA, HLAB27 normal. Positive rheumatoid factor at 17. Non-ttp over the GON and LON bilaterally without radiation. Ttp over the facets, positive facet load. Negative spurling's. Normal reflexes bue. Normal heel-toe, normal gait. Tender points throughout cervical musculature but no trigger points or spasm. Has h/o low back pain but I don't have the full history or imaging there.

Patient warned me prior to procedure that he has severe HA following each cervical esi and facet injection. After the history, PE I did uneventful bilateral c3-7 mbb using posterior approach and checking needle position in lateral prior to injection. 25 g 3.5", bupivicaine 9mL 0.25% with kenalog 40mg, 1mL at each site. He had versed 2mg, fentanyl 100mcg, propofol. Then, postop (immediately upon awakening in PACU) he grabs frontal area and starts moaning before he can even communicate fully. Appeared to be legit, toxic-appearing. HA radiates from occipital to frontal area, "whole head." BP normal. Vitals normal. After boat load of opioids and phenergan, pain level improves to tolerable 5/10. I call the other surgery center where his previous blocks were performed and they confirm that after all the prior blocks he has had severe HA, and they have usually given morphine 20 mg, demerol 25 mg, dilaudid 1mg if necessary, 12.5 phenergan. Patient has had lumbar esi's, mbb's previously without significant headache postoperatively.

I know this may be routine for some of you, but I haven't seen this previously. Any ideas regarding the headache? I asked all the usual questions about opioid abuse but patient appears to be legit, wife confirms everything. He takes lortab 7.5, one tablet daily after working all day. No tattoos, dresses well, pupils normal/reactive, no track marks.

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[lobelsteve]

Interesting case for me today and the first time I've seen this issue. 25 yom, thin, healthy, 6'3 200#. Referred by another pain management doc for cervical mb rfa. Neck pain for many years, axial; "burning" pain in axial neck, radiates from cervical area to occipital and frontal areas. He does have radiation from axial neck to supraspinous area to shoulder in C5-6 distribution with occasional muscle spasm. Pain is constant, but exacerbated by any type movement especially after long workday as lawn maintenance contractor. Pain level 5-9/10 varies with activity. Heat helps, PT no benefit. NSAID helping. Patient attributes onset of neck pain to working with horses and various falls while working, but no definitive injury. Neuro exam normal, non-focal. MRI shows small central osteophyte and focal disc protrusion with "borderline central canal stenosis," C7-T1 small right paracentral disc extrusion behind inferior endplate of C7 but no nerve root compression, small left T1-2 paracentral disc extrusion. Cervical Myelogram shows spur at T1-2 with symmetric filling of nerve root sleeves throughout cervical spine, a shallow right C7-T1 disc protusions without foraminal compromise; and left T1-2 disc/spur flattening the left anterior cord. The other pain doc has performed 3 cervical esi's at C7-T1 and C6-7 with benefit for 2-3 days each. He had right then left C3-4 and C4-5 facet injections with benefit for two weeks 60-70%. Bone scan Cspine normal. No RA, lupus, spondyloarthropathies in family, and patient's sed rate, ANA, HLAB27 normal. Positive rheumatoid factor at 17. Non-ttp over the GON and LON bilaterally without radiation. Ttp over the facets, positive facet load. Negative spurling's. Normal reflexes bue. Normal heel-toe, normal gait. Tender points throughout cervical musculature but no trigger points or spasm. Has h/o low back pain but I don't have the full history or imaging there.

Patient warned me prior to procedure that he has severe HA following each cervical esi and facet injection. After the history, PE I did uneventful bilateral c3-7 mbb using posterior approach and checking needle position in lateral prior to injection. 25 g 3.5", bupivicaine 9mL 0.25% with kenalog 40mg, 1mL at each site. He had versed 2mg, fentanyl 100mcg, propofol. Then, postop (immediately upon awakening in PACU) he grabs frontal area and starts moaning before he can even communicate fully. Appeared to be legit, toxic-appearing. HA radiates from occipital to frontal area, "whole head." BP normal. Vitals normal. After boat load of opioids and phenergan, pain level improves to tolerable 5/10. I call the other surgery center where his previous blocks were performed and they confirm that after all the prior blocks he has had severe HA, and they have usually given morphine 20 mg, demerol 25 mg, dilaudid 1mg if necessary, 12.5 phenergan. Patient has had lumbar esi's, mbb's previously without significant headache postoperatively.

I know this may be routine for some of you, but I haven't seen this previously. Any ideas regarding the headache? I asked all the usual questions about opioid abuse but patient appears to be legit, wife confirms everything. He takes lortab 7.5, one tablet daily after working all day. No tattoos, dresses well, pupils normal/reactive, no track marks.

That seems like an awful lot of medication for MBB. I would not have used sedation or more than 0.3cc per level. Nor would I have performed 5 levels bilaterally.

Your mileage may vary.
You may be a needle jockey if......

Sorry to sound accusatory, but that's a whole lot of medicine and a whole lot of levels for anybody in any given day.

