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Preparation and Block Routine:
We ask for your cooperation before and immediatley after the placement of the block.
1.Do not take any of your pain medications for the 6 hours prior to the time of your scheduled block. Other prescribed medicines should be taken normally (eg, blood pressure or heart pills, etc.).
2.Please refrain from eating any solid foods beginning 8 hours prior to the time of the scheduled block. You may have clear liquids for breakfast the morning of your block. (This includes tea, broth, jello, etc.).
A friend or family member should accompany you to the Nerve Block Clinic the day of your scheduled block. In the clinic, we will examine the lower part of your back to locate the proper position for the needle placement. We may use an x-ray machine during the first block in order to confirm positioning of the nerve block needle. Once the correct area has been located, the skin will be cleansed with a cold brown soap solution. an area, (the size of a dime) , will be numbed with the injection of a local anesthetic. Patients often describe a momentary "bee bite" followed by a transient burning senation as the area is numbed.
A lumbar sympathetic block requires the placement of between 1-3 needles; each is inserted through a numbed area of skin. If we are satisfied with the needle position, the local anesthetic solution will be injected through the needle(s). Patients sometimes describe a warm sensation at the time of the injection. It is very important that you do not move your back at this time. You will be asked if you hear ringing in your ears, if you feel dizzy or faint, or if you have any metallic taste in your mouth, It is common for the lower extremity on the side of the nerve block to feel flushed or warmer immediately after the block.
After a period of observation, you will be able to return home. You should avoid strenuous activity (which includes driving) for the rest of the day. Additionally, you might feel lightheaded, and we advise you to walk with assistance until the following day. If you feel nauseated, short of breath, dizzy, or uncomfortable in any way, please call us ... we want to know about it. Call us at: (516) 661-0400.
Treatment of cervical facet joint syndrome with injection of local anesthetic and steroid followed by radiofrequency thermocoagulation is a safe and effective technique. Although there are many potential complicaitons associated with needle placement in this area, hyperesthesia presumably secondary to incomplete lesioning of the medial branch was the only problem we experienced. Tactile hyperesthesia is usually self-limiting and resolves in a couple of months. We have successfully treated this with a centrally acting tranquilizer such as clonazepam 0.5 mg three times a day. Occasionally injection of the facet joint at C2 is necessary for treatment of headache.
Our workup often includes plain films, EMG, cat scan, magnetic resonance imaging, careful history, and physical exam. Lateral x-ray may show bony spurs. An EMG evidence of nerve injury consistent with radiculopathy necesstates treatment with a cervical epidural catheter. Our success rate in the treatment of radiculopathy via cervical epidural catheter is 85 percent. Physical exam includes lateral pressure on the facet joints. Lateral rotation of the neck as well as checking range of motion of the shoulder joint is necessary to rule out a frozen shoulder.
This study shouws that treatment of cervical facet joint syndrome can be safely and efficiently conducted with good initial results and at two year follow-up pain relief was sustained in a majority of patients. Over the past two years we have performed cervical facet injections in 80 patients, and 62 of these have gone on to receive radiofrequency thermocoagulation. Many were most to follow-up, but we present data obtained by telephone interview from 41 patients. Seventy-three percent (30/41) of our patients claimed relief from cervical facet joint syndrome after a diagnositc block was performed. This result compares favorably with that of Bogduk at al. In two of the patients the duration of pain relief from cervical facet joint injection was greater than 8 months. Patients who responded favorably to local anesthietc and steroid injections but had short duration improvement were candidates for radiofrequency thermocoagulation. Thirty-three patients went on to have complete relief of their symptoms. The duration of pain relief has varied from a few days to 18 months.
Nearly 25% of the patients claimed good to excellent pain relief for greater than 6 months. Patients with a good response to radiofrequency thrmocoagulation but without sustained pain relief (i.e., <6 months) were treated with repeat cervical facet injection. If this gave additional pain relief, then radiofrequency thermocoagulatin was performed. Our impression of the reason for the lack of sustained pain relief was most likely secondary to incomplete lesioning of the facet nerves. The overall effectiveness of these repeat blocks needs further follow-up.
