Scalene Muscle Injections for Neurogenic Thoracic Outlet Syndrome: Case Series

Abstract: Scalene muscle injections are used to confirm the diagnosis of neurogenic thoracic outlet syndrome and predict the response of patients to surgery. We performed a retrospective study to determine if relief of pain was related to brachial plexus blockade in these patients. Methods: We reviewed the charts of 12 patients who had anterior and middle scalene muscle injections, for neurogenic thoracic outlet syndrome, between April 2009 and September 2010. The injections were performed under ultrasound guidance wherein 2 to 5 mL of 0.25% bupivacaine was injected into the belly of the anterior and scalene muscles. The following were noted: (1) sites of preprocedure pain; (2) volume injected into each of the anterior and middle scalene muscles; (3) presence of numbness after injection; and (4) presence and duration of pain relief. Results: All 12 patients had relief of their pain. Six of the twelve patients developed numbness, which ranged from blockade of the C4‐5, C6‐7, and C4‐T1 dermatomes. In the patients who developed numbness, there was no relationship between the duration of numbness and the duration of pain relief or the location of numbness and the location of pain relief. Conclusions: The relief from scalene muscle injections in patients with neurogenic thoracic outlet syndrome is not related to blockade of the brachial plexus. ?     

Image Guidance Technologies for Interventional Pain Procedures: Ultrasound,Fluoroscopy, and CT

Chronic pain is a common medical condition. Patients who suffer uncontrolled chronic pain may require interventions including spinal injections and various nerve blocks. Interventional procedures have evolved and improved over time since epidural injection was first introduced for low back pain and sciatica in 1901. One of the major contributors in the improvement of these interventions is the advancement of imaging guidance technologies. The utilization of image guidance has dramatically improved the accuracy and safety of these interventions. The first image guidance technology adopted by pain specialists was fluoroscopy. This was followed by CT and ultrasound. Fluoroscopy can be used to visualize bony structures of the spine. It is still the most commonly used guidance technology in spinal injections. In the recent years, ultrasound guidance has been increasingly adopted by interventionists to perform various injections. Because its ability to visualize soft tissue, vessels, and nerves, this guidance technology appears to be a better option than fluoroscopy for interventions including SGB and celiac plexus blocks, when visualization of the vessels may prevent intravascular injection. The current evidence indicates the efficacies of these interventions are similar between ultrasound guidance and fluoroscopy guidance for SGB and celiac plexus blocks. For facet injections and interlaminar epidural steroid injections, it is important to visualize bony structures in order to perform these procedures accurately and safely. It is worth noting that facet joint injections can be done under ultrasound guidance with equivalent efficacy to fluoroscopic guidance. However, obese patients may present challenge for ultrasound guidance due to its poor visualization of deep anatomical structures. Regarding transforaminal epidural steroid injections, there are limited evidence to support that ultrasound guidance technology has equivalent efficacy and less complications comparing to fluoroscopy. However, further studies are required to prove the efficacy of ultrasound-guided transforaminal epidural injections. SI joint is unique due to its multiplanar orientation, irregular joint gap, partial ankylosis, and thick dorsal and interosseous ligament. Therefore, it can be difficult to access the joint space with fluoroscopic guidance and ultrasound guidance. CT scan, with its cross-sectional images, can identify posterior joint gap, is most likely the best guidance technology for this intervention. Intercostal nerves lie in the subcostal grove close to the plural space. Significant risk of pneumothorax is associated with intercostal blocks. Ultrasound can provide visualization of ribs and pleura. Therefore, it may improve the accuracy of the injection and reduce the risk of pneumothorax. At present time, most pain specialists are familiar with fluoroscopic guidance techniques, and fluoroscopic machines are readily available in the pain clinics. In the contrast, CT guidance can only be performed in specially equipped facilities. Ultrasound machine is generally portable and inexpensive in comparison to CT scanner and fluoroscopic machine. As pain specialists continue to improve their patient care, ultrasound and CT guidance will undoubtedly be incorporated more into the pain management practice. This review is based on a paucity of clinical evidence to compare these guidance technologies; clearly, more clinical studies is needed to further elucidate the pro and cons of each guidance method for various pain management interventions.     

