ISIS guidelines and algorithm for cervical MBBs/anterior joint injections

[Disciple]

The ISIS guidelines advocate blocking the cervical facet joints in a step-wise approach, 1 level at a time, based on the probability that a given level is painful (statistically speaking and per the facet pain referral map by Aprill et al), until a positive response is found or there is good reason to cease investigations.

In clinical practice, with many patients I have one, maybe two opportunities to block the cervical facet joints and hopefully identify the painful level(s).

The thought process I currently use when selecting levels to block:

1. Headache as a major component of neck pain (block C2/3 and often C3/4) 4/5 depending of the pain referral map by Aprill et al.

2. Tenderness at upper cervical paraspinals, pain worse with flexion, or pain worse with rotation after the spine is locked out in full flexion at the OA joint, headache and possible whiplash injury (OA and AA joints).

3. Pain worse with extension, lower cervical paraspinals, radiates to scapulae, headache +/- (block C6/7 and C5/6) C4/5 per facet pain referral map.

Anyone care to share their cervical facet/anterior joint algorithm (given the condition that you may only have one, at the most two opportunities to inject the patient)?

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[lobelsteve]

The ISIS guidelines advocate blocking the cervical facet joints in a step-wise approach, 1 level at a time, based on the probability that a given level is painful (statistically speaking and per the facet pain referral map by Aprill et al), until a positive response is found or there is good reason to cease investigations.

In clinical practice, with many patients I have one, maybe two opportunities to block the cervical facet joints and hopefully identify the painful level(s).

The thought process I currently use when selecting levels to block:

1. Headache as a major component of neck pain (block C2/3 and often C3/4) 4/5 depending of the pain referral map by Aprill et al.

2. Tenderness at upper cervical paraspinals, pain worse with flexion, or pain worse with rotation after the spine is locked out in full rotation, headache and possible whiplash injury (OA and AA joints).

3. Pain worse with extension, lower cervical paraspinals, radiates to scapulae, headache +/- (block C6/7 and C5/6) C4/5 per facet pain referral map.

Anyone care to share their cervical facet/anterior joint algorithm (given the condition that you may only have one, at the most two opportunities to inject the patient)?

Windsor's algorithm includes eithe high or low facets depending on timing, location, mechanism, and radiation of symptoms.

High = C3,4,TON
Low = C4-7

Pillar views, waist of the bone. 0.5cc per level, double diagnostic paradigm, 70% or better to advance to the next injection and then to RF.

 

[Mister Mxyzptlk]

What happened to C1/2? Doesn't anyone inject those besides me? IMHO that's a prime cause of occipital headaches (either directly through referral pain or indirectly through muscle spasm -> irritation of GON).

Step-wise injection by levels is fine if you have a patient who doesn't have a life. Otherwise you are chewing up someone's sick days. I round up the usual suspects and do more than one level at a time. You have to be practical.

Typically I mark the skin over the point of maximum tenderness and then inject the joint directly below that and then the ones above and below. In photography that's called bracketing exposures. If it's good enough for Ansel Adams it's good enough for me.

 

[Disciple]

That's what I've been getting at. How do you typically group your cervical facets/anterior joint syndomes with associated headache? ISIS Guidelines say that AA and OA are low probability for headache compared to C2/3.

C2/3, 3/4 first?

OA and AA first?

C2/3, OA and AA all at once?

So far I've only been able to differentiate through physical exam and occasionally history (if there is a mechanism of injury) as listed above.

At a recent ISIS radiology course one of the instructors recommended putting ATTN: craniocervical junction on cervical MRI requests to get a comment on the upper facet and anterior joints. I've since started doing this.

 

[Mister Mxyzptlk]

I group them as:

C1/2 and C2/3, +/- C3/4 (upper neck, occipital, usually tender at level of mastoid process)

C3/4 through C5/6, +/- C6/7 (mid-lower neck, most wear & tear, usually neck & shoulder pain, some headache sx usually due to spasm)

C7/T1 +/- C6/7 (tends to be below the "neck" and associated with computer users who hunch forward and cock their head back to look at the screen, or with people who read sitting up with their neck flexed, looking down at the book. I think headaches from this area are almost always due to muscle spasm.)