The informed consent is an important aspect of the cervical facet procedure. The listed hazards should include all the possible complications including bleeding, infection, drug reaction, seizures, convulsions, weakness, numbness, paralysis, temporary and permanent difficulty in breathing secondary to total spial as well as the possiblity of pneumothorax. While the list of potential complications indeed is horrendous, attention to the details described above should make incidents of these very, very minimal. There are no known actual predictors of incidents of complications other than the fact that one hears about the sporadic undesirable outcome along the lines of hte above listed complications.
These results confirm that diagnostic cervical facet injection followed by radiofrequency thermocoagulation is an effective therapy for the treatment of cervical facet joint syndrome.
There is a group formed for collecting an up-to-date list of references for radiofrequency lesioning. This may be obtained from Radionics, Inc.* P.O.Box 438, Cambridge Street*Burlington, Massachusetts 01803. This shall be periodically updated.
REFERENCES
1. Bogduk N: The innervation fo the cervical intervetebral disc.Spine, 13:1, 1988. 2. Bogduk N: The cervical zygapophysial joints as a source of neck pain.Spine, 13:6, 1988. 3. Racz GB: Techniques of neurolysis. Boston; Kluwer Academic Publishers, 1989. 4. Sluyter ME, Koetabeld-Baart CC: Interruption of pain pathways in the treatment ofthe cervical syndrome.Anestheisa, 35:202-307, 1980.
1. Please note A-P view must be used prior to lesioning to verify that the needle or electrode is at the lateral border of the cervical facet joint.
2. Patient in prone position, horizontal and anterior-posterior views are utilized to verify needle placement.
3. Needle placement to the posterior part of the facet joint view obtained with oblique visualization.
4. Needle placement inside the neural foramen for lesioning or ejecting the posterior primary ramus as it comes off just distal to the dorsal root ganglion.
5. Needle placement position for C7, C8, T1 facet rhizotomy.
Fig. 6 Sketches of the placements of needles for cervical and cervical zygapophysial joint blocks. A. Posterior view showing the courses of the third occipital nerve (ton), the metacervical dorsal rami and their aricular brances (a). On the left indicate the target points for a third occipital nerve block branch blocks. On the right, a needle is shown passing into the joint to illustrate the trajectory and placement used for interunilateral view of the cervical spine illustrating the passage of a C5-6 zygapophysial joint.
1. Please note A-P view must be used prior to lesioning to verify that the needle or electrode is at the lateral border of the cervical facet joint.
2. Patient in prone position, horizontal and anterior-posterior views are utilized to verify needle placement.
3. Needle placement to the posterior part of the facet joint view obtained with oblique visualization.
4. Needle placement inside the neural foramen for lesioning or ejecting the posterior primary ramus as it comes off just distal to the dorsal root ganglion.
5. Needle placement postion for C7, C8, T1 facet rhizotomy.
In Conclusion:
It is impossible to predict how effective a block will be. Two patients with the same problem and background can have very different results. Usually a series of B-10 blocks are needed to provide effective relief. These can then be repeated.
We hope this introduction has answered your questions. it is only a brief summary, not a patient consent form. We will talk to you about this block in greater detail in the clinic. If any questions remain, write them down so we can address them further.
The staff of Comprehensive Pain Care of Long Island realizes that most of our patients are greatly distressed by their pain. They are frustrated by the inability of other types of therapies to help them. We face the most difficult and challenging problem.... By working together, we can try to provide relief.
Introduction:
We the staff want you to understand what we are doing and why, as only by working closely together can we hope to achieve the best results. We can offer different nerve blocks and medicines to try to relieve your pain. In addition, we feel that answering your questions is just as important. The more you understand, the more comfortable you feel, the better, are our chances of success.
