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Thread: Cervical medial branch block-yes or no?

  1. #1

    Cervical medial branch block-yes or no?

    I have just begun research on the risks/benefits of a cervical medial branch
    block & neurotomy suggested by a new doctor. I would like to hear from
    others who have experienced this treatment for pain. Just found this site today so I may not be in the right place for this particular question. Thanks!

  2. #2
    Quote Originally Posted by Prism33
    I have just begun research on the risks/benefits of a cervical medial branch
    block & neurotomy suggested by a new doctor. I would like to hear from
    others who have experienced this treatment for pain. Just found this site today so I may not be in the right place for this particular question. Thanks!
    Prism33,

    Something is not right about your terminology. There is no such thing a "cervical medial branch". Are you sure that you are not talking about the median nerve? What kind of pain do you have? What kind of neurotomy is being proposed? In general, cutting of peripheral nerves does not eliminate pain and may aggravate peripheral nerve pain.

    Wise.

  3. #3
    Anyone considering any type of ablative surgery for pain should be well acquainted with the risks and possible long-term complications. Don't count on getting this information from a doctor who's proposing it, he's too likely to gloss over it or simply be in denial of it. Among the posible problems are phantom pain, or a return of the pain, sometimes even worse than before, after what appeared at first to be a successful surgery.

  4. #4
    Just heard about this procedure yesterday so it's no surprise that I have the terminology wrong! A truck hit me in my driver's side 2 years ago and I have been in pain since, neck and lower back. The procedure as best as I can understand it at this moment - put simply- begins with an epedural (or similar) near the facet. If this works then it is followed with "burning" the nerves to make the fix permanent. The doc gave me an article by a Paul Dreyfuss, the heading reads, " Cervical, Thoracic, Lumbosacral Medial Branch Block". My previous diagnosis was myofacsial pain syndrome. Of course, like everyone else I want a fix not a temporary cover up!! One can hope!

  5. #5
    Quote Originally Posted by Prism33
    Just heard about this procedure yesterday so it's no surprise that I have the terminology wrong! A truck hit me in my driver's side 2 years ago and I have been in pain since, neck and lower back. The procedure as best as I can understand it at this moment - put simply- begins with an epedural (or similar) near the facet. If this works then it is followed with "burning" the nerves to make the fix permanent. The doc gave me an article by a Paul Dreyfuss, the heading reads, " Cervical, Thoracic, Lumbosacral Medial Branch Block". My previous diagnosis was myofacsial pain syndrome. Of course, like everyone else I want a fix not a temporary cover up!! One can hope!
    Prism33, I just looked it up the article by Paul Dreyfuss http://www.spineuniverse.com/display...ticle1178.html and did a literature search for medial branch block. According to the Dreyfuss article, the medial branches are tiny peripheral nerves that mediate the pain associated with facet joints in the spine.

    I found the following studies.

    Machikanti, et al. (2006) did a double-blind randomized trial of 60 patients segregated into four groups:
    • Group I. Control, medial branch blocks with bupivacaine
    • Group II. block with bupivacaine and Sarapin.
    • Group III. block with bupivacaine and betamethasone (a steroid)
    • Group IV. block with bupivacaine, Sarapin, and betamethasone.
    They found significant pain relieve at 3, 6, and 12 months. The duration of pain relieve was 13.4±3.5 weeks in the non-steroid group and 15.9±8 weeks in the steroid group. The average number of treatments was 3.8 in the non-steroid group and 3.4 times in the steroid group (no difference). This study does not rule out a placebo effect.

    In a second study, Manchikanti, et al. evaluated thoracic medial branch block and found that 71% of the patients showed >50% reduction in pain scores and that the percentage of patients was sustained for 36 months.

    Lindner, et al. (2006) studied 48 patients with chronic low back pain, using pulsed radiofrequency treatment. Amazingly, they found that 21/29 non-operated patients responded and 5/19 operated patients responded. Shim, et al. (2006) used ultrasound guided lumbar medial branch block with fluoroscopy control. The visual analog score fell from 52 to 16 after the block. Finally, Shin, et al. (2006) reported the radiofrequencey neurotomy of cervical medial branches resulted in 68% successful outcome.

