Upper cervical pain and headaches

IPSIS: Formerly the Spine Intervention Society
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Aether2000

Aether2000

algosdoc
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Saw a former pro baseball player sent to me by a neurosurgeon for "C6/7 and C7/T1 facet blocks". The guy is an avid bicyclist and has had some upper neck pain since his pro pitching days 20 years ago but 4 months ago developed a sudden onset severe right upper neck pain with severe rotational limitation to 10 deg either direction of midline. No radicular pain, no tenderness appreciated over any facet, and loading maneuvers did not replicate the pain. The MRI report stated he had a C6/7 level DDD with facet hypertrophy. On viewing the MRI personally, a different picture emerged: a collapsed right C1/2 joint with bone edema in both the atlas and axis adjacent to the joint that had a posterior overlying osteophyte and internal joint irregularity with loss of articular cartilage. Did an AA injection right side only, no skin or muscle anesthesia, and used a 25ga quincke tip needle initially aiming for the lateral 1/3 of the joint. Tip could not enter the joint due to the overhanging C-1 osteophyte so moved the tip medially to the mid point of the posterior joint. Could not enter the joint and advance as usual over the convexity of the joint but was able to inject 1/4 ml of bupivicaine 0.5% plus triamcinolone 2.5mg into the joint capsule only. The patient obtained 90% instant relief.

So now what? I have in the past (on other patients) tried RF of the intraarticular and posterior capsule and C2DRG without success for denervation of this joint. He is too young for a C1-2 fusion.
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one observation, 2 comments.
1. i had a guy like this once who had in the past >10 C1-2 steroid injections (his doc left for Oregon). he wanted another. i did one or two, cannot recall how well they worked. i then did a trigger point injection in traps. patient had 100% relief for 6 months. we continued triggers after that.
2. your patient's C1-2 joint is trashed. this is a new finding. it is possible he has a rheumatologic disease for example lupus or RA. suggest obtaining rheumatology consult before proceeding. might go over imaging with an academic radiologist, sometimes they can see evidence of an active arthritis.
3. if further work up is negative, and patient is having a lot of pain at rest, i would not completely rule out a fusion. it will be a long time before it auto-fuses.
 
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How about at least an attempt at TON blocks.

I usually prefer to almost always rule out TON before moving higher up in the spine
 
Will try to post fluoro pics when I go back to the office (I work only one out of three weeks now). My hope was to find a long term solution....may not be possible.
 
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He is too young for a C1-2 fusion.

How old is he?
 
I've never attempted it, but Way Yin worked out a way to RF the C1-2 joint. I don't know if he still does the procedure or not. Could also pulse RF the joint. Both have minimal literature. I agree r/o some sort of rheum process.
 

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The baseline condition appears to be chronic given the history of 20 years as a pitcher with eccentric force vectors operating during standing with the head rotated 80 degrees and forces applied to the joint during the follow through. There was no other significant trauma in his life. However with the sudden onset of the acute on chronic pain and sudden limitation of rotation of the neck, it is possible he has a rheumatic (or infectious) process resulting in joint inflammation on the right side with auto-fusion. Thanks for the ideas!!! I will post pics when I get back to work.
 
algosdoc said:
The baseline condition appears to be chronic given the history of 20 years as a pitcher with eccentric force vectors operating during standing with the head rotated 80 degrees and forces applied to the joint during the follow through. There was no other significant trauma in his life. However with the sudden onset of the acute on chronic pain and sudden limitation of rotation of the neck, it is possible he has a rheumatic (or infectious) process resulting in joint inflammation on the right side with auto-fusion. Thanks for the ideas!!! I will post pics when I get back to work.
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Biomechanicallly that makes lots of sense Algos.
 
Great case... thanks for sharing. I've been thinking about doing C1-2 injections on a couple patients but have been too chicken. Maybe now I'll try it
 
WAY more dangerous than an CTFESI.
 
Hmmm....if the needle tip is inside the joint during injection probably not if there is a tortuous vertebral artery you may transsect it. Most of the vasculr structures i see at the posterior joint space introitus are venous. And there is that cord thingy if you are excessively medial with the tip....
 
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bedrock said:
This is based on what comparative study?

I expect it's only based on your disbelief in IPM in general.
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Medial to the VA lateral & deep to the cord. This is the most dangerous
injection.
 
101N said:
Medial to the VA lateral & deep to the cord. This is the most dangerous
injection.
Click to expand...

Certainly C1-C2 injections carry plenty of risk, but your bold proclamations that C1-C2 injections are "riskier that CTFESI", or "the most dangerous injection" have no scientific backing.

I'm well aware of the anatomy and you aren't any closer to the cord with a C1-C2 injection than you are with a typical cervical ILESI, and in contrast to CTFESI vascular studies in which the vertebral and radicular arteries around the C3-C7 foramina have been shown to often vary significantly in location, the VA at C1-C2 is consistently lateral to C1-C2.