Cooled Radiofrequency System for the Treatment of Chronic Pain from Sacroiliitis: The First Case‐Series

? Abstract: Sacroiliitis and sacroiliac (SI) joint dysfunction are frequent causes of the chronic lower back pain. Therapeutic solutions include intra‐atricular injections with short‐term pain relief and surgical fusion, which appears ineffective. Radiofrequency (RF) of the joint capsule or lateral branches has been previously reported with variable successes. Cooling tissue adjacent to the electrode (cooled RF) increases the radius of lesion. We present here the first retrospective data on pain relief and changes in function after such RF denervation. We reviewed electronic records of 27 patients with chronic low back pain (median 5 years) who underwent cooled RF of S1, S2, and S3 lateral branches and of dorsal ramus (DR) L5 following two diagnostic SI joint blocks (>50% of pain relief). Patient sample consisted of 20 women and 7 men, 38 to 92 years old. Pain disability index (PDI), visual analog scale (VAS) pain scores, global patient satisfaction (GPE) and opioid use before and 3–4 months after the procedure were analyzed. One patient had an incomplete chart. Observed were improvements in function (PDI) from 32.7 ± 9.9 to 20.3 ± 12.1 (P < 0.001) and VAS pain scores 7.1 ± 1.6 to 4.2 ± 2.5 (P < 0.001) at 3–4 months after the procedure. Opioid use decreased from median 30 to 20 mg morphine equivalent. Eighteen patients rated their improvement in pain scores using GPE as improved or much improved, while eight claimed minimal or no improvement. The majority of patients with chronic SI joint pain experienced a clinically relevant degree of pain relief and improved function following cooled RF of sacral lateral branches and DR of L5 at 3–4 months follow‐up. ?     

Epidural steroid injections for the treatment of dorsopathy

Spondylogenic (discogenic) nerve root syndromes often do not respond well to treatment. There are frequent side effects or drug intolerability, and only short periods of pain relief can be achieved. Thus, patients are not receptive to medication. A group of 40 patients with different clinical symptoms of pain syndrome were investigated in a prospective, double blind, randomized study. The study comprised three stages: recruitment of patients, which was followed by treatment (14 day duration), and outcome evaluation. The patients were divided into two groups: group 1 received epidural steroid injections (nerve blocks) and group 2 received non-steroid treatment, while both groups received manual (musculoskeletal) therapy (58 patients in total). Intensity and quality of the pain were evaluated throughout the therapeutic period. The results indicate that epidural steroid injections in chronic pain of discogenic etiology are highly effective.     

抗癫痫药物治疗神经病理性疼痛的对照研究

目的:通过对腰椎间盘突出症患者硬膜外注射糖皮质激素疗效的回顾性分析,探讨硬膜外注射对腰椎间盘突出症的短期和中远期疗效。方法:收集我院2008年~2009年62例腰椎间盘突出症并伴有下肢疼痛患者行硬膜外注射糖皮质激素的临床资料。完整随访44例,进行治疗后1天、1月和6月疗效随访调查,并行疗效评价分析。结果:硬膜外注射糖皮质激素后1天、1月视觉模拟评分(visual ananlogue scale,VAS)及Oswestry功能障碍指数(Oswestry disability index,ODI)与治疗前相比显著性降低(P<0.05),患者治疗后6个月VAS及ODI与治疗前相比无显著性差异(P>0.05)。VAS和ODI治疗后6个月与治疗后1个月相比,显著升高。结论:硬膜外注射糖皮质激素对椎间盘突出症有较好的短期(治疗后1天和1月)临床疗效,中长期(治疗后6月)疗效欠佳,建议与其他微创治疗方法联合使用。     

Botulinum Toxin Occipital Nerve Block for the Treatment of Severe Occipital Neuralgia: A Case Series

