Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 417 patients

OBJECTIVE: The primary objective of this retrospective chart review is to describe 1 year's experience of an academic emergency department (ED) in treating a wide spectrum of headache classifications with intramuscular injections of 0.5% bupivacaine bilateral to the spinous process of the lower cervical vertebrae. BACKGROUND: Headache is a common reason that patients present to an ED. While there are a number of effective therapeutic interventions available for the management of headache pain, there clearly remains a need for other treatment options. The intramuscular injection of 1.5 mL of 0.5% bupivacaine bilateral to the sixth or seventh cervical vertebrae has been used to treat headache pain in our facility since July 2002. The clinical setting for the study was an academic ED with an annual volume of over 75,000 patients. METHODS: We performed a retrospective review of over 2805 ED patients with the discharge diagnosis of headache and over 771 patients who were coded as having had an anesthetic injection between June 30, 2003 and July 1, 2004. All adult patients who had undergone paraspinous intramuscular injection with bupivacaine for the treatment of their headache were gleaned from these 2 larger databases and were included in this retrospective chart review. A systematic review of the medical records was accomplished for these patients. RESULTS: Lower cervical paraspinous intramuscular injections with bupivacaine were performed in 417 patients. Complete headache relief occurred in 271 (65.1%) and partial headache relief in 85 patients (20.4%). No significant relief was reported in 57 patients (13.7%) and headache worsening was described in 4 patients (1%). Overall a therapeutic response was reported in 356 of 417 patients (85.4%). Headache relief was typically rapid with many patients reporting complete headache relief in 5 to 10 minutes. Associated signs and symptoms such as nausea, vomiting, photophobia, phonophobia, and allodynia were also commonly relieved. CONCLUSION: Our observations suggest that the intramuscular injection of small amounts of 0.5% bupivacaine bilateral to the sixth or seventh cervical spinous process appears to be an effective therapeutic intervention for the treatment of headache pain in the outpatient setting.     

Ear Pain Due to Cervical Spine Arthritis: Treatment With Cervical Facet Injection

Two patients with cervical spine arthritis and ear pain were recently evaluated at our clinic. Injection of the C1-2 facet joints with local anesthetic plus corticosteroid resulted in relief of the pain. Therapeutic cervical facet injections may be indicated in cases of recalcitrant head and neck pain due to cervical spine arthritis.     

Intracerebroventricular opiate infusion for refractory head and facial pain

AIM: To study the risks and benefits of intracerebroventricular(ICV) opiate pumps for the management of benign head and face pain.METHODS: SSix patients with refractory trigeminal neuralgia and/or cluster headaches were evaluated for implantation of an ICV opiate infusion pump using either ICV injections through an Ommaya reservoir or external ventricular drain. Four patients received morphine ICV pumps and two patient S received a hydromorphone pump. Of the Four patients with morphine ICV pumps, one patient had the medication changed to hydromorphone. Preoperative and post-operative visual analog scores(VAS) were obtained. Patients were evaluated post-operatively for a minimum of 3 mo and the pump dosage was adjusted at each outpatient clinic visit according to the patient's pain level.RESULTS: All 6 patients had an intracerebroventricular opiate injection trial period, using either an Ommaya reservoir or an external ventricular drain. There was an average VAS improvement of 75.8%. During the trial period, no complications were observed. Pump implantation was performed an average of 3.7 wk(range 1-7) after the trial injections. After implantation, an average of 20.7 ± 8.3 dose adjustments were made over 3-56 mo after surgery to achieve maximal pain relief. At the most recent follow-up(26.2 mo, range 3-56), VAS scores significantly improved from an average of 7.8 ± 0.5(range 6-10) to 2.8 ± 0.7(range 0-5) at the final dose(mean improvement 5.0 ± 1.0, P 0.001). All patients required a stepwise increase in opiate infusion rates to achieve maximal benefit. The most common complications were nausea and drowsiness, both of which resolved with pump adjustments. On average, infusion pumps were replaced every 4-5 years.CONCLUSION: These results suggest that ICV delivery of opiates may potentially be a viable treatment option for patients with intractable pain from trigeminal neuralgia or cluster 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.     

8. Occipital Neuralgia

Occipital neuralgia is defined as a paroxysmal shooting or stabbing pain in the dermatomes of the nervus occipitalis major and/or nervus occipitalis minor. The pain originates in the suboccipital region and radiates over the vertex. A suggestive history and clinical examination with short‐term pain relief after infiltration with local anesthetic confirm the diagnosis. No data are available about the prevalence or incidence of this condition. Most often, trauma or irritation of the nervi occipitales causes the neuralgia. Imaging studies are necessary to exclude underlying pathological conditions. Initial therapy consists of a single infiltration of the culprit nervi occipitales with local anesthetic and corticosteroids (2 C+). The reported effects of botulinum toxin A injections are contradictory (2 C±). Should injection of local anesthetic and corticosteroids fail to provide lasting relief, pulsed radio‐frequency treatment of the nervi occipitales can be considered (2 C+). There is no evidence to support pulsed radio‐frequency treatment of the ganglion spinale C2 (dorsal root ganglion). As such, this should only be done in a clinical trial setting. Subcutaneous occipital nerve stimulation can be considered if prior therapy with corticosteroid infiltration or pulsed radio‐frequency treatment failed or provided only short‐term relief (2 C+).     

