scholarly journals Response to Cervical Medial Branch Blocks In Patients with Cervicogenic Vertigo

2018 ◽  
Vol 1 (21;1) ◽  
pp. 285-293
Author(s):  
Stephan Klessinger
Keyword(s):  
Cervical Spine ◽  
Neck Pain ◽  
Diagnostic Tool ◽  
Facet Joint ◽  
Electronic Medical Record System ◽  
Clinical Impression ◽  
Medial Branch ◽  
Case Scenario ◽  
Record System ◽  
Worst Case

Background: Among the various causes of vertigo, the so-called cervicogenic vertigo (CV) has been the most controversial. However, perturbations of proprioceptive signals and abnormal activity of the cervical afferents can induce vertigo. Medial branch blocks (MBBs) are a diagnostic tool designed to test whether a patient’s neck pain is mediated by one or more of the medial branches of the dorsal rami of the spinal nerve. It is unknown whether MBBs are also suitable for testing symptoms other than pain. Objectives: The purpose of this study was to test whether MBBs of the cervical spine can be used as a diagnostic tool to identify patients with CV. Study Design: A retrospective practice audit (clinical observation). Setting: An interventional pain management and spine practice. Methods: An electronic medical record system was used to identify patients in a single spine center. Included were consecutive patients with neck pain and vertigo, who had received cervical MBBs in a period from July 2001 to April 2016. The patients were tested with a MBB of about 1 mL of bupivacaine (0.25%) and 20 mg triamcinolone. Injections were performed with fluoroscopic visualization using established techniques in 2 or 3 levels on one or both sides. Vertigo was analyzed through the global clinical impression of the patient (i.e., “gone,” “better,” “the same,” or “worse”). Results: One-hundred seventy-eight patients met the inclusion criteria. One-hundred eleven patients (62.4%) experienced a significant improvement of the vertigo. In 47 patients (26.4%), no information about the vertigo was available at follow-up; these patients were assumed to have no improvement (worst-case scenario). Hence, altogether 67 patients (37.6%) had a negative result. The median relief of the vertigo was 2 months. Differences in age, gender, level of treatment, or pain duration between patients with relief of the vertigo and without relief were not found. Nine patients with a whiplash injury in their medical history were also tested. They experienced a lower success rate and had longer duration of pain before the treatment; however, these differences are not statistically significant. Limitations: It was the primary intention to treat neck pain; the assessment of vertigo was an additional aim. Therefore, the history taken and the clinical examination were not targeted specifically to vertigo. A placebo effect cannot be excluded. Further studies with the primary focus on CV are necessary to prove the significance of MBBs. Conclusions: This is the first study to demonstrate that MBBs of the cervical spine can be a useful tool for the diagnosis of CV, because they temporarily block cervical afferents. In 63.4% of patients with neck pain and suspected CV, the vertigo was significantly improved. Further placebo-controlled studies with the primary intention on CV are necessary to prove the significance of MBBs. Key words: Cervicogenic vertigo, medial branch block, facet joint, zygapophysial joint, neck pain, differential diagnosis

The Benefit of Therapeutic Medial Branch Blocks after Cervical Operations

2010 ◽  
Vol 6;13 (6;12) ◽  
pp. 527-534
Author(s):  
Stephan Klessinger
Keyword(s):  
Cervical Spine ◽  
Neck Pain ◽  
Joint Pain ◽  
Facet Joint ◽  
Medial Branch ◽  
Level Of Evidence ◽  
Nerve Blocks ◽  
Medial Branch Block ◽  
Cervical Facet ◽  
Cervical Facet Joint