▪ Abstract:   Persistent occipital neuralgia can produce severe headaches that are difficult to control by conservative or surgical approaches. We retrospectively describe a series of six patients with severe occipital neuralgia who received conservative and interventional therapies, including oral antidepressants, membrane stabilizers, opioids, and traditional occipital nerve blocks without significant relief. This group then underwent occipital nerve blocks using the botulinum toxin type A (BoNT-A) BOTOX® Type A (Allergan, Inc., Irvine, CA, U.S.A.) 50 U for each block (100 U if bilateral). Significant decreases in pain Visual Analog Scale (VAS) scores and improvement in Pain Disability Index (PDI) were observed at four weeks follow-up in five out of six patients following BoNT-A occipital nerve block. The mean VAS score changed from 8 ± 1.8 (median score of 8.5) to 2 ± 2.7 (median score of 1), while PDI improved from 51.5 ± 17.6 (median 56) to 19.5 ± 21 (median 17.5) and the duration of the pain relief increased to an average of 16.3 ± 3.2 weeks (median 16) from an average of 1.9 ± 0.5 weeks (median 2) compared to diagnostic 0.5% bupivacaine block. Following block resolution, the average pain scores and PDI returned to similar levels as before BoNT-A block. In conclusion, BoNT-A occipital nerve blocks provided a much longer duration of analgesia than diagnostic local anesthetics. The functional capacity improvement measured by PDI was profound enough in the majority of the patients to allow patients to resume their regular daily activities for a period of time. ▪     

Facet joint injection and facet nerve block: a randomised comparison in 86 patients with chronic low back pain.

Eighty-six patients with refractory chronic low back pain were randomly assigned to receive either facet joint injection or facet nerve block, using local anaesthetic and steroid. There was no significant difference in the immediate response. The duration of response after facet joint injection was marginally longer than after facet nerve block (P less than 0.05 1 month after infiltration), but for both groups the response was usually short-lived; by 3 months only 2 patients continued to report complete pain relief. Patients who had complained of pain for more than 7 years were more likely to report good or excellent pain relief than those with a shorter history (P less than 0.005), but no other clinical feature was of value in predicting the response to infiltration. Facet joint injections and facet nerve blocks may be of equal value as diagnostic tests, but neither is a satisfactory treatment for chronic back pain.     

Upper Cervical Facet Joint and Spinal Rami Blocks for the Treatment of Cervicogenic Headache

(Headache 2010;50:657‐663) Objective.— To evaluate the efficacy of upper cervical facet joint injections and spinal rami blocks in the treatment of cervicogenic headache. Background.— Cervicogenic headache has been recognized as a common and often disabling disorder. The treatment of this headache type remains challenging. Methods.— We conducted a retrospective chart review of 31 patients with refractory cervicogenic headache who underwent fluoroscopically guided C_1/2, C_2/3 facet joint injections and C₂, C₃ spinal rami blocks using a mixture of 0.25% bupivacaine and 3 mg betamehtasone. The outcome measures were the change in headache severity, assessed using an 11‐point numerical pain scale, after treatment, and the duration of head pain relief. Results.— Twenty‐eight (90.3%) patients experienced >50% headache relief after treatment, with an average duration of 21.7 (1‐90) days. Mean (±SD) head pain intensity decreased from 7.5 ± 1.3 before treatment to 2.7 ± 1.9 immediately after it (P < .0001). The procedures were well tolerated. Conclusions.— C_1/2, C_2/3 facet joint injections and C₂, C₃ spinal rami blocks were effective and well tolerated for the treatment of cervicogenic headache in this study. The procedures provided significant and prolonged pain relief in the majority of patients. Larger controlled studies are needed to further evaluate the efficacy of this treatment modality in cervicogenic headache.     

Are Diagnostic Lumbar Facet Injections Influenced by Pain of Muscular Origin?

Introduction: Nonradicular low back pain can be a difficult entity to accurately diagnose and treat. Facet joints, muscle, ligaments, and fascia have all been reported to be etiologies of acute and chronic low back pain. However, the facet joint as a source of low back pain is controversial. The diagnosis of facet joint pain is made by diagnostic facet joint or median nerve branch injections with a local anesthetic. The purpose of this study was to determine if the results of diagnostic facet joint injections are influenced by the technique used to perform these injections. Methods: Seventy‐five male patients aged 45 years or younger and 18 years or older who were injured while performing heavy work with nonradicular low back pain were included in this study. Diagnostic injection therapy was performed following Institutional Review Board approval and the patient's informed consent. Patients were assigned to one of five groups to receive diagnostic injections in a double‐blinded fashion as follows: Group I: facet joint injection with continuous lidocaine administration from the skin to the facet joint as the needle was advanced; Group II: facet joint injection with saline administration from the skin to the facet joint as the needle was advanced; Group III: median nerve branch injection with a lidocaine advancing needle technique; Group IV: median nerve branch injection with saline advancing needle technique; and Group V: injection of the paraspinous muscles with local anesthetic and steroid following noted areas of pain diagnosed with saline injection and radiopaque contrast. After one week, the patients in Groups I to IV who had no pain relief with facet joint or median nerve block injections subsequently received paraspinous muscle injections, while the patients in Group V who had no long‐term relief with muscle injections were given facet joint injections. The appropriate parametric and nonparametric tests were performed with statistical significance defined as P ≤ 0.05. Results: There were no differences among the groups demographically. The incidence of pain relief was significantly higher in subjects who had a continuous injection of local anesthetic into their musculature than in those individuals who received continuous saline followed by an injection of local anesthetic into their facet joint or median nerve branch. Discussion: The results of this study demonstrated that local anesthetic injections are useful for the diagnosis of nonradicular low back pain but may yield false positive results with respect to lumbar facet pain depending upon the technique utilized.     

