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Thread: Medial Branch Block for Pain

  1. #1

    Medial Branch Block for Pain

    A carecure member just wrote the following private message to me:
    I was wondering if you could give your thoughts. I have compression from buldging disc between c-5 and c-6. they did a epidural steroid injection about a year ago into my spine. maybe a little relief?? now they want to localize and do a epidural steroid injection and facet and medial branch block. if they determine that is the cause they are talking about burning the nerve to relieve pain. what do you think. I was very interested in your post and you seem to have knowledge on subject.
    thanks,
    The cause of spinal pain is not well understood. Some people have pain while others don't with herniated discs and degenerated joint disease. It is logical to assume that those who have pain may have innervation of the spinal structures that are affected. So, for many years, clinicians have sought to use local anesthesia to block specific nerves to the spine and then using radiofrequency to destroy the nerve if the block reduces pain. The following are various studies of the outcomes of such procedures:

    In 1999, MacDonald, et al. {McDonald, 1999 #75098} in Australia published their experience with 28 patients that had radiofrequency neurotomies. They found that 71% of the patients had complete relief of their pain. Of the patients that did not respond, none responded to a second neurotomy. However, in patients where the pain returned after initial relief, all responded to a second neurotomy. The median duration of relief was 219 days but it was 422 days when only the successful cases were considered. So, this study indicates that about 3 of 4 patients will experience pain relief, the pain recurs in about a year and half, and repeated procedures in responders are effective.

    There were no other studies on this until 2005. Pevzner, et al. {Pevzner, 2005 #75097} studied 28 patients with low back pain and 8 patients with neck pain. Note that they applied pulsed radiofrequency to the dorsal root ganglia rather than to the nerves to the spine. They had "excellent results" in 2 cases (7%), "good results" in 12 cases (43%), "fair results" in 9 cases (32%), and unchanged 5 cases (18%). The patients showed significant reduction in visual analog scale results. Martin, et al. {Martin, 2007 #75093} reported similar beneficial effects of pulsed radiofrequency lesion.

    In 2006, Manchikanti, et al. {Manchikanti, 2006 #75095} reported a double-blind randomized study (the best kind) that randomized 60 patients to bupivacaine (local anesthetic) injection alone, bupivacaine + Sarapin, bupivacaine + betamethasone (corticosteroid), and bupivacaine + Sarapin + betamethasone, to block the medial branch. By the way, Sarapin is "a sterile aqueous solution of soluble salts of the volatile bases from Sarraceniaceae (Pitcher Plant)". They found significant pain relief in all the patients, regardless of the presence of Sarapin and betamethasone. In 2007, Manchukonda, et al. {Manchukonda, 2007 #75092} reported a retrospective study of 500 patients that received nerve blocks that suggested that 39% of cervical pains, 34% of thoracic, and 27% of lumbosacral pain is affected by facet joint injections.

    In 2007, Boswell, et al. {Boswell, 2007 #75094} reviewed the literature from 2004 though 2006. They conclude that the there is limited evidence that facet joint injections reduced cervical pain and "moderate" evidence for relief of lumbar pain. On the other hand, medial branch blocks and neurotomies both appear to have moderate evidence supporting short- and long-term pain relief.

    Inadvertent injection into blood vessels is a potential complication of the procedure, particularly the vertebral artery {Huntoon, 2009 #75089}. In 2008, Verrills, et al. {Verrills, 2008 #75091} reported a 3.5% rate of inadvertent vascular injections compared to 8% reported previously. Wasan, et al. {Wasan, 2009 #75090} found that patients with high psychopathology scores were much more likely to report pain relief after nerve blocks than those who have low scores.

    In summary, it seems that diagnostic blocks followed by selective neurotomy does provide pain relieve in 50-70% of cases. The pain recurs after a year and half but, in those patients who respond to the neurotomy initially, a second procedure appears to be as effective. One possible complication is inadvertent injection into the vertebral artery, which may have serious consequences. However, this risk appears to be declining and is comparable in magnitude to the risk of surgical compliations, i.e. 3.5%. Thus, it seems to be a worthwhile therapy with a reasonable risk profile.