Background: Persistent neck pain is a common problem after surgery of the cervical spine. No therapy recommendation exists for these patients. Objectives: The objective of this study was to determine if a therapeutic medial branch block is a rational treatment for patients with postoperative neck pain after cervical spine operations. Study Design: Retrospective practice audit. Setting: Review of charts of all patients who underwent cervical spine operations for degenerative reasons during a time period of 3 years. Methods: Patients with persistent postsurgical pain were treated with therapeutic medial branch blocks (local anesthetic and steroid). A positive treatment response was defined if at least 80% reduction of pain could be achieved or if the patient was sufficiently satisfied with the relief. All patients with a minimum follow up time of 6 month were included. Results: Of the 312 operations performed, 128 were artificial disc operations, 125 were stand alone cages, and 59 were fusions with cage and plate. Persistent neck pain occurred in 33.3 % of the patients. There was no difference between the patients with neck pain and the whole group of patients. More than half of the patients with neck pain—52.9%—were treated successfully with therapeutic medial branch blocks. Since no further treatment was necessary, the initial treatment was considered successful. Nearly a third—32.2%—of the patients were initially treated successfully, but their pain recurred and further diagnostics and treatments were necessary. In this group of patients, significantly more with double level operations were found (P = 0.003). Patients not responding to the medial branch block were 14.9%. Limitations: This audit is retrospective and observational, and therefore does not represent a high level of evidence. However, to our knowledge, since this information has not been previously reported and no recommendation for the treatment of post-operative zygapophysial joint pain exists, it appears to be the best available research upon which to recommend treatment and to plan higher quality studies. Conclusions: For persistent postsurgical neck pain only limited therapy recommendations exist. This study suggests treating these patients in a first instance with therapeutic medial branch blocks. The success rate is 52.9 %. Key words: Chronic neck pain, cervical zygapophysial pain, cervical facet joint pain, medial branch blocks, therapeutical cervical facet joint nerve blocks, postsurgery syndrome, pain therapy Pain Physician

scholarly journals Posterior Ligamentous Complex Reconstruction for Cervical Dislocation and Instability in Patients without Vertebral Fracture with Artificial Ligaments: A Technical Note

2020 ◽  
Author(s):  
Chengyi Huang ◽  
Beiyu Wang ◽  
Hao Liu ◽  
Tingkui Wu ◽  
Kangkang Huang ◽  
...  
Keyword(s):  
Cervical Spine ◽  
Vertebral Fracture ◽  
Neck Pain ◽  
Facet Joint ◽  
Spinous Process ◽  
Posterior Ligamentous Complex ◽  
Reconstruction Surgery ◽  
Artificial Ligaments ◽  
Cervical Surgery ◽  
Patient Reported

Abstract Introduction: The posterior ligamentous complex (PLC) offers restraints to deformation in a complex and interconnected manner. The stability and range of motion (ROM) of the posterior cervical spine is greatly restricted when the PLC is damaged, even without bone disruptions. We describe a novel surgical technique, its advantages, and the postoperative condition of the first patient to use artificial ligament in a reconstruction surgery of PLC injuries in patients without lower cervical vertebral fracture. This technique aimed to fully retain the mobility of the injured segment based on spinal stability and apply dynamic reconstruction in patients’ treatment.Method: We present a detailed description of the reconstruction surgery with artificial ligaments performed on C4-6 PLC injuries in a 27-year-old male presented with neck pain and restricted movement following a high fall injury accompanied by impaired movement of limbs. Results: Immediately postsurgery, the patient’s neck pain and quadriparesis had been improved. The spinal canal decompression and cervical spine sequence results were satisfactory, the facet joint face was in a good position, and the spinous process spacing returned to normal. After three months of rehabilitation, the patient reported improvement of symptoms and the physical and imaging examination showed a significant improvement in the patient’s condition. The patient’s neck mobility motor function had improved further.Conclusion: The present data demonstrate that the novel technique for reconstruction of PLC injury is feasible and safe. However, familiarity with cervical anatomy and adequate experience in lateral mass screws placement during surgery is crucial for this procedure. Therefore, a highly experienced cervical surgery team is recommended to perform the surgery.

scholarly journals Systematic Review of the Therapeutic Effectiveness of Cervical Facet Joint Interventions: An Update