 

[PainMD23]

1mL is too much for cervical. I use 1mL in Lumbar and 0.5mL cervical but I understand the ISIS guidelines say 0.3mL for cervical. Your criticism is well-taken, I assure you. I am a new grad and obviously still learning here. Obviously for cervical esi and mb rfa, I don't sedate (well, I use 2mg versed max...but they all stay lucid and communicative). I usually don't like to sedate for cervical mbb's, but I will if the patient requests it. Concerning the bilateral block, I have to admit that I will block bilateral lumbar mb's. I don't rfa bilaterally, and have them return for the other side. I'm trying not to be a needle jockey but maybe I meet your definition.

My main point is that this patient has had a severe headache after cervical esi x2, and after both left and right cervical facets (I did not do any of these blocks but this is confirmed from the asc records at the other facility). The other pain doc is a physiatrist who does not perform cervical rfa, and has asked me to perform cervical rf. Has anyone seen this response? Could it have been the bupivicaine? Kenalog? Propofol? Anything else? Just wondering out loud if anyone has seen this previously.

 

[PMR 4 MSK]

By a review of 300 consecutive patients I did a couple years ago (maybe 3 years now), 3% of ESI's and 3% of non-ESI's got headaches. No spinal headaches. Some non-ESI HA's seen even after hip and SIJ inj. So any injection can cause a headache.

My guess is these are tension headaches - bilateral, pressure feeling, often occipital, temporal or frontal, or some combo. Could argue for cervicogenic HA. Either way, it's most likely a needle reaction - either irritation of the soft tissues, or just anxiety-driven.

BTW, what is your rationale for steroid in a MBB? It's a purely diagnostic test. I also use .3 cc lumbar and cervical - any more than that and the spread is all over - try it with 1 cc contrast and you'll see. Bilateral procedure is debateable - some do, I don't for MBB. For intra-articular facet I'll do bilateral, but no more than 1 cc steroid per side. Some here don't do intra-articular, only MBB with RFA if beneficial.

 

[Tenesma]

painmd23...

medial branch block with 1ml????
medial branch block with steroid????
medial branch block bilaterally from C3 to C7????
medial branch block with SEDATION????

so if he gets better, what do you do with that information?
how do you know the sedation isn't what made him feel better for a bit
how do you know that some systemic absorption of steroid didn't make him feel better for a bit

if your answer is that you are going to do a Cervical RF from C3-C7 bilaterally, then you are either a fool or you need to redo a pain fellowship... did you do one by any chance?

re: headaches... i have had a few patients with severe headaches similar to your description and it usually is in younger folk with bad necks who are made to lie prone with their head still for an extended period of time.... such as with cervical ESIs and posterior approach cervical injections

recommendation: i suspect if you had done your cervical MBB in a lateral decub position for just 1 or 2 levels you would have not seen the headache.

 

[Tenesma]

re: bilateral...

rarely need bilateral in the neck... for some reason, if the diagnosis is accurate i tend to see good resolution with unilateral care

more frequently see bilateral disease in lumbar spine - usually in the setting of a lot of micro-motion (ie: w/ spondylisthesis), and therefore will do bilateral lumbar MBB (one level, 2 at MOST) if pain is bilateral.

 

[chauffeur]

Sounds like it could be myofascial.

This patient is only 25! He is in for a lifetime of injections. Something is missing.

 

[Ligament]

painmd23;

This patient raises lots of red flags. I have seen post-procedure frontal headaches; they tend to occur in very old people with lots of bilateral facet arthrosis. Surprisingly, my experience is in complete contrast to Tenesma's observation of this phenomenon occurring in his young population.

My theory is that laying prone with the neck in one position (usually with the OA joint hyper extended) induces a cervicogenic headache, or compromises the vertebral arteries in some fashion to induce ischemia. Surfboarders can get transverse myelitis and I wonder if is due to the above mechanisms since they too assume a similar position for a period of time. But I have never seen this reaction in anybody under 50.

On a more important note; I agree with everybody's critique of your technique and indications. This is a 25 y/o young man, why burn his whole neck? Usually in kids this young if you have to do an RF (which is rare), they will usually respond to one or two levels. Also, that is a ton of sedation used for this case.

One thought; any chiari malformations? Sometimes they can have weird symptoms like this at a young age.

 

[Ligament]

re: bilateral...

rarely need bilateral in the neck... for some reason, if the diagnosis is accurate i tend to see good resolution with unilateral care

more frequently see bilateral disease in lumbar spine - usually in the setting of a lot of micro-motion (ie: w/ spondylisthesis), and therefore will do bilateral lumbar MBB (one level, 2 at MOST) if pain is bilateral.

Tenesma, I too find the same in the neck; people might have a neck that "looks" bad bilaterally, but I too get good resolution with unilateral care. Can't explain it.

I also see very frequent bilateral disease in the lumbar spine in OLD patients. I do a LOT of multilevel lumbar RF, but my average patient age is almost 70 for such procedures. I will often do bilateral L2-L5 RF in these ancient patients. They want OFF their opioids at all costs!! (can you believe it?)

Tenesma, do you limit yourself to 2 levels bilaterally in severe multilevel spondylosis in the elderly?

 

[Tenesma]

that is a good question about the elderly---

i find that while there is global spondylotic disease present, that suprisingly not all of the joints are painful.... i choose the joints based on exam primarily, but occasionally will use thin-cut CT or SPECT to help choose which ones i do.

i have not had to do more than 2 levels in the elderly in the last 2 years (since becoming a bit more selective)... and they seem to do okay --- the issue is that once you start with 3 or 4 level MBBs, your hand is kind of forced to do a 3 or 4 level RF

 

[pars]

How do you determine painful levels on exam?