Anatomy and Theory:
The stellate ganglion is a mass of nerves approximately 1" long, 1/2" wide and 1/4" thick, located deep within the right and left side of the neck. The nerves which travel through the stellate ganglion belong to the sympathetic nervous system, a specialized group of nerves whose fibers connect the spinal cord with blood vessels and other nerves in the body. (These are not the same nerves which connect the skin and muscles with the spinal cord.) Those sympathetic nerves which travel through the stellate ganglia travel to the arms, head and upper chest.
Injection of a local anesthetic into the area of the stellate ganglion numbs only the sympathetic nerves. This effect is helpful in treating several conditions of the upper torso, since sensation and movement are not compromised in these areas. Nerve blocks of the stellate ganglion are often performed to relieve the pain of early herpes zoster, reflex sympathetic dystrophy, and causalgia. Vasopastic conditions such as Raynaud's and Buerger's Disease, arterial crush injuries, and swelling disorders can also be treated. In fact, prior to the introduction of modern medications, both angina and asthma were treated with stellate ganglion blocks.
The stellate ganglion is surrounded by vital structures making needle placement extremely important. Major arteries and veins connecting the head, arm and chest border the ganglion. The spinal cord and the upper border of the lung also lie in close proximity. Thus, a complication resulting from the injection of medication through a misplaced needle is always a possibility.
LUMBAR OR CERVICAL FACET BLOCK
Cervical facet syndrome is a diffuse entitry characterized by neck pain, limitation of movement, shoulder pain, arm pain, and possibly headache. There may be a radiating component secondary to muscle spasm and nerve root compression. The diagnosis is often missed and commonly labeled as trigger points of the trapezius muscle. The etiology may be related to trauma, whiplash injury, posture, arthritis, muscle spasm, tension, or without identifiable cause. Associated syndromes include occipital and temporal pain via cranial nerves 2 and 3 and the auricular verves. Diagnosis of this syndrome is via history and physical exam. History of trauma should be followed by examination, by lateral pressure on the cervical facet joints, as well as pressure over the trapezius muscles causing pain. Tenderness to palpation of the trapezius muscle alone may be secondary to trigger points buy when seen in combination with neck tenderness, it is usually caused by cervical facet syndrome. Cervical facet injections with local anesthetic and steroid provide a high yield of pain relief in 17 out of 24 consecutive patients with neck pain using facet injections. Radiofrequency thermocoagulation has been employed by Sluijer to treat neck pain. The purpose of this paper is to look at the benefit of diagnostic cervical facet syndrome. We have treated 80 patients with cervical facet syndrome over the past 24 months.
TECHNIQUE OF LOCAL ANESTHETICS AND STEROID INJECTION
The patient is placed supine on a special fluoroscopy table with a head extension which overhangs the legs of the table so that the C-arm has free circumferential rotation. An IV is started and monitors placed (EKG, dinamap, and pulse oximeter). The posterior border of the cervical transverse processes are palpated, and a line is marked on the skin using a marking pen. Needle entry points are marked on this line with the shaft of the needle horizontal to avoid anterior placement of the needle tip and possible spearing of a nerve root. The neck is painted with sterile solution and draped. The C-arm is then brought in from the head of the table and is initially rotated 30 degrees obliquely. (Figure 1) This reveals the facet joint as a string of beads. (Figure 2) The location of the vertibral artery and the cervical nerve root can also be determined in the oblique view. Under fluoroscopy guidance a 21 gauge 2" needle is placed near the facet joint at the desired levels. Correct location of the needle is indicated when it is in contact with bone prior to injection. The oblique view will reveal anterior needle placement as if the needle enters the neural foramen. The view assures that the needle stays free of the vertebral artery or nerve root. An anterior-posterior view rules out placement of the needle into the spinal canal or cord. Confirmation of correct needle placement by an anterior posterior view will show the needle touching the lateral border of the cervical spine at the level of the joint. (Figure 3) After negative aspiration, 2cc of a mixture of 0.5% marcaine plus 40mg trimcinalone is injected. This is repeated at other levels based on the patient's examination. Most commonly C2-C5 levels are injected with the patient in the supine position. Below C5 there is a possibility of pneumothorax as a complication with the supine-horizontal needle approach. for C5, C7 and upper thoracic levels the prone position posterior approach is used. Flaccidity of the trapezius muscle is often noted upon completion of the block. After the diagnostic block, the patient's neck is moved back and forth, and the patient is asked to evaluate his pain. Aggressive physical therapy is very important for maintaining and increasing the therapeutic effectiveness of the block. The patient may expect the effects of the block to last from several hours to several days to a lifetime. Before attempting this technique, it is helpful to observe these procedures.