2012 ◽  
Vol 6;15 (6;12) ◽  
pp. E839-E868 ◽  
Author(s):  
Frank J.E. Falco
Keyword(s):  
Systematic Review ◽  
Neck Pain ◽  
Joint Pain ◽  
Observational Studies ◽  
Facet Joint ◽  
Medial Branch ◽  
Radiofrequency Neurotomy ◽  
Facet Joint Interventions ◽  
Cervical Facet ◽  
Cervical Facet Joint

Background: The prevalence of chronic, recurrent neck pain is approximately 15% of the adult general population. Controlled studies have supported the existence of cervical facet or zygapophysial joint pain in 36% to 67% of these patients, when disc herniation, radiculitis, and discogenic are not pathognomic. However, these studies also have shown false-positive results in 27% to 63% of the patients with a single diagnostic block. There is also a paucity of literature investigating therapeutic interventions of cervical facet joint pain. Study Design: Systematic review of therapeutic cervical facet joint interventions. Objective: To determine and update the clinical utility of therapeutic cervical facet joint interventions in the management of chronic neck pain. Methods: The available literature for utility of facet joint interventions in therapeutic management of cervical facet joint pain was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, and limited or poor based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to June 2012, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: The primary outcome measure was pain relief (short-term relief = up to 6 months and long-term > 6 months). Secondary outcome measures were improvement in functional status, psychological status, return to work, and reduction in opioid intake. Results: In this systematic review, 32 manuscripts were considered for inclusion. For final analysis, 4 randomized trials and 6 observational studies met the inclusion criteria and were included in the evidence synthesis. Based on one randomized, sham-controlled, double-blind trial and 5 observational studies, the indicated evidence for cervical radiofrequency neurotomy is fair. Based on one randomized, double-blind, active-controlled trial and one prospective evaluation, the indicated evidence for cervical medial branch blocks is fair. Based on 2 randomized controlled trials, the evidence for cervical intraarticular injections is limited. Limitations: Paucity of the overall published literature and specifically lack of literature for intraarticular cervical facet joint injections. Conclusions: The indicated evidence for cervical radiofrequency neurotomy is fair. The indicated evidence for cervical medial branch blocks is fair. The indicated evidence for cervical intraarticular injections with local anesthetic and steroids is limited. Key words: Chronic neck pain, cervical facet or zygapophysial joint pain, cervical medial branch blocks, cervical radiofrequency neurotomy, cervical intraarticular facet joint injections

scholarly journals A Critical Look at the Data Supporting Ultrasound Guided Cervical Medial Branch Blocks

2020 ◽  
Author(s):  
Meredith Barad
Keyword(s):  
Cervical Spine ◽  
Facet Joint ◽  
Meta Analysis ◽  
Current Evidence ◽  
Medial Branch ◽  
Spine Injections ◽  
American Society ◽  
Cervical Facet ◽  
Cervical Facet Joint ◽  
Joint Injections

According to guidelines published by the American Society of Interventional Pain Physicians in 2013 ‎1, ‎2, the current evidence for cervical facet joint injections is fair. Yet the volume of these procedures continues to rise ‎3. There is a need for a more critical appraisal of the benefit, technique and adverse effects associated with cervical spine injections. The systematic review and meta-analysis by Paredes et al ‎4 seeks to better assess the evidence for use of ultrasound (US) guidance with cervical medial branch blocks. This article is also a response to a recently published critique by Schneider et al ‎5 raising concerns about the paucity of evidence evaluating the safety, accuracy, and effectiveness of US-guided cervical spine procedures.

scholarly journals Consensus practice guidelines on interventions for cervical spine (facet) joint pain from a multispecialty international working group