I try extension and lateral loading and try to estimate nearest facet joint to point of maximal tenderness...but I'm not sure that is really accurate. Pain generator does not need to be adjacent to the point of maximal tenderness. Look at the compression fracture population. A fair number of T12, L1 compression fracture patients present with lumbosacral type pain and actually get better with cement augmentation.

I think determining painful facet levels is a bit of trial and error. Some exam, some imaging, some targeted injections.

 

[Tenesma]

I agree absolutely.... however, the premise that the best way to figure out the source of pain is to perform a 4 or 5 level MBB doesn't stand.

and i also am always surprised how so many T12/L1 fx act like SI joint pain...

 

[SSdoc33]

i echo everyone's sentiments, regarding the way the procedure is done. if if i got 320 mg of kenalog, id have a headache as well. however, again, why is a 25 y/o patient having this many procdures done on his neck and is low back? something is fishy, besides your technique.

i dont have a great explantion for why he had the same reaction after every procedure, although one might suspect that that there is a psychogenic component to it. does this happen if you stick i needle in his thigh?

otherwise, there are too many variables and too many medications involved to know exactly whats going on with all the different procedures. did thay all get sedation? did they all use the same corticosteroid? etc.

 

[ampaphb]

I did uneventful bilateral c3-7 mbb using posterior approach and checking needle position in lateral prior to injection. 25 g 3.5", bupivicaine 9mL 0.25% with kenalog 40mg, 1mL at each site.

I am just curious - did you really give this patient a total of 90ml of bupivicaine and 400mg of kenalog?

 

[Tenesma]

i think he means that a total of 10ml was distributed w/ 1ml at each site... and that the 10ml was bupi incl. 1ml of kenalog...

at least I hope that is what he meant.

 

[SSdoc33]

i think he means that a total of 10ml was distributed w/ 1ml at each site... and that the 10ml was bupi incl. 1ml of kenalog...

at least I hope that is what he meant.

on re-reading it, i think that is most likely what happened. that makes it better.....slightly......

 

[nvrsumr]

Pain Physician 2007; 10:425-440

Evaluation of Lumbar Facet Joint Nerve Blocks in the Management of Chronic
Low Back Pain: Preliminary Report of A Randomized, Double-Blind Controlled Trial: Clinical Trial NCT00355914

Laxmaiah Manchikanti, MD

Design: A prospective, randomized, double-blind trial.
Setting: An interventional pain management setting in the United States.
Methods: In this preliminary analysis, data from a total of 60 patients were included, with 15 patients in each of 4 groups. Thirty patients were in a non-steroid group consisting of Groups I(control, with lumbar facet joint nerve blocks using bupivacaine ) and II (with lumbar facet jointnerve blocks using bupivacaine and Sarapin); another 30 patients were in a steroid group consistingof Groups III (with lumbar facet joint nerve blocks using bupivacaine and steroids) and IV(with lumbar facet joint nerve blocks using bupivacaine, Sarapin, and steroids). All patients metthe diagnostic criteria of lumbar facet joint pain by means of comparative, controlled diagnostic
blocks.Outcome Measures: Numeric Rating Scale (NRS) pain scale, the Oswestry Disability Index2.0 (ODI), employment status, and opioid intake.
Results: Significant improvement in pain and functional status were observed at 3 months,6 months, and 12 months, compared to baseline measurements. The average number oftreatments for 1 year was 3.7 with no significant differences among the groups. Duration ofaverage pain relief with each procedure was 14.8 ± 7.9 weeks in the non-steroid group, and12.5 ± 3.3 weeks in the steroid group, with no significant differences among the groups.

Conclusion: Therapeutic lumbar facet joint nerve blocks with local anesthetic, with or without Sarapin or steroids, may be effective in the treatment of chronic low back pain of facet joint origin.

I think this study demonstrates there is no utility in using steroids for MBB. That being said I sometimes use a touch in patients with "ancient spine syndrome" and find some (the magic 30%) have relief of LBP for months after a MBB.

Also, basically same article published in Spine: SPINE Volume 33, Number 17, pp 1813–1820 Laxmaiah Manchikanti 2008

 

[PMR 4 MSK]

I am just curious - did you really give this patient a total of 90ml of bupivicaine and 400mg of kenalog?

I read it as 10 ml total - 9 bupiv, 1 kenalog, divided into Ten 1ml injections, so each MBB got 0.9 bupiv and 4 mg kenalog.

Regarding the headaches - could the anesthesia be to blame - not common I know, but sounds like all blocks were done under MAC?

 

[SSdoc33]

I've seen tons of vertebral disc/facet syndromes. Besides myself, my chiropractor (DC) always straightens em out.

Admittedly I was very skeptical at first. Then a severe car wreck screwed me up with C5-6 , C6-7 HNP. My wife sent me to her DC. He got me back into my game with specific upper cervical adjustments and axial decompression.

You can't compete with the skilled DC in these cases. Eventually many of your patients will find the DC (hopefully before the surgeon).

Think: "KISS"

Do you really believe chemistry will screw together a screwed up spine?

oy..... might i inquire as to what level of training you are at in your "MD/PhD training"?