    References

    1. McDonald GJ, Lord SM and Bogduk N (1999). Long-term follow-up of patients treated with cervical radiofrequency neurotomy for chronic neck pain. Neurosurgery 45: 61-7; discussion 67-8. Newcastle Bone and Joint Institute, University of Newcastle, NSW, Australia. OBJECTIVE: To determine the long-term efficacy of percutaneous radiofrequency medial branch neurotomy in the treatment of chronic neck pain. METHODS: Between 1991 and 1996, radiofrequency neurotomy was performed in 28 patients diagnosed as having cervical zygapophysial joint pain on the basis of controlled diagnostic blocks. The procedure was repeated in patients whose pain recurred. Outcome measures were the proportion of patients who responded to the initial procedure and the duration of relief subsequently obtained. Outcome was correlated with the operator performing the procedure, the type of electrode used, litigation status, and the type of diagnostic blocks used to establish the diagnosis. RESULTS: Complete relief of pain was obtained in 71% of patients after an initial procedure. No patient who failed to respond to a first procedure responded to a repeat procedure, but if pain returned after a successful initial procedure, relief could be reinstated by a repeat procedure. The median duration of relief after a first procedure was 219 days when failures are included but 422 days when only successful cases are considered. The median duration of relief after repeat procedures was at least 219 days; several patients had ongoing relief at the time of follow-up. Outcome did not differ according to the operator, the type of electrode used, litigation status, or the type of diagnostic block used. CONCLUSION: Radiofrequency neurotomy provides clinically significant and satisfying periods of freedom from pain, and its effects can be reinstated if pain recurs.

    2. Pevzner E, David R, Leitner Y, Pekarsky I, Folman Y and Gepstein R (2005). [Pulsed radiofrequency treatment of severe radicular pain]. Harefuah 144: 178-80, 231. Spinal Care Unit, Meir Medical Center, Kfar Saba. evgenyf@clalit.org.il. Radiofrequency (RF) lesions have been used for over 25 years in the treatment of intractable pain of spinal origin. The conventional idea is that the heat generated in the tissue surrounding the electrode tip leads to destruction of nerve fibers. In case of mechanical back pain, an electrode positioned adjacent to the medial branch of the dorsal root may reduce the input of noxious nerve stimuli and alleviate pain. For treatment of patients with severe radicular pain the authors often apply pulsed radiofrequency current. This technique enables the application of a relatively high voltage near the dorsal root ganglion, avoiding the deleterious thermal effect of the current. It was found to exert a beneficial effect in cases of intractable radicular pain. This study reports the result of pulsed RF in 28 patients suffering from severe radicular pain treated by pulsed radiofrequency current with follow-up at periods of 3, 6 and 12 months after treatment. There were 20 cases of low back pain and 8 with neck pain, with an average age of 56.7 years. The first follow-up after 3 months revealed the following results: excellent results in 2 cases (7.1%), good results in 12 cases (42/9%), fair in 9 (32/1%) and 5 (17/9%) reported that their condition have not changed. Results after 6 and 12 months were excellent in 2 (both groups), good in 7 and 6 respectively, 11 fair (both groups) and unresponsiveness to treatment was noticed in 8 patients after 6 and 9 after 12 months. Significant reduction was found in the Visual Analog Scale for pain from an average of 8.8 to 4.2 after 3 months, 4.8 after 6 months and 4.9 after 1 year. CONCLUSION: Pulsed RF treatment is a safe and simple procedure to control radicular pain in the cervical and lumbar regions. Following the current study the authors stress the need for further prospective, double-blind studies for better investigation of this technique.