2021 ◽  
pp. rapm-2021-103031
Author(s):  
Robert W Hurley ◽  
Meredith C B Adams ◽  
Meredith Barad ◽  
Arun Bhaskar ◽  
Anuj Bhatia ◽  
...  
Keyword(s):  
Cervical Spine ◽  
Clinical Practice ◽  
Radiofrequency Ablation ◽  
Neck Pain ◽  
Working Group ◽  
Selection Criteria ◽  
Medial Branch ◽  
Pain Medicine ◽  
En Bloc ◽  
Joint Injections

BackgroundThe past two decades have witnessed a surge in the use of cervical spine joint procedures including joint injections, nerve blocks and radiofrequency ablation to treat chronic neck pain, yet many aspects of the procedures remain controversial.MethodsIn August 2020, the American Society of Regional Anesthesia and Pain Medicine and the American Academy of Pain Medicine approved and charged the Cervical Joint Working Group to develop neck pain guidelines. Eighteen stakeholder societies were identified, and formal request-for-participation and member nomination letters were sent to those organizations. Participating entities selected panel members and an ad hoc steering committee selected preliminary questions, which were then revised by the full committee. Each question was assigned to a module composed of 4–5 members, who worked with the Subcommittee Lead and the Committee Chairs on preliminary versions, which were sent to the full committee after revisions. We used a modified Delphi method whereby the questions were sent to the committee en bloc and comments were returned in a non-blinded fashion to the Chairs, who incorporated the comments and sent out revised versions until consensus was reached. Before commencing, it was agreed that a recommendation would be noted with >50% agreement among committee members, but a consensus recommendation would require ≥75% agreement.ResultsTwenty questions were selected, with 100% consensus achieved in committee on 17 topics. Among participating organizations, 14 of 15 that voted approved or supported the guidelines en bloc, with 14 questions being approved with no dissensions or abstentions. Specific questions addressed included the value of clinical presentation and imaging in selecting patients for procedures, whether conservative treatment should be used before injections, whether imaging is necessary for blocks, diagnostic and prognostic value of medial branch blocks and intra-articular joint injections, the effects of sedation and injectate volume on validity, whether facet blocks have therapeutic value, what the ideal cut-off value is for designating a block as positive, how many blocks should be performed before radiofrequency ablation, the orientation of electrodes, whether larger lesions translate into higher success rates, whether stimulation should be used before radiofrequency ablation, how best to mitigate complication risks, if different standards should be applied to clinical practice and trials, and the indications for repeating radiofrequency ablation.ConclusionsCervical medial branch radiofrequency ablation may provide benefit to well-selected individuals, with medial branch blocks being more predictive than intra-articular injections. More stringent selection criteria are likely to improve denervation outcomes, but at the expense of false-negatives (ie, lower overall success rate). Clinical trials should be tailored based on objectives, and selection criteria for some may be more stringent than what is ideal in clinical practice.

The utility of radionucleotide imaging in the surgical management of axial neck pain from cervical facet joint arthropathy

2020 ◽  
Vol 32 (2) ◽  
pp. 168-173
Author(s):  
Christopher D. Witiw ◽  
Nataliya Tsapenko ◽  
Vincent C. Traynelis
Keyword(s):  
Cervical Spine ◽  
Neck Pain ◽  
Facet Joint ◽  
Case Series ◽  
Tracer Uptake ◽  
Cross Sectional ◽  
Cross Sectional Imaging ◽  
Axial Neck Pain ◽  
Cervical Facet ◽  
Facet Arthropathy