Value of the magnetic resonance imaging in patients with painful lumbar spinal stenosis (LSS) undergoing lumbar epidural steroid injections

OBJECTIVES: Purpose of this study is to examine the relationship between the magnetic resonance imaging (MRI) findings, pain scores, and opiates use in patients with lumbar spinal stenosis (LSS) undergoing lumbar epidural steroid (LES) injections by retrospective review of 719 patients' electronic medical records. METHODS: Reviewed were Visual Analog Scale (VAS) pain scores and opioid use before and 8 to 12 weeks after series of LES injections. The stenosis pain index (SPI) was produced by adding an assigned numerical value of severity (1=mild, 2=moderate, 3=severe) to the number of lumbar vertebral levels affected by LSS on MRI (lateral or central). RESULTS: The average age of patients was 68.4 years. There was no relationship between the pretreatment age, sex, or number of vertebral levels affected on MRI with pretreatment VAS pain scores or opioid use. The degree of LSS present on MRI, categorized as a mild, moderate, or severe, correlated clearly with initial VAS pain scores (P=0.017). The improvement in VAS pain scores after LES injections correlated well with number of levels affected (P=0.003) and the severity of stenosis (P=0.12). Positive correlation was observed between change in VAS pain score 8 to 12 weeks after the series of LES injections and the SPI (P=0.001). There were no differences found in opioid use. DISCUSSION: The improvement in VAS pain scores after LES injections correlated well with the changes in the SPI except in those patients classified on MRI as severe LSS and more than 3 lumbar levels affected. That patient group is unlikely to benefit from LES injections.     

开胸术后肋间神经低温毁损镇痛效果观察

目的:观察肋间神经冷冻术用于胸部手术后患者镇痛的临床效果。方法:250例全麻胸部手术患者,随机分为两组:实验组(n=125,施行肋间神经冷冻术);对照组(n=125,未施行肋间神经冷冻术)。术后观察并记录镇痛药物用量、疼痛评分(VAS)及肺炎、肺不张等并发症的发生情况。结果:两组间术后镇痛药物用量、VAS评分及肺部并发症的发生率有显著性差异(P<0.01)。结论:冷冻肋间神经能减轻患者术后疼痛、减少镇痛药物用量,并可减少术后并发症的发生。     

Radio Frequency Ablation and Pulsed Radiofrequency for Treating Peripheral Neuralgias

Purpose of Review

Peripheral nerve pain is common among patients with typical management including the use of pain medications, neuropathic agents, steroid injections, and nerve blocks. Additionally, the use of pulsed radiofrequency (PRF) and radiofrequency ablation (RFA) can be used in the management of chronic peripheral nerve pain. Previous studies investigating the effectiveness of RFA and PRF, typically case reports, have demonstrated that peripheral nerve RFA and PRF have the potential to provide relief of chronic pain for long duration. Our study aimed at testing efficacy of RFA/PRF for treating peripheral neuralgia. This was a retrospective review. We identified 16 patients who received 17 RFAs/PRFs. Outcomes of interest collected included pain scores before and after procedures, percent improvement in pain after each procedure, and duration of improvement until the time of data collection. In addition, demographic data including age, sex, and nerves involved were collected.