    3. Manchikanti L, Damron K, Cash K, Manchukonda R and Pampati V (2006). Therapeutic cervical medial branch blocks in managing chronic neck pain: a preliminary report of a randomized, double-blind, controlled trial: clinical trial NCT0033272. Pain Physician 9: 333-46. Pain Management Center of Paducah, Paducah, KY, USA. drm@apex.net. BACKGROUND: Based on the criteria established by the International Association for the Study of Pain, the prevalence of persistent neck pain, secondary to involvement of cervical facet or zygapophysial joints has been described in controlled studies as varying from 54% to 67%. Intraarticular injections, medial branch nerve blocks and neurolysis of medial branch nerves have been described in managing chronic neck pain of facet joint origin. OBJECTIVES: To determine the clinical effectiveness of therapeutic cervical medial branch blocks in managing chronic neck pain of facet joint origin and to evaluate the effectiveness of the addition of Sarapin and steroids to local anesthetics. DESIGN: A double-blind, randomized, controlled trial. SETTING: An interventional pain management setting in the United States. METHODS: In this preliminary analysis, data from a total of 60 patients were included, with 15 patients in each of the 4 groups. Thirty patients were in a non-steroid group (combined Group I and II); and 30 patients were in a steroid group (combined Group III and IV). All of the patients met the diagnostic criteria of cervical facet joint pain by means of comparative, controlled diagnostic blocks. Four types of interventions were included. Group I served as control, receiving medial branch blocks using bupivacaine. Group II consisted of cervical medial branch blocks with bupivacaine and Sarapin. Group III consisted of cervical medial branch blocks with bupivacaine and betamethasone. Group IV consisted of cervical medial branch blocks with bupivacaine, Sarapin and betamethasone. OUTCOME MEASURES: Numeric pain scores, Neck Pain Disability Index, opioid intake, and work status were evaluated at baseline, 3 months, 6 months and 12 months. RESULTS: Significant pain relief (> or =50%), and functional status improvement was observed at 3 months, 6 months and 12 months. The average number of treatments for 1 year was 3.8 +/- 0.7 in the non-steroid group and 3.4 +/- 1.0 in the steroid group with no significant difference among the groups. Duration of average pain relief with each procedure was 13.4 +/- 3.5 weeks in the nonsteroid group, and it was 15.9 +/- 8.0 weeks in the steroid group with no significant difference among the groups. CONCLUSION: Therapeutic cervical medial branch nerve blocks, with or without Sarapin or steroids, may provide effective management for chronic neck pain of facet joint origin.

    4. Boswell MV, Colson JD, Sehgal N, Dunbar EE and Epter R (2007). A systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician 10: 229-53. Texas Tech University Health Science Center, Lubbock, TX, USA. boswellmv@earthlink.net. BACKGROUND: Facet joints are considered to be a common source of chronic spinal pain. Facet joint interventions, including intraarticular injections, medial branch nerve blocks, and neurotomy (radiofrequency and cryoneurolysis) are used to manage chronic facet-mediated spinal pain. A systematic review of therapeutic facet interventions published in January 2005, concluded that facet interventions were variably effective for short-term and long-term relief of facet joint pain. OBJECTIVE: To provide an updated evaluation of the effectiveness of 3 types of facet joint interventions in managing chronic spinal pain. STUDY DESIGN: A systematic review utilizing criteria established by the Agency for Healthcare Research and Quality (AHRQ) for evaluation of randomized and non-randomized trials and the Cochrane Musculoskeletal Review Group for randomized trials. METHODS: Data sources included relevant literature of the English language identified through searches of MEDLINE and EMBASE (November 2004 to December 2006) and manual searches of bibliographies of known primary and review articles within the last 2 years. Results of the analyses were performed for the different modes of facet joint interventions for the cervical, thoracic and lumbar spine, to determine short- and long-term outcome measurements and complications associated with these procedures. OUTCOME MEASURES: The primary outcome measure was pain relief. For intraarticular facet joint injections and medial branch blocks, short-term pain relief was defined as relief lasting less than 6 weeks and long-term relief as 6 weeks or longer. For medial branch blocks, repeated injections at defined intervals provided long-term pain relief. For medial branch radiofrequency neurotomy, short-term pain relief was defined as relief lasting less than 3 months and long-term relief as lasting 3 months or longer. Other outcome measures included functional improvement, improvement of psychological status, and return to work. RESULTS: For cervical intraarticular facet joint injections, the evidence is limited for short- and long-term pain relief. For lumbar intraarticular facet joint injections, the evidence is moderate for short- and long-term pain relief. For cervical, thoracic, and lumbar medial branch nerve blocks with local anesthetics (with or without steroids), the evidence is moderate for short- and long-term pain relief with repeat interventions. The evidence for pain relief with radiofrequency neurotomy of cervical and lumbar medial branch nerves is moderate for short- and long-term pain relief, and indeterminate for thoracic facet neurotomy. CONCLUSION: With intraarticular facet joint injections, the evidence for short- and long-term pain relief is limited for cervical pain and moderate for lumbar pain. For medial branch blocks, the evidence is moderate for short- and long-term pain relief. For medial branch neurotomy, the evidence is moderate for short- and long-term pain relief.