 

[chauffeur]

I've seen tons of vertebral disc/facet syndromes. Besides myself, my chiropractor (DC) always straightens em out.

Admittedly I was very skeptical at first. Then a severe car wreck screwed me up with C5-6 , C6-7 HNP. My wife sent me to her DC. He got me back into my game with specific upper cervical adjustments and axial decompression.

You can't compete with the skilled DC in these cases. Eventually many of your patients will find the DC (hopefully before the surgeon).

Think: "KISS"

Do you really believe chemistry will screw together a screwed up spine?

In chronic pain the old spine never gets screwed together again. When people get better it's often because of a change in their own neurophysiology and pain processing. The anatomy very rarely changes and if I does, it doesn't correlate with anything.

 

[ampaphb]

I've seen tons of vertebral disc/facet syndromes. Besides myself, my chiropractor (DC) always straightens em out.

Admittedly I was very skeptical at first. Then a severe car wreck screwed me up with C5-6 , C6-7 HNP. My wife sent me to her DC. He got me back into my game with specific upper cervical adjustments and axial decompression.

You can't compete with the skilled DC in these cases. Eventually many of your patients will find the DC (hopefully before the surgeon).

Think: "KISS"

Do you really believe chemistry will screw together a screwed up spine?

Do you really believe your chiropractor (it remains offensive to me that they call themselves "doctor") altered your anatomy in anyway when he "adjusted" you? Or that any form of external mechanical "decompression" is legitimate care? If you really are an MD/PhD student (and not the chiropractic student I suspect), you should base your claims on science, rather than the voodoo the chiropractors present as the basis for their field. "Axial Decompression" (a quasi-surgical replacement term for what we all recognize is traction) is typically a cash-only series of procedures, and anyone who recommends or advocates that kind of quackery is deserving of derision.

 

[Tenesma]

i don't have a problem with chiropractors having doctorates... they do spend about 4 years in post-graduate training... PhamDs are doctors... PTs are doctors (more so recently).... Pastors are doctors of divinity... lawyers have a doctorate in law...

but neurohero... your posting is kinda lame.

 

[ampaphb]

i don't have a problem with chiropractors having doctorates... they do spend about 4 years in post-graduate training... PhamDs are doctors... PTs are doctors (more so recently).... Pastors are doctors of divinity... lawyers have a doctorate in law...

Most practitioners in the fields you make reference to do not introduce themselves as "Doctor" ____.

The typical MD has at least EIGHT years of post-graduate training.

PTs added one additional ear to their training, and now grant a doctorate rather than a masters (largely to get around direct access laws)

Lawyers used to receive LL.B.s (Bachelors Degree of Law). Comically, even though they now receive JDs, if you do an EXTRA year of sub-specialty training, you are only then granted an LL.M. (Masters Degree of Law)

 

[axm397]

I've seen tons of vertebral disc/facet syndromes. Besides myself, my chiropractor (DC) always straightens em out.

Admittedly I was very skeptical at first. Then a severe car wreck screwed me up with C5-6 , C6-7 HNP. My wife sent me to her DC. He got me back into my game with specific upper cervical adjustments and axial decompression.

You can't compete with the skilled DC in these cases. Eventually many of your patients will find the DC (hopefully before the surgeon).

Think: "KISS"

Do you really believe chemistry will screw together a screwed up spine?

Neuro hero, funny how 4 out of your 5 posts on sdn are all about chiros being great yet you claim to be a practicing physician on some of the other forums. Chiropractic care has its place and there are some ex-DCs here on this forum who have or will become excellent physiatrists but it's not a cure-all like anything else in medicine.

 

[drrinoo]

Interesting case for me today and the first time I've seen this issue. 25 yom, thin, healthy, 6'3 200#. Referred by another pain management doc for cervical mb rfa. Neck pain for many years, axial; "burning" pain in axial neck, radiates from cervical area to occipital and frontal areas. He does have radiation from axial neck to supraspinous area to shoulder in C5-6 distribution with occasional muscle spasm. Pain is constant, but exacerbated by any type movement especially after long workday as lawn maintenance contractor. Pain level 5-9/10 varies with activity. Heat helps, PT no benefit. NSAID helping. Patient attributes onset of neck pain to working with horses and various falls while working, but no definitive injury. Neuro exam normal, non-focal. MRI shows small central osteophyte and focal disc protrusion with "borderline central canal stenosis," C7-T1 small right paracentral disc extrusion behind inferior endplate of C7 but no nerve root compression, small left T1-2 paracentral disc extrusion. Cervical Myelogram shows spur at T1-2 with symmetric filling of nerve root sleeves throughout cervical spine, a shallow right C7-T1 disc protusions without foraminal compromise; and left T1-2 disc/spur flattening the left anterior cord. The other pain doc has performed 3 cervical esi's at C7-T1 and C6-7 with benefit for 2-3 days each. He had right then left C3-4 and C4-5 facet injections with benefit for two weeks 60-70%. Bone scan Cspine normal. No RA, lupus, spondyloarthropathies in family, and patient's sed rate, ANA, HLAB27 normal. Positive rheumatoid factor at 17. Non-ttp over the GON and LON bilaterally without radiation. Ttp over the facets, positive facet load. Negative spurling's. Normal reflexes bue. Normal heel-toe, normal gait. Tender points throughout cervical musculature but no trigger points or spasm. Has h/o low back pain but I don't have the full history or imaging there.