Recent Findings

Eleven patients (12 RFAs/PRFs) (80%) reported improvement after their procedure. Pain scores improved significantly from 6.3?±?2.3 before each procedure to 3.6?±?2.7 after each procedure (p?=?0.003). Eleven patients (12 RFAs/PRFs) reported an average improvement of 60.8%?±?35% after their procedure with an average duration of improvement of 128.8?±?106.8 days.

Summary

RFA and PRF can be used to treat chronic peripheral pain after conservative methods fail to do so. Large clinical trials are needed to confirm our finding.

     

Urgent care peripheral nerve blocks for refractory trigeminal neuralgia

Objective

After medication failure, patients with refractory trigeminal neuralgia (TGN) often present urgently and seek more potent or invasive therapies such as opioids or surgical options. Peripheral nerve blocks, safe and simple, may offer extended pain relief prior to opioid use or more invasive ganglion level procedures.

Abstract 2: Efficacy of epidural steroid injections

Objectives: To test the efficacy of epidural steroid injections (ESIs) for the relief of radicular-, facet joint-, and lumbar stenosis-related pain 3 months postinjections and to demonstrate whether the presence of litigation and smoking influenced the response to treatment. Design: Prospective survey. Setting: Community-based hospital. Participants: 300 patients who received steroid injections for radicular-, facet joint-, and lumbar stenosis-related pain. Interventions: All participants had clinical and diagnostic evidence of lumbar radiculopathy, spinal stenosis, or facet pain. Each was then treated with a series of ESIs. Each patient filled out a preinjection survey to determine the duration and distribution of their pain. A 10-point analog pain scale determined their pre-injection pain. Factors also evaluated were the etiology of pain, the presence of a lawsuit, and if the patient was a habitual smoker. At 3 months postinjection, each participant received a survey to rate their current pain and declare other interventions such as physical therapy and surgery. Main Outcome Measures: Percentage of participants who received pain relief from their ESIs and specifically which etiology of back pain showed a better response. Results: 3 months after ESIs, approximately 80% of patients had a decrease in their symptoms by 2 or more points on the 10-point analog pain scale. Patients who experienced the most pain relief were those with radicular or stenotic symptoms, nonsmoking, or without concomitant litigation. Conclusion: Steroid injections for back pain of radicular or stenotic nature (not facet), especially for nonsmokers or those without litigation, are an effective means of treating low back pain (LBP) in the first 3 months. This study will be followed by a 6 month and 12 month survey to determine the long-term efficacy of steroid injections for LBP.     

Thoracic Epidural Steroid Injection for Rib Fracture Pain

Treatment for rib fracture pain can be broadly divided into pharmacologic approaches with oral and/or parenteral medication and interventional approaches utilizing neuraxial analgesia or peripheral nerve blocks to provide pain relief. Both approaches attempt to control nociceptive and neuropathic pain secondary to osseous injury and nerve insult, respectively. Success of treatment is ultimately measured by the ability of the selected modality to decrease pain, chest splinting, and to prevent sequelae of injury, such as pneumonia. Typically, opioids and NSAIDs are the drugs of first choice for acute pain because of ease of administration, immediate onset of action, and rapid titration to effect. In contrast, neuropathic pain medications have a slower onset of action and are more difficult to titrate to therapeutic effect. Interventional approaches include interpleural catheters, intercostal nerve blocks, paravertebral nerve blocks, and thoracic and lumbar epidural catheters. Each intervention has its own inherent advantages, disadvantages, and success rates. Rib fracture pain management practice is founded on the thoracic surgical and anesthesiology literature. Articles addressing rib fracture pain are relatively scarce in the pain medicine literature. As life expectancy increases, and as healthcare system modifications are implemented, pain medicine physicians may be consulted to treat increasing number of patients suffering rib fracture pain and may need to resort to novel therapeutic measures because of financial constraints imposed by those changes. Here we present the first published case series of thoracic epidural steroid injections used for management of rib fracture pain.     

抗病毒联合皮下及肋间神经阻滞治疗带状疱疹痛

目的：观察抗病毒治疗联合镇痛药物治疗带状疱疹痛的临床效果.方法：60例胸部带状疱疹神经痛患者随机分为三组,A组：皮内注射消炎镇痛药＋抗病毒治疗;B组：肋间神经阻滞＋抗病毒治疗;C组：单纯抗病毒治疗.以视觉模拟评分（VAS）和睡眠质量评分（QS）评定治疗效果.结果：治疗后从即刻开始至观察期（30d）结束,A、B组VAS评分较治疗前显著降低（P＜0.01）,睡眠状况也明显改善（P＜0.01）;而C组患者仅在第14天开始疼痛有所减轻,睡眠状况好转.结论：采用皮内注射或肋间神经阻滞行镇痛治疗、联合抗病毒药物治疗对带状疱疹患者的疼痛缓解和睡眠质量改善有很好的疗效.     