    5. Martin DC, Willis ML, Mullinax LA, Clarke NL, Homburger JA and Berger IH (2007). Pulsed radiofrequency application in the treatment of chronic pain. Pain Pract 7: 31-5. Pain Medicine Program, Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia, Augusta, Georgia, USA. damartin@mail.mcg.edu. The efficacy of pulsed radiofrequency (PRF) in the treatment of painful lumbosacral spondylosis has been reported. This case series reviews 22 consecutive patients presenting to clinic who had been previously treated with PRF with good results. Patients being prescribed opioids were excluded. During the PRF application, tissue temperature was limited to 43 degrees C. A minimum of 200 mA of current was delivered in each case. The minimum current (at 50 Hz) necessary to stimulate the involved nerve was recorded. The duration of time from PRF treatment until the patient requested a subsequent application was documented. The effective duration of PRF in patients treated for lumbosacral spondylosis ranged from 5 to 18 months (mean +/- SD: 9 +/- 3.7 months; n = 16). PRF applications to dorsal root ganglia were effective from 2 to 12 months (7 +/- 3.8 months; n = 8). Similar results were observed when PRF was applied to cervical medial branch nerves, one suprascapular nerve, and one stellate ganglion. The mean (50 Hz) sensory stimulation thresholds obtained before treatment ranged from 0.08 V to 0.14 V. In this select population of patients not receiving controlled substances, who had a favorable response to a previous PRF application, the duration of pain relief supports the use of PRF as an effective pain treatment.

    6. Manchukonda R, Manchikanti KN, Cash KA, Pampati V and Manchikanti L (2007). Facet joint pain in chronic spinal pain: an evaluation of prevalence and false-positive rate of diagnostic blocks. J Spinal Disord Tech 20: 539-45. Pain Management Center of Paducah, Paducah, KY 42003, USA. STUDY DESIGN: A retrospective review. OBJECTIVES: Evaluation of the prevalence of facet or zygapophysial joint pain in chronic spinal pain of cervical, thoracic, and lumbar origin by using controlled, comparative local anesthetic blocks and evaluation of false-positive rates of single blocks in the diagnosis of chronic spinal pain of facet joint origin. SUMMARY OF BACKGROUND DATA: Facet or zygapophysial joints are clinically important sources of chronic cervical, thoracic, and lumbar spine pain. The previous studies have demonstrated the value and validity of controlled, comparative local anesthetic blocks in the diagnosis of facet joint pain, with a prevalence of 15% to 67% variable in lumbar, thoracic, and cervical regions. False-positive rates of single diagnostic blocks also varied from 17% to 63%. METHODS: Five hundred consecutive patients receiving controlled, comparative local anesthetic blocks of medial branches for the diagnosis of facet or zygapophysial joint pain were included. Patients were investigated with diagnostic blocks using 0.5 mL of 1% lidocaine per nerve. Patients with lidocaine-positive results were further studied using 0.5 mL of 0.25% bupivacaine per nerve on a separate occasion. Medial branch blocks were performed with intermittent fluoroscopic visualization, at 2 levels to block a single joint. A positive response was considered as one with at least 80% pain relief from a block of at least 2 hours duration when lidocaine was used, and at least 3 hours or longer than the duration of relief with lidocaine when bupivacaine was used, and also the ability to perform prior painful movements. RESULTS: A total of 438 patients met inclusion criteria. The prevalence of facet joint pain was 39% in the cervical spine [95% confidence interval (CI), 32%-45%]; 34% (95% CI, 22%-47%) in the thoracic pain; and 27% (95% CI, 22%-33%) in the lumbar spine. The false-positive rate with a single block in the cervical region was 45%, in the thoracic region was 42%, and in the lumbar region 45%. CONCLUSIONS: This retrospective review once again confirmed the significant prevalence of facet joint pain in chronic spinal pain.