Patient warned me prior to procedure that he has severe HA following each cervical esi and facet injection. After the history, PE I did uneventful bilateral c3-7 mbb using posterior approach and checking needle position in lateral prior to injection. 25 g 3.5", bupivicaine 9mL 0.25% with kenalog 40mg, 1mL at each site. He had versed 2mg, fentanyl 100mcg, propofol. Then, postop (immediately upon awakening in PACU) he grabs frontal area and starts moaning before he can even communicate fully. Appeared to be legit, toxic-appearing. HA radiates from occipital to frontal area, "whole head." BP normal. Vitals normal. After boat load of opioids and phenergan, pain level improves to tolerable 5/10. I call the other surgery center where his previous blocks were performed and they confirm that after all the prior blocks he has had severe HA, and they have usually given morphine 20 mg, demerol 25 mg, dilaudid 1mg if necessary, 12.5 phenergan. Patient has had lumbar esi's, mbb's previously without significant headache postoperatively.

I know this may be routine for some of you, but I haven't seen this previously. Any ideas regarding the headache? I asked all the usual questions about opioid abuse but patient appears to be legit, wife confirms everything. He takes lortab 7.5, one tablet daily after working all day. No tattoos, dresses well, pupils normal/reactive, no track marks.

Interesting case for me today and the first time I've seen this issue. 25 yom, thin, healthy, 6'3 200#. Referred by another pain management doc for cervical mb rfa. Neck pain for many years, axial; "burning" pain in axial neck, radiates from cervical area to occipital and frontal areas. He does have radiation from axial neck to supraspinous area to shoulder in C5-6 distribution with occasional muscle spasm. Pain is constant, but exacerbated by any type movement especially after long workday as lawn maintenance contractor. Pain level 5-9/10 varies with activity. Heat helps, PT no benefit. NSAID helping. Patient attributes onset of neck pain to working with horses and various falls while working, but no definitive injury. Neuro exam normal, non-focal. MRI shows small central osteophyte and focal disc protrusion with "borderline central canal stenosis," C7-T1 small right paracentral disc extrusion behind inferior endplate of C7 but no nerve root compression, small left T1-2 paracentral disc extrusion. Cervical Myelogram shows spur at T1-2 with symmetric filling of nerve root sleeves throughout cervical spine, a shallow right C7-T1 disc protusions without foraminal compromise; and left T1-2 disc/spur flattening the left anterior cord. The other pain doc has performed 3 cervical esi's at C7-T1 and C6-7 with benefit for 2-3 days each. He had right then left C3-4 and C4-5 facet injections with benefit for two weeks 60-70%. Bone scan Cspine normal. No RA, lupus, spondyloarthropathies in family, and patient's sed rate, ANA, HLAB27 normal. Positive rheumatoid factor at 17. Non-ttp over the GON and LON bilaterally without radiation. Ttp over the facets, positive facet load. Negative spurling's. Normal reflexes bue. Normal heel-toe, normal gait. Tender points throughout cervical musculature but no trigger points or spasm. Has h/o low back pain but I don't have the full history or imaging there.

Patient warned me prior to procedure that he has severe HA following each cervical esi and facet injection. After the history, PE I did uneventful bilateral c3-7 mbb using posterior approach and checking needle position in lateral prior to injection. 25 g 3.5", bupivicaine 9mL 0.25% with kenalog 40mg, 1mL at each site. He had versed 2mg, fentanyl 100mcg, propofol. Then, postop (immediately upon awakening in PACU) he grabs frontal area and starts moaning before he can even communicate fully. Appeared to be legit, toxic-appearing. HA radiates from occipital to frontal area, "whole head." BP normal. Vitals normal. After boat load of opioids and phenergan, pain level improves to tolerable 5/10. I call the other surgery center where his previous blocks were performed and they confirm that after all the prior blocks he has had severe HA, and they have usually given morphine 20 mg, demerol 25 mg, dilaudid 1mg if necessary, 12.5 phenergan. Patient has had lumbar esi's, mbb's previously without significant headache postoperatively.

I know this may be routine for some of you, but I haven't seen this previously. Any ideas regarding the headache? I asked all the usual questions about opioid abuse but patient appears to be legit, wife confirms everything. He takes lortab 7.5, one tablet daily after working all day. No tattoos, dresses well, pupils normal/reactive, no track marks.

From a physiological standpoint, the caudal subnucleus is involved as is the case for most headache disorders since it receives sensory afferents from the upper cervical nerve roots and the intracranial dura (via V1). It would be a stretch to say the RF or cervical mbb affected the sensory input to the caudal subnucleus and led to the headache---but from a physiological standpoint this is the most likely culprit.

As far as criticisms your technical approach (on this forum), the ISIS guidelines stand true only if you exclusively believe in an anatomic model of neck pain (the Cartesian approach from the 1600s). In fact the use of 0.3 ml is based exclusively on a very narrow view of anatomy--the minimal amount of volume to prevent egress into the spinal canal or onto the cervical spinal nerve

But is 0.3 ml actually more than necessary?
There are 2 ways to look at this

1. A segment of the cervical medial branch is probably 3-4 mm in length and may be about 0.5mm in diameter---> using pi*r(2)*h (volume of a cylinder)..this volume would be:
about 0.6 mm (cubed) or about 0.6 x .001 cm (cubed) or .006 ml.
So, 0.3ml would be too much.