I'll say it again------- C1-C2 injections carry plenty of risk, but your bold proclamations that C1-C2 injections are "riskier that CTFESI", or "the most dangerous injection" have no scientific backing.
 
bedrock said:
Certainly C1-C2 injections carry plenty of risk, but your bold proclamations that C1-C2 injections are "riskier that CTFESI", or "the most dangerous injection" have no scientific backing.

I'm well aware of the anatomy and you aren't any closer to the cord with a C1-C2 injection than you are with a typically cervical ILESI, and in contrast to CTFESI vascular studies in which the vertebral and radicular arteries around the C3-C7 foramina have been shown to often vary significantly in location, the VA at C1-C2 is consistently lateral to C1-C2.

I'll say it again------- C1-C2 injections carry plenty of risk, but your bold proclamations that C1-C2 injections are "riskier that CTFESI", or "the most dangerous injection" have no scientific backing.
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I have to agree with this. Plenty of risk, but to proclaim the riskiest is a big step.
 
It's the riskiest anatomy, far and away. But, it is an injection that is infrequently performed, thus
it likely isn't the one leading to the most morbidity.
 
101N said:
It's the riskiest anatomy, far and away. But, it is an injection that is infrequently performed, thus
it likely isn't the one leading to the most morbidity.
Click to expand...

101n,

I love how you just put your head in the sand and just keep repeating whatever you have chosen to believe, without trying to come up with a scientific or anatomical way to refute my stated disagreement with your previous point.
I hope this "scientific method" doesn't carry over to your CS theories.

Please prove to me scientifically how the C1-C2 injection is the riskiest injection compared to all other injections. Remember, we all agree that is it's a risky injection, however no one else on this board is saying that it's the "riskiest injection of them all"
 
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bedrock said:
101n,

I love how you just put your head in the sand and just keep repeating whatever you have chosen to believe, without trying to come up with a scientific or anatomical way to refute my stated disagreement with your previous point.
I hope this "scientific method" doesn't carry over to your CS theories.

Please prove to me scientifically how the C1-C2 injection is the riskiest injection compared to all other injections. Remember, we all agree that is it's a risky injection, however no one else on this board is saying that it's the "riskiest injection of them all"
Click to expand...

I keep my eyes open the whole time when doing this injection. I think that definitely reduces its riskiness.
 
How many surgeons you that you know - if you know any - perform C1/C2 fusions? Not many, even though C1/2
spondylosis is a well known cause of morbidity.Why, the anatomy is dangerous a pedicle screw in a VA is a bad thing.
The same applies to people sticking a needle there. If you do, and you have a bad outcome, you will have a slew of
experts to skewer you on the stand. Much, much riskier anatomy than a simple CTFESI, at least there you aren't
placing the needle VENTRAL to the cord in AP fluoroscopy.

Imagine being on the stand when the expert is showing the jury the anatomy involved in this injection: "So you see
ladies and gentleman of the jury that my needle is passing right past the spinal cord and right next to the vertebral
artery, if I hit either we could have a catastrophe. And given that there isn't any data to suggest that the injection
provides either meaningful diagnostic or symptomatic relief, was it worth it? Moreover, did Dr. X inform the
plaintiff of the risks - death, quadraparesis, stroke - of this procedure should it go south?"
 
Surgeons typically offer c1-c2 fusions for trauma but not elective cases, it's true. Because the VA and other vessels are more at risk during C1-C2 screw placement than your typical ACDF, as the surgical technique is rather different.

Any catastrophic outcome after a CTFESI or C1-C2 injection will often result in lawsuit, so that doesn't prove your point at all.

We can agree to disagree, but you haven't proven (at all) that C1-c2 injections are "the riskiest injection" and by extension, riskier than CTFESI.
 
Ligament said:
I read this article, and it does not state the mechanism of injury. Was the VA injured, or did the patient have an idiopathic stroke on the table? It can happen. I had an ICU nurse patient have an MI on the table during a CESI...unrelated...patient did fine.
Click to expand...

True. I had a patient in their early sixties suffer a CVA 5 minutes into a lumbar RFA. Unrelated to procedure, thankfully she eventually had minimal post CVA deficits.
 
My patients are informed of these risks with every spinal area injection and i do agree this is an important part of the process. Sticking the cord normally results in minimal deficits as long as nothing is injected. Pithing the vertebral artery may cause plaque dislodgement, spasm, dissection, but may result in nothing at all. Injecting particulates into this artery is universally a bad thing based on sheep studies. So yes, there are definitely serious risks. Slow advancement of a small diameter needle in a quiet field with attention to detail with knowlege of the fine anatomy provides the optimal chance for a good outcome. However, there is risk!
 
surprised you didnt consider(yet) a regenerative procedure. The torque of pitching and hitting repetitively over decades takes it's toll....ask me how i know
 
1991-UD-ToddVanPoppel-286x400.jpg

Could it be?
 
Doctodd said:
surprised you didnt consider(yet) a regenerative procedure. The torque of pitching and hitting repetitively over decades takes it's toll....ask me how i know
Click to expand...

College ball?

What injuries? Labral Tear?
 
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