Pain in neck and shoulder after posterior fusion

[PinchandBurn]

You guys know the patient

has had posterior fusion. Lots of scarring in the center of the spine. TPI dont work or only transient.

SCS is not an option d/t epidural scar likely.


Any of you guys do peripheral stim? What nerves are you blocking? Suprascapular or Supraclavicular or both?

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[willabeast]

I would first get a good history and try to figure out if he could modify his behavior and if this is a new pain or not. If that fails would try low dose of a TCA. If TCA fails Gabapentin HS. All this with permission from PCP first. If that fails turmeric. If that fails diagnostic facet above or below fusion or both. Peripheral stim is not going to help nor peripheral nerve blocks unless there is more to the story.

 

[PinchandBurn]

I would first get a good history and try to figure out if he could modify his behavior and if this is a new pain or not. If that fails would try low dose of a TCA. If TCA fails Gabapentin HS. All this with permission from PCP first. If that fails turmeric. If that fails diagnostic facet above or below fusion or both. Peripheral stim is not going to help nor peripheral nerve blocks unless there is more to the story.

Most of those meds tried. Has scarring badly extenerally.

Fusion from C3-7 so cant really do cervical MBBs...

Botox helps but transisently. Pt seems legit. UNfortuntaely had bad outcome after surgery. has good social support,etc

 

[callmeanesthesia]

C2-3 and C7-T1 MBB/RFA? I don’t see why not at least try it. Doesn’t seem to do all that great in this population but I have some where it helps. Botox maybe?

 

[GlowInTheDark]

Some patients need opioids.

 

[Tramadeezy]

Retrograde C2 SCS paddle by a good Neurosurgeon.

 

[Taus]

Topicals. Pills. Tens. Manual soft tissue treatments with PT/DC.

 

[Laryngospasm]

I hate seeing these patients because it seems like nothing helps them. Medication including opioids if necessary, tpi, mbb/rfa help sometimes. Would like to try Botox on some of them if insurance approved. Most of my patients don’t have the money to pt for Botox.

 

[Orin]

Low risk, I would check out the cervical SPR PNS. Stim the axial neck musculature aiming at the facet joint in the middle of the fusion.

Workup wise, NM bone scan overlaid on a CT C-spine or a formal CT-SPECT of the neck to see if there is a bony fusion issue. Sometimes see a hot facet joint that is not really fused and may respond to IA steroid. The usual referral patterns suggest that the pain should be from fused region but sometimes they're wrong.

 

[Agast]

I would first get a good history and try to figure out if he could modify his behavior and if this is a new pain or not. If that fails would try low dose of a TCA. If TCA fails Gabapentin HS. All this with permission from PCP first. If that fails turmeric. If that fails diagnostic facet above or below fusion or both. Peripheral stim is not going to help nor peripheral nerve blocks unless there is more to the story.

Why is your algorithm TCA-> gabapentin-> turmeric

 

[bedrock]

I hate seeing these patients because it seems like nothing helps them. Medication including opioids if necessary, tpi, mbb/rfa help sometimes. Would like to try Botox on some of them if insurance approved. Most of my patients don’t have the money to pt for Botox.

Just have to call it torticollis

 

[Laryngospasm]

I may try that. I haven’t tried that trick in a while. Thx

 

[clubdeac]

Low risk, I would check out the cervical SPR PNS. Stim the axial neck musculature aiming at the facet joint in the middle of the fusion.

Workup wise, NM bone scan overlaid on a CT C-spine or a formal CT-SPECT of the neck to see if there is a bony fusion issue. Sometimes see a hot facet joint that is not really fused and may respond to IA steroid. The usual referral patterns suggest that the pain should be from fused region but sometimes they're wrong.

I agree with this. I would try PNS over the medial branch at C5 or C6. I had a patient with this issue get relief from 12 sessions of LLLT performed by another doc. Apparently helps with soft tissue healing and blood flow aiding in removal of peripheral nociceptive mediators.

Also tell this patient to stretch their pecs, Lats and serratus multiple times throughout the day. Patients with posterior fusions typically have loss of the normal cervical lordosis resulting in tight pecs and lats with subsequent trap pain and hypertonicity