2. If the cervical medial branch may contain on the order of magnitude 500000 axons and since you only need to block 3 nodes of ranvier per axon to get a conduction block....you would have to calculate the number of milligrams of a sodium channel blocker (lidocaine) that would be necessary to lead to an effective conduction block. 0.3 ml of 1% lidocaine is 3 mg. I don't know if this is too much or too little.

In any event, the regional anesthesia literature uses a stair case method (adjusting the dose up or down based on the response of the last patient) or sequence allocation to determine the minimun effective analgesic concentration or dose for regional blocks. This has not been done in cervical mbbs (a peripheral nerve).

Also, if you believe in a chronic neurobiological disease framework of neck pain (Curatolo) then it is virtually impossible to diagnose neck pain based on an anatomic model.

So to criticize the poor fellow for using 1 cc of lidocaine for cervical mbb may be valid....but a scientific approach should be used---the ISIS guidelines are not grounded in science (outside of anatomy). And the anatomic construct of neck pain has way to many holes to be meaningful in the interpretation of diagnostic blocks

 

[nvrsumr]

So to criticize the poor fellow for using 1 cc of lidocaine for cervical mbb may be valid....but a scientific approach should be used---the ISIS guidelines are not grounded in science (outside of anatomy). And the anatomic construct of neck pain has way to many holes to be meaningful in the interpretation of diagnostic blocks

What a great post. Too little science in pain medicine for so much dogma. Though Im sure some needle(self proclaimed) gurus could block the MBs with 0.006 ml lido every time!

 

[Tenesma]

while I appreciate DrRinoo's thoughts.... there are some fundamental issues though

1) volume for injectate:... clearly the nerve does not have a volume of 0.3ml... however, equating volume of a nerve with volume of injectate doesn't correlate clinically...

You are going to inject enough medication to cover the area that needs to be blocked without having that injectate affect other important structures. I find that injecting 0.3ml of contrast (albeit more viscous) rarely if ever extends towards the foramen or very far lateral once you are on os.

2) your statement regarding diagnosing (or the inability to diagnose) neck pain based on an anatomical model is erroneous.... there are few pain syndromes with good studies - cervical medial branch studies are so far the best we have. If i have a patient with neck pain and headaches and i block the third occipital nerve with 0.3ml and they report 95-100% relief within a few minutes and that relief is reproducible with a 2nd block, and that relief is maintained for >6 months after a neurotomy (and this thought process is supported in the literature) then how can you say that the neck pain is NOT based on an anatomical model? what model are you referring to as being more appropriate?

 

[ampaphb]

Whenever Dr. Shah contributes to this forum, I am reminded of how little I know.

Curatolo's chronic neurobiological disease framework of neck pain is central hypersensitization, for we mere mortals.

Also, as Drrinoo theoretically does these procedures as part of his practice, I am curious if he would care to describe, given all the limitations of the model, what parameters he uses to determine if it is reasonable to move forward with RF after MBBs.

 

[PainMD23]

Patient called back. No relief during the 12 hours post-injection, no relief the following day. Physiatrist is asking for rheum consult.
To answer a few questions--1 mL total (0.9mL bupiv 0.25%) per level.
Concerning the steroid with mbb: Sometimes during my fellowship these mbb's became "therapuetic" with patient describing 3 months relief. Granted these patients were the minority. Obviously placebo response could be playing a role, and I freely admit that there is scant scientific evidence for adding steroid to mbb. However, we were able to avoid RFA in many patients by performing these "therapeutic" mbb's every 3-6 months. If patient is getting >50% relief for 3-6 months, why RF? There is always chance of neuroma, and the mb becomes harder and harder to rf after 4-5 previous rf's. I don't use steroid in every mbb. This patient, however, had experienced severe post-op headache with each previous cervical block and had modest benefit following cervical facet (granted, I did not do these prior blocks but per report). I decided to use steroid hoping that this mbb would become "therapeutic," and possibly avoid future rf and further procedures. Concerning the sedation for the procedure, he had received midazolam and fentanyl for prior cervical procedures. The patient reported that he had received IV meds to break the headache post-op with his last few injections, and that the anesthesiologist had given him something during the procedure to prevent ha. Therefore, I ok'd the fentanyl for the procedure based on the prior post-op ha's. It was my belief that I would be able to evaluate the patient post-op despite the fentanyl and versed. Patient was extremely anxious regarding the procedure, and although it is not usual policy, I ok'd judicious use of propofol for the mbb knowing that it has very quick on/off effect and that patient would likely tolerate procedure much better with it. I also felt that severe anxiety may have played a part in his prior ha's, and I wanted to remove that factor. I felt that I could do the procedure quickly and safely with the sedation, and that perhaps he would avoid ha.
Unfortunately due to the meds he received post-op for the ha, I was unable to immediately assess response to mbb. However, patient completed pain diary once home and the next few days. He and his wife concluded no benefit.
I have changed my practice following the discussion here. Yesterday I used volume at 0.4mL bupiv 0.5% per cervical mbb. I used contrast as suggested at 0.3mL and see that it spreads quite nicely in the target area. I will continue to use midazolam and small quantity of fentanyl for sedation. Thanks for all of your feedback...except the "you are an idiot" response above. I guess the anonymity of the internet allows us to lose our decorum and civility?