Often cervical facet injection will need to be supplemented with suboccipital nerve block or injection of upper thoracic facet joints. The suboccipital nerve block will relieve pain secondary to entrapment of the greater and lesser occipital nerves and auricular nerves. Injection of the upper thoracic facet joints is necessary because with injection of the cervical facet joints the lowest facet that can be blocked is C6 or C7. In order to inject the upper thoracic facet joints, the patient must be placed in a prone position.
The cervical facet joints are innervated by the posterior-primary rami of the nerve roots as these are given off distal to the dorsal root ganglion. The dorsal rami travel in the groove of the transverse procis of the cervical vertebra and divide into the ariculating branch and the medial branches. The nerves subsequently sand branch to the joint above and the joint below so that if the innervation is considered, one needs to be involved in blocking or lesioning the affected joint as well as the nerve above and the nerve below. (Figure 1)
Because of the work of Bogduk and recognition of the innervation and causation of neck pain from the disc as well as the facet joints, there are three techniques in approaching the pain originating from the facet joints. Of the three techniques, we have described the one where the oblique fluoroscopic visualization is used to place the needle at the posterior border of the cervical facet joint for radiofrequency lesioning purposes because this is the technique where the least likely damage from a misplaced needle can be observed because of the oblique fluoroscopic visualization during the movement of the needle. Basically there are three recognized techniques:
1. This technique is a slightly more anterior approach whree the needle is intentionally placed to the posterior neural foramen, and the needle is walked off the bone and advanced into the neural formen in the anterior=posterior view in such a way that the needle does not go beyond halfway the distance of the facet joint. Once the needle enters the neural foraman, beyond the halfway distance, the distinct hazard is the entry into the vertebral artery. Additional hazard is the needle entering into the segmental spinal artery especially at C6 area. Paresthesia should bot be ellicited because the presence of parasthesia may indicate closeness of the needle to segmental artery blood supply as mentioned earlier especially at C6. Injection or severing of the feeding artery is a definite hazard that should be avoided.
2. Our preferred technique is where the oblique fluoroscopic visualization is used, and the posterior part of the facet joint is aimed for. During radiofrequency lesioning, the high frequency stimulation (50-75Hz) at the low amplitude (0-1 volt) will reproduce the pain followed by motor stimulation of 2x sensory amplitude and 2Hz that may cause contracture of posterior neck muscles but not of the muscles of the arm. Following stimulation outlined, the lesioning is safely carried out without significant hazard to the mixed cervical primary nerve roots. Also this approach avoids the hazard of hitting the segmental spiral artery at C6 as well as the placement of the needle into the spial cord as is the faint possibility with technique 1.
3. This is the approach which is carried out in the prone position where the initial needle placement is to the lamina, and the needle is walked off into the mid grove position of the transverse process. The posterior primary ramus comes underneath a transverse ligament, and high frequency stimulation reproduces the recognizable paresthesia and pain. Motor stimulation will verify up to twice the sensory stimulation that the needle is not close to the cervial motor nerve root; additionally because a larger part of the uninsulated radiofrequency needle is placed along a longer segment of the posterior primary ramus, the size of the lesioned segment of the nerve is going to be larger. The effectiveness of the technique likely will be greater than the lateral approach. Usually a 5 mm uninsulated needle is used to carry out the lesioning when radiofrequency technique is utilized.