    7. Verrills P, Mitchell B, Vivian D, Nowesenitz G, Lovell B and Sinclair C (2008). The incidence of intravascular penetration in medial branch blocks: cervical, thoracic, and lumbar spines. Spine (Phila Pa 1976) 33: E174-7. Metro Spinal Clinic, Caulfield South, Melbourne, Australia. STUDY DESIGN: Clinical observational study. OBJECTIVE: To quantify the incidence of inadvertent intravascular injections in spinal medial branch blocks in a clinical setting. SUMMARY OF BACKGROUND DATA: Previous research established the rate of inadvertent intravascular injection in lumbar medial branch blocks at 8%. The incidence of intravascular injection in cervical and thoracic medial branch blocks has not been reported previously. This study establishes the rate of inadvertent intravascular injection in patients receiving medial branch blocks of the cervical and thoracic spines. Further, this study reports a significantly lower rate of inadvertent intravascular injection for lumbar medial branch blocks than previously reported. METHODS: Patients were originally referred to the clinic, for diagnosis and treatment of chronic spinal origin somatic pain. Medial branch blocks were then performed as diagnostic procedures to confirm the zygapophysial joint(s) as the suspected source of pain. Blocks were performed by experienced practitioners on nonidentified patients over a 3-year period. Clinical observations were recorded for 14,312 separate medial branch block levels. The level of the spine and the incidence of inadvertent intravascular injections were recorded. RESULTS: This study demonstrates that the overall incidence of intravascular penetration in medial branch blocks is rare, with an overall rate of 3.5%. This study also establishes the rate of intravascular injection for levels within the spine: the cervical spine is likely to be intravascular 3.9% of the time and the lumbar spine 3.7%, whereas the thoracic spine is significantly lower, with just 0.7% injections reported as intravascular. Significant differences were also observed between individual vertebral levels. CONCLUSION: The false-negative rate for medial branch blocks is likely to be lower than previously reported. The rate of inadvertent intravascular injection for thoracic medial branch blocks is 0.7%. Cervical and lumbar medial branch blocks are associated with an overall rate of 3.9% and 3.7%, respectively. Although these rates are lower than previously reported, the incidence of false-negative blocks still justifies the use of contrast to confirm nonvascular injection.