OBJECTIVEAxial neck pain is common and often debilitating. Diagnosis of the specific pain source can be a challenge, and this confounds effective treatment. Cervical facet arthropathy is implicated in many of these cases. The diagnosis is readily made on conventional cross-sectional imaging modalities, particularly CT imaging. However, this modality falls short in determining if an osteoarthritic facet joint is truly the source of symptoms. Radionucleotide imaging presents a noninvasive radiological adjunct to conventional cross-sectional imaging in the workup of patients with suspected facetogenic pain. Herein, the authors present the patient-reported outcomes (PROs) following posterior instrumented arthrodesis of the subaxial cervical spine from a consecutive case series of patients with a diagnosis of cervical facet joint arthropathy and a concordant positive radionucleotide tracer uptake.METHODSThe clinical case series of patients treated by the senior author at a single tertiary care institution between September 2014 and April 2018 was reviewed. Patients were selected for inclusion if their primary symptom at presentation was axial neck pain without neurological deficits and if CT imaging revealed facet arthropathy of the cervical spine. These patients underwent radionucleotide imaging in the form of a planar 99mTc methylene diphosphonate (99mTc MDP) bone scintigraphy study. Those with a finding of radionucleotide tracer uptake at a location concordant with the facet arthropathy were selected to undergo posterior cervical instrumented arthrodesis of the affected levels. PROs were recorded at the time of surgical consultation (i.e., after nonoperative treatment) and at 6 weeks, 3 months, 6 months, and 1 year following surgery. These included neck and arm pain, the Neck Disability Index (NDI) and the 12-Item Short Form Health Survey responses.RESULTSA total of 11 patients were included in this retrospective case series. The average reported neck pain and NDI scores were high at baseline; 7.6 ± 2.3 and 37.1 ± 13.9 respectively. Twelve months after surgical intervention, a significant decrease in reported neck pain of −4.5 (95% CI −6.9, −2.1; p = 0.015) and a significant decrease in NDI of −20.0 (95% CI −29.4, −10.6; p = 0.014) was observed.CONCLUSIONSThis case series represents the largest to date of patients undergoing surgical arthrodesis following a finding of facet arthropathy with a concordant positive radioisotope image study. These observations add support to a growing body of evidence that suggests the utility of radioisotope imaging for identification of a facetogenic pain generator in patients with primary axial neck pain and a finding of cervical facet arthropathy. These preliminary data should serve to promote future prospective, controlled studies on the incorporation of radionucleotide imaging into the workup of patients with suspected facetogenic pain of the cervical spine.

scholarly journals Comparative Outcomes of a 2-Year Follow-Up of Cervical Medial Branch Blocks in Management of Chronic Neck Pain: A Randomized, Double-Blind Controlled Trial

2010 ◽  
Vol 5;13 (5;9) ◽  
pp. 437-450 ◽  
Author(s):  
Laxmaiah Manchikanti
Keyword(s):  
Pain Relief ◽  
Neck Pain ◽  
Local Anesthetic ◽  
Facet Joint ◽  
Neck Disability Index ◽  
Chronic Neck Pain ◽  
Medial Branch ◽  
Group I ◽  
Cervical Facet ◽  
Cervical Facet Joint

Background: Cervical therapeutic intraarticular facet joint injections, therapeutic medial branch blocks, and radiofrequency neurotomy have been applied in managing chronic neck pain of cervical facet joint origin. However, the effectiveness of these modalities continues to be debated. The purpose of this study was to determine the clinical effectiveness of therapeutic cervical medial branch blocks with or without steroids. Study Design: A randomized, double-blind, controlled trial. Setting: An interventional pain management practice, a specialty referral center, a private practice setting in the United States. Objective: To evaluate the clinical outcomes of therapeutic cervical medial branch blocks with local anesthetic with or without steroids in managing chronic neck pain of facet joint origin. Methods: A total of 120 patients meeting inclusion criteria were included. All of the patients met the diagnostic criteria of cervical facet joint pain by means of comparative, controlled diagnostic blocks, with at least 80% relief. Group I consisted of cervical medial branch blocks with bupivacaine only and Group II consisted of cervical medial branch blocks with bupivacaine and steroid. Therapeutic cervical medial branch blocks with local anesthetic with or without steroids were administered. Main outcome measures included numeric pain scores, Neck Disability Index (NDI), opioid intake, and work status evaluated at baseline, 6, 12, 18, and 24 months. The one-year results of outcomes were published in 2008. This manuscript describes the 2-year results. Significant improvement was defined as at least 50% improvement in pain relief and/or functional status improvement. Outcomes Assessment: Patient outcomes were measured at baseline, 3, 6, 12, 18, and 24 months post-treatment with the Numeric Rating Scale (NRS), the Neck Disability Index (NDI), employment status, and opioid intake. Decrease of ≥ 50% of NRS scores and Oswestry scores were considered significant. Results: Eighty-five percent of patients in Group I and 93% of patients in Group II showed significant pain relief (≥ 50%) at 2 years. The average number of treatments for 2 years was 5.7. The duration of average pain relief with each procedure was 17-19 weeks on average in both groups. Significant improvement of pain and function was demonstrated for 83 to 89 weeks over a period of 2 years. Limitations: The study limitations include the lack of a placebo group. Conclusions: In this study, therapeutic cervical medial branch blocks instituted after the diagnosis, with controlled comparative local anesthetic blocks with 80% concordant pain relief, repeated approximately 6 times over a period of 2 years, provided significant improvement over a period of 2 years. Key words: Chronic neck pain, cervical facet or zygapophysial joint pain, facet joint nerve or medial branch blocks, comparative controlled local anesthetic blocks, therapeutic cervical facet joint nerve blocks