Introduction
We the staff want you to understand what we are doing and why, as only by working closely together can we hope to achieve the best results. We can offer different nerve blocks and medicines to try to relieve your pain. In addition, we feel that answering your questions is just as important. The more you understand, the more comfortable you feel, the better, are our chances of success.
Anatomy and Theory:
Pain syndrome of the upper abdomen and thorax such as postherpetic neuralgia (pain from shingles) and post thoracotomy syndrome can be treated by the blocking of the nerves controlling the affected areas as they exit the spinal column in the back. The injection of different solutions to numb the nerves provides the pain relief. Such injections can be made at various points along the path of the nerve. Paravertebral nerve block injections are placed at a point in the nerve's pathway when it has already passed out of the spinal column.
Chronic pain is transmitted through an abnormal pathway where the same impulses are repeatedly recycled. The instillation of local anesthetics breaks this abnormal cycle and may provide pain relief for weeks to months. Often prolonged and effective relief may often be obtained from a series of several blocks over a 3-4 month period.
As in any invasive procedure, the possibility of a complication exists.
Preparation and Procedure:
We ask for your cooperation before and immediately after the placement of the block.
1. Do not take any of your pain medication for the 6 hours prior to the time of your scheduled block. Other prescribed medicine should be taken normally (e.g. blood pressure or heart pills, etc.)
2. Please refrain from eating any solid foods beginning 8 hours prior to the scheduled block. You may have clear liquids for breakfast the morning of the block. (This includes tea, broth, jello, etc.)
A friend or family member should accompany you the day of the procedure.
At the time of the block, we will examine your back to locate the precise site(s) for the placement of the needle(s). These sites are often in the middle of your back, quite some distance from the area which is painful. The area will then be cleansed with a cold brown soap solution. And the skin at the sites of the needles (an area the size of a dime) will be numbed with the injection of a local anesthetic. Patients often descibe this as a small "bee bite" followed by a momentary burning sensation. Through these area, the block needles will be placed. When we are satisfied with their accuracy, a solution of local anesthetic will be injected. This is usually not painful, however, patients sometimes describe a discomfort during the injection. It is very important that you do not move while the injections are being placed. We will ask if you have feelings of dizziness, ringing in your ears, or if you have a metallic taste in your mouth.
After a brief period of observation, you will be able to return home. Strenuous activity, which includes driving, should be avoided for the rest of the day. You should resume taking your pain medicines in the usual manner; we will gradually taper these drugs. If you feel short of breath, dizzy, faint, nauseated, or uncomfortable in any way, please call us; we want to know (516-661-0400).
It is impossible to predict how effective the block will be. Two patients with the same problem and background can have very different results. Usually a series of 8-10 blocks are needed to provide effective relief. If these are successful, we can consider injecting a different solution which produces a more permanent block (lasting from several months to years).
In Conclusion:
We hope this introduction has answered your questions. It is only a brief summary, not a patient consent form. We will talk about this block in greater detail in the office. If any questions remain, write them down so we can discuss them further.
The staff of Comprehensive Pain Care of Long Island realizes that most of our patients are greatly distressed by their pain. They are frustrated by the inability of other types of therapies to help them. We face the most difficult and challenging problem..... By working together, we can try to provide relief.
Introduction
We the staff want you to understand what we are doing and why, as only by working closely together can we hope to achieve the best results. We can offer different nerve blocks and medicines to try to relieve your pain. In addition, we feel that answering your questions is just as important. The more you understand, the more comfortable you feel, the better, are our chances of success.