    8. Wasan AD, Jamison RN, Pham L, Tipirneni N, Nedeljkovic SS and Katz JN (2009). Psychopathology predicts the outcome of medial branch blocks with corticosteroid for chronic axial low back or cervical pain: a prospective cohort study. BMC Musculoskelet Disord 10: 22. Department of Anesthesiology, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA. awasan@partners.org. BACKGROUND: Comorbid psychopathology is an important predictor of poor outcome for many types of treatments for back or neck pain. But it is unknown if this applies to the results of medial branch blocks (MBBs) for chronic low back or neck pain, which involves injecting the medial branch of the dorsal ramus nerves that innervate the facet joints. The objective of this study was to determine whether high levels of psychopathology are predictive of pain relief after MBB injections in the lumbar or cervical spine. METHODS: This was a prospective cohort study. Consecutive patients in a pain medicine practice undergoing MBBs of the lumbar or cervical facets with corticosteroids were recruited to participate. Subjects were selected for a MBB based on operationalized selection criteria and the procedure was performed in a standardized manner. Subjects completed the Brief Pain Inventory (BPI) and the Hospital Anxiety and Depression Scale (HADS) just prior to the procedure and at one-month follow up. Scores on the HADS classified the subjects into three groups based on psychiatric symptoms, which formed the primary predictor variable: Low, Moderate, or High levels of psychopathology. The primary outcome measure was the percent improvement in average daily pain rating one-month following an injection. Analysis of variance and chi-square were used to analyze the analgesia and functional rating differences between groups, and to perform a responder analysis. RESULTS: Eighty six (86) subjects completed the study. The Low psychopathology group (n = 37) reported a mean of 23% improvement in pain at one-month while the High psychopathology group (n = 29) reported a mean worsening of -5.8% in pain (p < .001). Forty five percent (45%) of the Low group had at least 30% improvement in pain versus 10% in the High group (p < .001). Using an analysis of covariance, no baseline demographic, social, or medical variables were significant predictors of pain improvement, nor did they mitigate the effect of psychopathology on the outcome. CONCLUSION: Psychiatric comorbidity is associated with diminished pain relief after a MBB injection performed with steroid at one-month follow-up. These findings illustrate the importance of assessing comorbid psychopathology as part of a spine care evaluation.

    9. 1. Huntoon MA (2009). The Vertebral Artery is Unlikely to be the Sole Source of Vascular Complications Occurring during Stellate Ganglion Block. Pain Pract Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, U.S.A. Abstract Introduction: Stellate ganglion block (SGB) is commonly performed for upper extremity complex regional pain syndrome and other conditions. Known complications of stellate block include Horner's syndrome, hoarseness, hematoma formation, airway compromise, immediate seizure (presumably from vertebral artery injection), and death. A previous arterial anatomy study demonstrated other vessels, eg, the ascending and deep cervical arteries, reinforcing the blood supply of the spinal cord and brain stem. The potential role of these vessels in the pathogenesis of seizures or hematoma during SGB has not been studied. Methods: The anatomical recording log from 10 cadaver dissections and photographic records of same were reviewed to ascertain the presence of the ascending or deep cervical arteries, or other branches emanating from the thyrocervical or costocervical trunk and their relationship to the medial anterior surface of the C6 and C7 transverse processes. Results: In 4 cases, as determined by the dissection log, and in 6 cases, determined by photographic images, the ascending cervical artery or a branch from the thyrocervical trunk passed over the anterior aspect of the transverse processes of C6 or C7. Discussion: Arterial vessels other than the vertebral artery that also supply the anterior spinal cord and brain stem pass directly anterior to the transverse processes at the most common sites of the SGB. It is anatomically possible, therefore, that accidental injection or induced spasm of these vessels and not the vertebral arteries is responsible for some cases of seizure, hematoma, or other vascular complications during SGB.

  2. #2
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    Dr Young,
    Thank you for the information. My ex boyfriend is a t2-t4. He has neuropathic pain. The VA hospital in Tucson would give him rounds of anathesia to help with the pain. It only helped him for 24 hours, but he felt great. I don't know of any other hospitals that do it, but it helped him immensly. TY again for the information.