    So, the treatment is not 100% effective but it seem help between 60-70% of people and for prolonged periods.

    Wise.

    References
    1. 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. 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. Pain Management Center of Paducah, Paducah, KY, USA. drm@apex.net http://www.ncbi.nlm.nih.gov/entrez/q..._uids=17066118
    2. Manchikanti L, Manchikanti KN, Manchukonda R, Pampati V and Cash KA (2006). Evaluation of therapeutic thoracic medial branch block effectiveness in chronic thoracic pain: a prospective outcome study with minimum 1-year follow up. Pain Physician 9: 97-105. BACKGROUND: The prevalence of persistent upper back and mid back pain due to involvement of thoracic facet joints has been described in controlled studies as varying from 43% to 48% based on IASP criteria. Therapeutic intraventions utilized in managing chronic neck pain and low back pain of facet joint origin include intraarticular injections, medial branch nerve blocks, and neurolysis of medial branch nerves by means of radiofrequency. These interventions have not been evaluated in managing chronic thoracic pain of facet joint origin. OBJECTIVE: To determine the clinical effectiveness of therapeutic thoracic medial branch blocks in managing chronic upper back and mid back pain of facet joint origin. DESIGN: A prospective outcome study. SETTING: Interventional pain management setting in the United States. METHODS: Fifty-five consecutive patients meeting the diagnostic criteria of thoracic facet joint pain by means of comparative, controlled diagnostic blocks were included in this evaluation. All medial branch blocks were performed in a sterile operating room under fluoroscopic visualization with mild sedation with midazolam and/or fentanyl. Statistical methods incorporated intent-to-treat analysis. OUTCOME MEASURES: Numeric pain scores, significant pain relief > or = 50%), Oswestry Disability Index, work status and Pain Patient Profile (P-3). Significant pain relief was defined as an average 50% or greater reduction of numeric pain rating scores. RESULTS: The results showed significant differences in numeric pain scores and significant pain relief (50% or greater) in 71% of the patients at three months and six months, 76% at 12 months, 71% at 24 months, and 69% at 36 months, compared to baseline measurements. Functional improvement was demonstrated at one year, two years, and three years from baseline. There was significant improvement with increase in employment among the patients eligible for employment (employed and unemployed) from baseline to one year, two years, and three years (61% vs 96% to 100%) and improved psychological functioning. CONCLUSION: Therapeutic thoracic medial branch blocks were an effective modality of treatment in managing chronic thoracic pain secondary to facet joint involvement confirmed by controlled, comparative local anesthetic blocks. Pain Management Center of Paducah, Kentucky 42003, USA. drm@apex.net http://www.ncbi.nlm.nih.gov/entrez/q..._uids=16703969
    3. Lindner R, Sluijter ME and Schleinzer W (2006). Pulsed radiofrequency treatment of the lumbar medial branch for facet pain: a retrospective analysis. Pain Med 7: 435-9. BACKGROUND: The use of pulsed radiofrequency (PRF) for treatment of the medial branch is controversial. STUDY DESIGN: A retrospective study of the results of PRF treatment of the medial branch in 48 patients with chronic low back pain was carried out. Patients who did not respond were offered treatment with conventional radiofrequency heat lesions. PATIENT MATERIAL: Patients were included who had low back pain and >50% pain relief following a diagnostic medial branch block. The mean age was 53.1 +/- 13.5 years, the mean duration of pain was 11.4 +/- 10.9 years (range 2-50). Nineteen patients had undergone surgery. METHODS: Pain scores on a numeric rating scale of 1-10 were noted before and after the diagnostic nerve block, before the procedure, and at 1-month and 4-month follow-up. PRF was applied for 2 minutes at a setting of 2 x 20 ms/s and 45 V at a minimum of two levels using a 22G electrode with a 5 mm active tip. Heat lesions were made at 80 degrees