Anatomy and Theory:
The celiac plexus is a small bundle of nerves half the size of a dime, located in the back of the abdomen. There are two separate bundles, one on the right and one on the left side. The nerves run in both directions, connecting the spinal cord with such organs as the pancreas, liver, parts of the stomach, the kidneys, and adrenal glands. These nerves are active in relaying pain sensations to the brain.
By injecting a local anesthetic into the area of these bundles, we can "put the nerves to sleep," much like a dentist does when he numbs your teeth and gums. if this initial trial is successful in relieving your pain, we can then inject a different solution in hopes of obtaining more permanent relief.
The success of such a nerve block is dependent on several factors such as the amount of inflammation or fibrosis present (from past surgery or radiation treatments) and the precise position of the needle. Needle placement is extremely important in order to maximize our chances of pain relief and because there are several very important structures located very close to the plexus. These include the aorta and vena cave (the two most important blood vessels in the body), the spinal cord, lung space, kidneys, adrenal glands, and the smaller vessels, nerves, and back muscles in the area. We take great care in placing these needles aided by the use of an X-ray machine (either CAT Scanner or a fluoroscopy machine). This lets us follow the tips of the needles in order to insure their accurate placement.
Preparation and Celiac Block Routine
We ask for your cooperation before and immediately after the placement of the block.
1. Please drink lots of fluids beginning four days prior to the block. An additional 2-3 glasses per day is fine.
2. Do not take any of your pain medication for the 6 hours prior to the time of your scheduled block. Other prescribed medicine should be taken normally (e.g. blood pressure or heart pills, etc.)
3. Please refrain from eating any solid foods beginning 8 hours prior to the scheduled block. You may have clear liquids for breakfast the morning of the block. (This includes tea, broth, jello, etc.)
A friend or family member should accompany you to the hospital/office the day of your scheduled block.
To begin, we will insert an intravenous time into one of the veins in the back of your hand or arm. You will be placed face down (on a pillow) on the X-Ray machine. After we locate and mark the area on your back for the needle insertion, this area, about the size of a penny, will be put to sleep with a small injection of a local anesthetic. You will feel what is often described as a "bee sting" followed by a localized momentary burning sensation as that area becomes numb. The nerve block needles will then be placed into the area of the celiac plexus with the aid of an X-ray machine and sometimes the use of a small amount of X-ray dye injected from a syringe. Once the needle is correctly positioned a small test dose of local anesthetic will be injected. Patients sometimes descibe a warm sensation in their back and a tightness in their chest at the time of injection. At this point in the procedure, we will want to know if you can move your feet, if you feel dizzy or faint, if you hear ringing in your ears, or have a metallic taste in your mouth.
If this test dose injection is successful in relieving some or all of your pain, we will then inject another solution containing alcohol, which results in a more permanent block. Again, patients often describe a warm sensation or even transient pain at this time. At this point, it is very important that you do not move your back.
Following completion of the block, we will observe you for at least one hour, after which time, the intravenous line will be removed and you may return home. You are not to engage in any strenuous activity (which includes driving) until the following day. Please walk with assistance for the rest of the day. For a few hours after the block, you may feel weak and your chronic pain might even feel stronger. Some patients also describe a numb area on the side of their thigh. Rest assured that this is quite normal and transient. You should resume taking your pain medications just as you were taking them before; we will gradually taper them. Following the block, if you feel short of breath, nauseated, lightheaded, or uncomfortable in any way, please call us as we want to know about it (516-661-0400).
In Conclusion:
We have no way of predicting how successful your celiac plexus block will be. Two patients with the same problem and background can have very different results with the block. Relief may last from several weeks to several months.
We hope this introduction has answered your questions. It is only a brief summary, not a patient consent form.
The staff of Comprehensive Pain Care of Long Island realizes that most of our patients are greatly distressed by their pain. They are often frustrated by the inability of other types of therapies to help them. We face the most difficult and challenging problems..... By working together, we can try to provide relief.
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