Fear-Avoidance Beliefs in Chronic Cervical Zygapophyseal Joint Pain Relieve With Medial Branch Block

2018 ◽  
Vol 1 (2) ◽  
pp. 12
Author(s):  
Farid Yudoyono
Keyword(s):  
Neck Pain ◽  
Physical Examination ◽  
Neurological Deficit ◽  
Joint Pain ◽  
Facet Joint ◽  
Medial Branch ◽  
Zygapophyseal Joint ◽  
Fear Avoidance ◽  
Posterior Neck ◽  
Facet Joint Pain

Background: Chronic posterior neck pain is common, affecting 50–75% of people for 1 year or longer. The zygapophyseal joint is reported to be one of most common causative factors. The fear-avoidance is a model that describes how individuals develop chronic pain as a result of avoidant behaviour based on fear. Previous studies shown that medial branch block (MBB) and radio frequency neurotomy were effective for intractable pain.Material And Method: Case 1, TMK, Male, 57 yo, left posterior neck pain, VAS neck 7-8, NDI 46 %, no radiating pain, no neurological deficit. FABQ-PA score showed high fear (60%). Physical examination provokes facet joint pain. Neuroimaging revealed facet degeneration on T1WI and T2WI MRI. Case 2, RDW, Male, 45 yo, left posterior neck pain, VAS neck 8-9, NDI 40 %, no radiating pain, no neurological deficit. FABQ-PA score showed high fear (63%). Physical examination provokes facet joint pain. Neuroimaging revealed facet degeneration on T1WI and T2WI MRI. Case 3, TAY, Female, 52 yo, bilateral posterior neck pain, VAS neck  8-9, NDI 52 %, no radiating pain, no neurological deficit. FABQ-PA score showed high fear (60%). Physical examination provokes facet joint pain. Neuroimaging revealed facet degeneration on T1WI and T2WI MRI.Results: Our study reveals that C-MBB might ensure pain relief and decrease analgesic need. Physical activity at 1-, 3- and 6-months post-CMBB intervention were 65%, 60% and 68% of patients, respectively, gained >50% pain relief.Conclusion: Therapeutic MBB may provide an option for chronic high fear-avoidance beliefs pain of zygapophyseal joint.

Reducing Probabilistic Weather Forecasts to the Worst Case Scenario: Anchoring Effects

2008 ◽  
Author(s):  
Sonia Savelli ◽  
Susan Joslyn ◽  
Limor Nadav-Greenberg ◽  
Queena Chen
Keyword(s):  
Case Scenario ◽  
Worst Case ◽  
Weather Forecasts ◽  
Worst Case Scenario ◽  
Anchoring Effects
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