C for 1 minute. OUTCOME DEFINITION: A successful outcome was defined as a >60% improvement on the numeric rating scale at 4-month follow-up. RESULTS: In 21/29 nonoperated patients and 5/19 operated patients, the outcome was successful. In the unsuccessful patients who were subsequently treated with heat lesions, the success rate was 1/6. CONCLUSION: The setup of our study does not permit a comparison with the results of continuous radiofrequency (CRF) for the same procedure, other than the detection of an obvious trend. When comparing our results with various studies on CRF of the medial branch such a trend could not be found. Based on these retrospective data, prospective and randomized trials, for example, radiofrequency vs PRF are justified. Department of Anesthesiology, Intensive Care and Pain Treatment, The Swiss Paraplegic Center, Nottwil, Switzerland. http://www.ncbi.nlm.nih.gov/entrez/q..._uids=17014603
    4. Shim JK, Moon JC, Yoon KB, Kim WO and Yoon DM (2006). Ultrasound-guided lumbar medial-branch block: a clinical study with fluoroscopy control. Reg Anesth Pain Med 31: 451-4. BACKGROUND AND OBJECTIVES: For diagnostic lumbar medial-branch blocks, fluoroscopic guidance is considered mandatory, but this technique comes with radiation exposure. The clinical feasibility of the ultrasound-guided lumbar medial-branch block has been demonstrated. We evaluated the success rate and validity of this new method by use of fluoroscopy controls in patients previously diagnosed with lumbar facet joint-mediated pain. METHODS: In 20 patients, 101 lumbar medial-branch blocks were performed under ultrasound guidance. The target point was the groove at the cephalad margin of the transverse process adjacent to the superior articular process. C-arm fluoroscopy was performed afterward to confirm the needle position. Pain scores were assessed by use of visual analog scale (VAS 0 to 100). RESULTS: All 101 needles were placed in the correct lumbar segment. Ninety-six of the 101 needletips were in the correct position with a success rate of 95%. Two needles were associated with intravascular spread of the contrast dye. VAS score was reduced from 52 to 16 after the block. CONCLUSIONS: Ultrasound-guided lumbar medial-branch blocks can be performed with a high success rate. However, to be completely independent from fluoroscopy controls, this technique requires further studies regarding the detection of intravascular spread. Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea. http://www.ncbi.nlm.nih.gov/entrez/q..._uids=16952818
    5. Shin WR, Kim HI, Shin DG and Shin DA (2006). Radiofrequency neurotomy of cervical medial branches for chronic cervicobrachialgia. J Korean Med Sci 21: 119-25. Chronic neck and arm pain or cervicobrachialgia commonly occurs with the degeneration of cervical spine. Authors investigated the usefulness of radiofrequency (RF) neurotomies of cervical medial branches in patients with cervicobrachialgia and analyzed the factors which can influence the treatment outcome. Demographic data, types of pain distribution, responses of double controlled blocks, electrical stimulation parameters, numbers and levels of neurotomies, and surgical outcomes were evaluated after mean follow-up of 12 months. Pain distribution pattern was not significantly correlated with the results of diagnostic blocks. Average stimulation intensity was 0.45 V, ranging from 0.3 to 0.69, to elicit pain response in cervical medial branches. The most common involvement of nerve branches was C4 (89%), followed by C5 (82%), C6 (75%), and C7 (43%). Among total of 28 patients, nineteen (68%) reported successful outcome according to outcome criteria after 6 months of followup (p=0.001), and eight (42%) of 19 patients reported complete relief (100%) of pain. Four patients showed recurrence of pain between 6 and 12 months. It was therefore concluded that cervical medial branch neurotomy is considered useful therapeutic modality for the management of cervicobrachialgia in selected patients, particularly in degenerative zygapophyseal disorders. Department of Neurosurgery, Presbyterian Medical Center, Jeonju, Korea. http://www.ncbi.nlm.nih.gov/entrez/q..._uids=16479077