 

[lobelsteve]

Thanks for all of your feedback...except the "you are an idiot" response above. I guess the anonymity of the internet allows us to lose our decorum and civility?

I didn't call you an idiot (but I thought I did so I wrote this post and then checked the posts) and I've got my name and website listed with each post.

I do appreciate your flexibility and ego checking ability to modify your technique and take counsel from a collection of generally nice and knowledgeable folks. It is a rare trait in a Pain Specialist.

All you need in this field is a love for anatomy and to sincerely care for the individual in front of you in the exam room every day. The rest just falls into place.

Right patient, right procedure, right time- everybody wins.

 

[PainMD23]

Not referring to your post but the "fool" comment by someone else above

 

[Tenesma]

i think you are referring to my post... while I am glad that you are open to constructive suggestions, I still stand by my inital point... it takes a fool to make anytype of RF decision (which is what that patient was referred to you for), based on a bilateral C3-C7MBB.

One of the things that hurts our field is when we apply new(er) technologies without fully understanding the basic concepts behind it and the implications of what we do...

just look at how we single-handedly killed IDET...

if you are offended by my posting, then you shouldn't EVEN dare share your initial post w/ Dr. Aprill or Dr. Bogduk... they'd have convulsions...

 

[Tenesma]

actually, on second thought, you are right... i shouldn't have used the word fool.

i apologize.

 

[drrinoo]

Whenever Dr. Shah contributes to this forum, I am reminded of how little I know.

Curatolo's chronic neurobiological disease framework of neck pain is central hypersensitization, for we mere mortals.

Also, as Drrinoo theoretically does these procedures as part of his practice, I am curious if he would care to describe, given all the limitations of the model, what parameters he uses to determine if it is reasonable to move forward with RF after MBBs.

Thanks for the feed back.

There is no doubt that interventional pain specialists have to follow some sort of algorithm based on their understanding of neck pain. However, we bought the anatomic model lock, stock, and barrel--it has been a good model over the past 25-30 years and it has served spine surgeons well, for longer periods. I recognize that in the absence of an anatomic model, we may open the flood gates with respect to utilization and the introduction of sham procedures.

The neurobiology of pain is so complex and the manifest behaviors of pain patients even more complex (analogous to a higher Cantor infinite set)....that a pain practitioner could not use this in any practical sense and this can lead to the creation of untestable theories of pain, e.g., traditional chinese medicine, chiropractic models of pain, psychological theories of pain, anatomic (Cartesian) theories of pain, ad nauseum....since these theories are untestable, each and every practitioner could stand on firm ground and say that their interventional approach is the best.

These are dangerous grounds to stand on....and rife for abuse.

But we are pain specialists, first. We study central sensitization for the boards, but it does not mean we should discard it in practice. Most of the folk making inroads in neurobiology are not interventionalists--so we interventionalists get a pass from these scientists and we can debate all day long about anatomy and by proxy the best anatomist is the best interventionalist. Every day, however, we see patients that don't fit an anatomic model--most of them do not fit (unless you select them out of your practice, e.g., 'I only see monoradicular pain due to a paracentral disc herniation' specialist). Pain patients present disconfirming information and challenge our anatomic model. So, the scientific process is to continually re-evaluate our anatomic model; however, to blame a patient for not fitting anatomy and calling them 'poor historians', 'malingerers', 'work comp', 'supratentorial', 'somatoform disorder'....is not scientific.

So, use the anatomic approach--but don't be dogmatic about it (to paraphrase an above poster)---since this is not scientific

In any case, here are some problems with anatomy and clinical practice (diagnostic blocks):


Case A. Young healthy non smoker--no history of neck pain--falls and develops neck pain and right sided painful dyesthesias going down to the thumb; this pain has been present for two weeks. The pcp sent the patient for an mri and it shows a right c5-6 foraminal hnp. The pcp sent the patient for an emg and it showed a right c6 radiculopathy. You see the patient and the patient has mild asymmetry in the right biceps reflex and good motor strength. Conservative treatment has failed.In this patient, a diagnostic c6 snrb will almost certainly be 100% concordant to the aforementioned findings. So, in this clear cut anatomic problem the diagnostic block will demonstrate high concordancy but it will have the lowest diagnostic yield--since we know where the problem originated.

Case B. On the other hand, a patient who is obese, smoker, 7-8 year history of chronic neck pain and arm pain, evaluated by multiple specialists, multiple injections, on chronic opioids, major depression, and anger......mri with multilevel ddd, multilpe disc bulges, etc....In this patient, a diagnostic snrb will have a very low yield (lack concordancy) ---yet in this patient a diagnostic test would have the highest value.So in patients with clear cut anatomic problems---a diagnostic block would have high concordancy but low yield; In patients with non-anatomic problems, a diagnostic block would have low concordancy but potentially have the highest value.

So, how do you choose which patient gets a diagnostic block.

Would reducing the volume of local anesthetic improve the diagnostic accuracy in Case A vs. Case B? Or do we say that our anatomic model fits Case A, and we must ignore Case B (even though Case B represents the more typical scenario in an unselected population of pain patients).