  3. #3
    thank you for your promp reply, Dr. Young. I am trying to figure at what point I do the procedure. How much pain must I be in. and if the pain goes away will I be able to lift, swim, ride a bike? all these things put pressure on my c-5. Or do I do what I want to do now (within reason) and when the pain becomes intolerable, then I do the epidural steroid injection and facet and medial branch block. I function ok by limiting myself but also would like to do the things I did in the past. but everyday I sense the stiffness in the neck

  4. #4
    Wise, as of yesterday I began the duragesic patch to get some relief from my pain. From what I undersand, the pain is neuropathic pain. On Tuesday, I went to see a new doctor who was very thorough and has prescribed it for me. We will be working towards getting me out of the bed without pain and have a therapist to help with me with exercises too. We are very hopeful that things will be changing for the better now.

    When I saw this thread the thought crossed my mind if blocking some nerves might help in taking neuropathic pain away or at least easing it for most of us and what or which ones os us would benefit from it. I did notice that in the above post xJdinox did mention her boyfriend getting nerve blocks for it and it helping at least for awhile. What are your thoughts on this? Thank you for any advice or reply.

    Btw, my patch seems to be giving me a bit of relief. I have been prescribed the lowest dose for now. It has given me a bit of time to post here too.

    Raven
    Have courage for the great sorrows of life and patience for the small ones; and when you have laboriously accomplished your daily task, go to sleep in peace. ~Victor Hugo~

    A warrior is not one who always wins,
    but one who keeps on fighting to the end ~ Unknown ~

  5. #5
    Would this help with CE pain? The injection I last had worked for about 30 hours, but it was a steroid & lidocain (or some such) mix.

  6. #6
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    I just had a bi-lateral RF of L3/L4/L5 and S1 and AFTER one set of facet injections. It is working great! I should add also that Dr. Wise is correct; it can be repeated. I have had the L5/S1 RF'd before...twice. And each time the relief lasted well over a year. It is just that this time around was a bit different; doing another level and BOTH sides. I have to admit I have never opted for an RF in my neck since it seems the facet injections done (normally C2/C3) last a good long time. I am ready to get another set done in about 3-4 weeks at the C2/C3 (the wait is only because my PM used a steroid for the RF). And if I remember correctly, the last set was done in August of 2008!

    Monofrio, the key seems to be, at least for me, is to put an ice or cold pack immediately on the site after the injection (alternating on and off for about twenty minutes). And waiting about 3 days before I do anything even considered semi strenous. Swimming is good (but you have to learn CERTAIN exercises that won't aggravate your neck) and I don't think riding a bike is all that bad...but WATCH the lifting! I have had two cervical fusions and can state without a doubt that if I don't watch my activity level, the pain and pressure hits the levels above and below the fusions. So, just be careful. The injections are not cure alls or fixes; they just help to alleviate the pain enabling you to go into PT/rehab. But you certainly don't want to make things worse.
    Last edited by Kathi49; 10-12-2009 at 10:32 AM. Reason: Correction

  7. #7

    real proof

    1: Annu Rev Neurosci. 2009;32:1-32. Links

    Neuropathic pain: a maladaptive response of the nervous system to damage.

    Costigan M, Scholz J, Woolf CJ.
    Neural Plasticity Research Group, Department of Anesthesia and Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02129, USA. mcostigan@partners.org
    Neuropathic pain is triggered by lesions to the somatosensory nervous system that alter its structure and function so that pain occurs spontaneously and responses to noxious and innocuous stimuli are pathologically amplified. The pain is an expression of maladaptive plasticity within the nociceptive system, a series of changes that constitute a neural disease state. Multiple alterations distributed widely across the nervous system contribute to complex pain phenotypes. These alterations include ectopic generation of action potentials, facilitation and disinhibition of synaptic transmission, loss of synaptic connectivity and formation of new synaptic circuits, and neuroimmune interactions. Although neural lesions are necessary, they are not sufficient to generate neuropathic pain; genetic polymorphisms, gender, and age all influence the risk of developing persistent pain. Treatment needs to move from merely suppressing symptoms to a disease-modifying strategy aimed at both preventing maladaptive plasticity and reducing intrinsic risk.
    PMID: 19400724 [PubMed - in process]

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