  6. #6
    Wow! Thank you for doing the research! Hopefully, I'll have time tomorrow to go through it very carefully. This is all new to me so it will take some work to digest it all. I very much appreciate it. Hopefully, someone that has experienced this will speak up as well.

  7. #7
    Dear Dr. Young,

    Thank you for taking the time to comment on MBB. I have had personal experience with this, but not for my central pain. It was rather for a cervical facet syndrome which presumably had to do with multiple vertebrectomies, fusions, and who knows what else. In other words, it was mechanical and not for nociceptive pain, although CP hyperpathia certainly can upgrade noxious events, even if neuropathy is not causative.

    Anyone who has wrestled will find the experience of MBB extraordinary. Although I have no physical activity and have not for years, my neck muscles kept bending the needle. It took many passes and a very long time and a bigger needle. You are awake of course and it is a very big needle--(ten feet long and one foot thick, more or less, come to think of it, maybe an 18 or 20 gauge, about six inches or so. big enough to start an IV in a rhinoceros). It requires some considerable endurance of pain. The injecting needle goes inside the trochar so it is not a picnic. The CT fluoro does not look as comforting as those ergonomic graceful circles, there seemed to be pieces of dried blood all over it--I have no idea what it was, but probably it was dried blood. The radiologist had a neat trick for the local. He added a little bicarb to the mix which took away the sting of the local. That was the least he could do considering he was sticking the giant needle in my neck. Actually I wonder why more docs don't do that. He blocked the MBB and also hit the facet zone, the actual facets have disappeared. In my case they did it six times. (three levels, bilat) All injections involved both a local anesthetic and kenalog. I got about three hours of remarkable relief and about two months of significant relief. I was not prepared for the mental side effects of the kenalog. It caused me to think I was going crazy. Of course, I think my total was something like 200 mg. of Kenalog. At that dose, the steroids affect your thinking and if you have not been forewarned, you will wonder what is happening to you. I retained water for three months afterward. I suspect my glucose tolerance test would have been abnormal for at least a year.

    I felt the block was worth it for diagnostic purposes, to rule out a neuropathic etiology, and to avoid yet another worrhless surgery, but the relief was short lived. I learned that a medical faculty member had had the epidural version of the block just a month before and had died on the table from vasospasm. I kept my injection at the medial branch and did not ask them to see if an epidural dose would give better or more long lasting relief, so I cannot speak to that and do not wish to assume the risk.

    I have seen doctors who attempt to freeze the medial branch with a cryoprobe and then went back in. The nerve regrows in a year no matter how it is destroyed, so I am very skeptical of reports claiming 36 months relief from injection.

    My neuroradiologist said docs in the pain clinic were probably only hitting the medial branch about 30% of the time because there was no CT fluoro, however, he knew of a radiologist who had gotten so good at them that he could do them without any imaging, just by feel. This was the result of long years of doing it under CT fluoro until he had the feel of each layer.

    P.S. If you have this done, ask about CT fluoroscopy, since the accuracy is good. There is more radiation, which you would have to consider.

    That is my two cents. Thank you again for the literature references.
    Last edited by dejerine; 02-15-2007 at 08:56 PM.

  8. #8
    the word nociceptive is a typo. It should read the MBB was NOT done for neuropathic pain. The server wont' let me edit my original.

  9. #9

    Smile

    My hubby had his first cervical medial branch block procedure today....
    hmmmm..not sure about this procedure and the one that is suppose to follow it and be up to 3-6 months of relief from pain for him. He is just trying to hold out on the 6 hrs the doc asked and not take any pain meds....but he is in pain....I say to heck with it take a pain pill...but I don't like pain! His pain is in his neck and shoulders from cancer(head & neck)...he has had numerous operations,chemo,radiation...(adenocarcinoma of salivary glands and submandibular carcinoma.)
    He is stable at this point but we never kid ourselves with this very aggressive and invasive nasty cancer....but we never quit fighting it either!
    He had steroid shots the last few weeks and it gave him some relief.
    He also has been trying some muscle relaxers and he says they are helping.
    Any input would be helpful.... Thanks!

  10. #10
    Senior Member alan's Avatar
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    I'd like some kind of nerve block that would provide some relief to my shoulder blade areas. Does such a block exist?
    Alan

    Proofread carefully to see if you any words out.

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