I have not witnessed any other diagnostic test in the field of medicine that has been so heavily influenced by external factors.

Hence reducing the volume of local anesthetic to reduce false positives for cervical mbbs (or other diagnostic blocks) seems very tempting, but it may not improve diagnostic accuracy in the general population.

In fact, while we debate these issues...Dr Carragee has recently published a paper stating that we cannot even rely on the patient to tell us an accurate history....so, by proxy, can we truly assess 20% vs. 80% pain relief?

I don't have the answers, but I do believe practitioners have to slowly challenge the anatomic approach.

 

[Tenesma]

you make some good and appropriate points...

but to date, the anatomic model has the most consistency...

 

[lobelsteve]

I see my job as the following:

I have to match the history to the exam to the imaging/EMG/vascular/bloodwork

When there is concordance, I am better able to have success.
When there is discordance in 2 or 3, I am better able to offer hope.
When there is discordance in 3 of 3, I am better able to offer a referral.

My success rate for group 1 is 95%.
My success rate for group 2 is 75%.
My success rate for group 3 is 25%

It is much more frustrating failing a group 1 patient than a group 3 patient.
It is much more rewarding helping a group 3 patient than a group 1 or 2.

Group 3 patients utilize more medication, procedures, labs, modalities and seem destined to fail. But for that 1 in 4, the chance of getting off the downward spiral and back into work/family/social reintegration and their formal lives is as good as it gets for me.

Based on Dr. Rinoo's post: Group 1 fits the anatomic model and typically gets better with no care, minimal care, or any care provided. Group 2 will get some better or all better, but it takes more work (healthcare dollars). Group 3 is unlikely to get better based on the anatomical model because they have become "Ben's Babies*". Chronic pain that maybe once fit the anatomic model but has become so clouded by myofascial and neuropathic overlay, psychological factors, depression, personality disorders, and a society that allows for this and even fosters this (WC/MC/Mcaid). Peripheral and central sensitization happens. And the best we can do at this time is throw a bunch or 5HT, NE, Gaba, alpha-2, etc agents in the mix and hope. We may embrace the anatomic model and hopefully embrace the histologic model when the research in neurobiophysiology catches up to our patients' needs.

* Ben Crue " The Myth of Chronic Pain"

From a Crue interview:

How do you view current U.S. pain treatment?

Anesthesiologists have taken over recent treatment of chronic pain. While anesthesiologists are very good at dealing with acute and post-operative pain, I view their treatment of chronic pain as a catastrophe. This is based largely on their adherence to a peripheralist, nociceptive model. Fortunately, a few healthcare professionals in many different specialties are gradually accepting the central factors in chronic pain.


I really should be sleeping.

 

[ampaphb]

Case A. Young healthy non smoker--no history of neck pain--falls and develops neck pain and right sided painful dyesthesias going down to the thumb; this pain has been present for two weeks. The pcp sent the patient for an mri and it shows a right c5-6 foraminal hnp. The pcp sent the patient for an emg and it showed a right c6 radiculopathy. You see the patient and the patient has mild asymmetry in the right biceps reflex and good motor strength. Conservative treatment has failed.In this patient, a diagnostic c6 snrb will almost certainly be 100% concordant to the aforementioned findings. So, in this clear cut anatomic problem the diagnostic block will demonstrate high concordancy but it will have the lowest diagnostic yield--since we know where the problem originated.

This is a straw man argument - afterall, if we already are fairly certain of the diagnosis, then we can be confident that the therapeutic componennt of the transforaminal or interlaminar epidural steroid injection should also provide relief. Very little of what we do is purely diagnostic, and the only folks I know who do cervical SNRBs do them for surgeons during their pre-operative work-up.

Would reducing the volume of local anesthetic improve the diagnostic accuracy in Case A vs. Case B? Or do we say that our anatomic model fits Case A, and we must ignore Case B (even though Case B represents the more typical scenario in an unselected population of pain patients).

Furman recently confirmed that all injections of greater than 0.5cc are non-selective. Reducing the volume to less than 0.5cc seems non-productive.

However, our original topic of discussion was MBBs, not SNRBs. In that setting, what can be safely said is that, if you use a large amount of volume of contrast, it clearly spreads beyond the target area, and thus can not be said to be specific. When the needle is targeted properly, 0.3cc of contrast seems sufficient, in my experience, to cover the area where the nerve generally lies.

Whether we like it or not, evidence based medicine is going to be the basis of what is and is not paid for by insurers. Medicare's recent determination not to cover intra-discal thermal technologies is a case in point. Pain is clearly an field fraught with subjective responses, but many other fields employ similar measures to justify what they do. Until any of the alternate hypotheses are subjected to the scientific rigors the "anatomic model" has been and currently is, they are nice theories, but nothing more.

Dr. Rinoo harped on non-radicular pain patterns, when he knows that facets have a consistent pain referral pattern all their own which has been documented, both by Slipman a while back, and Cooper more recently. Patients who do not fit known pain referral patterns are not, as Dr. Shah suggests, labeled "poor historians', 'malingerers', 'work comp', 'supratentorial', or 'somatoform disorder' in the absence of supporting data (i.e. documenting a DRAM). Instead, they are appropriately described as suffering pain in a non-anatomic distribution.