Efficacy and safety of high concentration lidocaine for trigeminal nerve block in patients with trigeminal neuralgia

AIMS: Local anaesthetics, which act as neurolytics and Na(+) channel blockers, have been used for disrupting the neural firings in certain neuropathic pain conditions. This study was undertaken to investigate the clinical outcome of trigeminal nerve block with 10% lidocaine in the management of trigeminal neuralgia (TN). METHODS: Thirty-five patients with primary TN received trigeminal nerve blocks with 10% lidocaine. Success was defined as complete pain relief or mild pain without medication 1 day after the treatment. We followed the patients up every 2 months assessing for pain recurrence, sensory changes and other complications for a total of 37-45 months (median 43 months). RESULTS: Twelve of the 35 patients (34.3%) responded favourably to the treatment and were considered as success. Eleven patients experienced complete pain relief and one could tolerate pain without medication 1 day after the blocks, which lasted for 3-172 weeks. Four patients experienced mildly decreased sensation in the region of the face supplied by the nerve 1 day after the blocks; however, all recovered normal skin sensation in 6 months. There was neither allodynia nor other sensory discomfort. The pain intensity and current pain duration before treatment were significantly different between the two groups. CONCLUSION: Trigeminal nerve block with high concentration lidocaine (10%) is capable of achieving an intermediate period of pain relief, particularly in patients with lower pain intensity and shorter pain duration prior to the procedure.     

Effect of local anesthesia on atypical odontalgia--a randomized controlled trial

The aim of the study was to evaluate the analgesic effect of lidocaine in a double-blind, controlled multi-center study on patients with atypical odontalgia (AO)--a possible orofacial neuropathic pain condition. Thirty-five consecutive AO patients (range 31-81 years) with a mean pain duration of 7.2 years (range 1-30 years) were recruited from four different orofacial pain clinics in Sweden. In a randomized cross-over design, 1.5 ml local anesthesia (20mg/ml lidocaine and 12.5 microg/ml adrenaline) or 1.5 ml saline (9 mg/ml NaCl solution) (placebo) was injected to block the painful area. The VAS pain scores showed an overall effect of time (ANOVA: P<0.001) and treatment (ANOVA: P=0.018) with a significant interaction between the factors (ANOVA: P<0.001). Overall, VAS pain relief was significantly greater at 15-120 min following the lidocaine injections compared to the placebo injections (Tukey: P<0.05). All patients demonstrated significant disturbances in somatosensory function on the painful side compared to the non-painful side as revealed by quantitative sensory tests, however, only one significant inverse correlation was found between percentage pain relief and the magnitude of brush-evoked allodynia (Spearman: P<0.01). In conclusion, AO patients experienced significant, but not complete, pain relief from administration of local anesthetics compared with placebo. The findings indicate that the spontaneous pain in AO patients only to some extent is dependent on peripheral afferent inputs and that sensitization of higher order neurons may be involved in the pathophysiology of AO.     

Cervical steroid epidural nerve blocks in the palliation of pain secondary to intractable tension-type headaches

Headaches are among the most common pain syndromes encountered in clinical practice. Of these headaches, 70%–80% are ultimately diagnosed as tension type headaches (TTH). Most patients suffering from TTH will experience improvement when treated with traditional modalities, including tricyclic antidepressants, nonsteroidal antiinflammatory agents, and cognitive therapies. Unfortunately, not all patients respond to the traditional modalities. We wish to report 48 patients suffering from pain secondary to intractable TTH who failed to respond to traditional treatment modalities and were treated with cervical steroid epidural nerve blocks (CSENB). The average number of CSENB performed per patient was four. Average pain score prior to CSENB was 4.8. Six weeks following CSENB, the average pain score was 0.95. At 3 months follow-up, the VAS score was 0.35. These results suggest that CSENB may appear to provide effective relief of pain to some patients with intractable TTH.