椎旁阻滞联合牛痘疫苗接种家兔炎症皮肤提取物治疗带状疱疹神经痛的疗效观察

目的:观察单纯药物治疗及联合椎旁神经阻滞治疗胸腰背部带状疱疹神经痛的疗效。方法:选择2009年3月至2010年5月我院门诊及住院的60例经确诊患带状疱疹皮损已痊愈而后持续、剧烈、顽固性疼痛、痛觉过敏、麻木、感觉异常且自然病程1~22月,病变累及范围限于T1~L5节段神经支配区的患者,将其随机分为椎旁阻滞与牛痘疫苗接种家兔炎症皮肤提取物(神经妥乐平,NTP)联合用药组(阻滞组)及单纯NTP组(单药组),每组30例。分别给予静脉NTP制剂7.2 NU,每日静滴,连续应用15天。阻滞组在此基础上据疱疹累及的脊神经节段分别给予腰椎旁、胸椎旁神经阻滞治疗,观察患者阻滞及用药后1 d、7 d、15 d、30 d麻木、痛觉过敏、睡眠障碍的改善情况。结果:阻滞组镇痛有效率90.0%,与单药组镇痛有效率63.3%比较差异显著(P<0.01),治疗后1、7、15、30天VAS评分,QS评分较治疗前均有改善(P<0.05),睡眠障碍明显改善(P<0.05)。两组间比较,VAS评分、QS评分、痛觉过敏等症状,阻滞组显著降低(P<0.05)。结论:椎旁神经阻滞联合牛痘疫苗接种家兔炎症皮肤提取物治疗带状疱疹神经痛疗效明显优于单纯神经修复药组,且效果持续,副作用小。     

Botulinum Toxin A in the Treatment of Chronic Tension-Type Headache With Cervical Myofascial Trigger Points: A Randomized, Double-Blind, Placebo-Controlled Pilot Study

Objective.— To evaluate the efficacy of botulinum toxin A (BT-A) as a prophylactic treatment for chronic tension-type headache (CTTH) with myofascial trigger points (MTPs) producing referred head pain. Background.— Although BT-A has received mixed support for the treatment of TTH, deliberate injection directly into the cervical MTPs very often found in this population has not been formally evaluated. Methods.— Patients with CTTH and specific MTPs producing referred head pain were assigned randomly to receive intramuscular injections of BT-A or isotonic saline (placebo) in a double-blind design. Daily headache diaries, pill counts, trigger point pressure algometry, range of motion assessment, and responses to standardized pain and psychological questionnaires were used as outcome measures; patients returned for follow-up assessment at 2 weeks, 1 month, 2 months, and 3 months post injection. After 3 months, all patients were offered participation in an open-label extension of the study. Effect sizes were calculated to index treatment effects among the intent-to-treat population; individual time series models were computed for average pain intensity. Results.— The 23 participants reported experiencing headache on a near-daily basis (average of 27 days/month). Compared with placebo, patients in the BT-A group reported greater reductions in headache frequency during the first part of the study (P = .013), but these effects dissipated by week 12. Reductions in headache intensity over time did not differ significantly between groups (P = .80; maximum d = 0.13), although a larger proportion of BT-A patients showed evidence of statistically significant improvements in headache intensity in the time series analyses (62.5% for BT-A vs 30% for placebo). There were no differences between the groups on any of the secondary outcome measures. Conclusions.— The evidence for BT-A in headache is mixed, and even more so in CTTH. However, the putative technique of injecting BT-A directly into the ubiquitous MTPs in CTTH is partially supported in this pilot study. Definitive trials with larger samples are needed to test this hypothesis further.     

Greater occipital nerve block is ineffective in chronic tension type headache

Patients with primary headache syndromes often describe a pain distribution, that does not respect the trigeminal innervation of the head. In addition to pain in frontal areas, innervated by the first (ophthalmic) division of the trigeminal nerve, the pain often occurs in occipital parts of the head, innervated by the greater occipital nerve, a branch of the C2 spinal nerve root. Anatomical and neurophysiological studies in animals suggest a convergence of cervical and trigeminal input in the trigeminal nucleus caudalis. Modulation of this pathway has been discussed to be of potential benefit in headache disorders. We investigated in an open pilot study the effect of bilateral block of the greater occipital nerve with 50 mg prilocaine and 4 mg dexamethasone in patients with chronic tension type headache. From 15 patients, only one patient described a headache relief after initial exacerbation of headache for 2 days. Headache intensity was unchanged in 11 patients. In further three patients, the headache worsened in the first hours or days after injection. No serious adverse events were observed. One patient showed a bradycardia (36/min) after the first injection during palpation of the muscles of the neck. Three patients suffered pain on the injection site for a few days. Our results indicate that block of the greater occipital nerve is not effective in the treatment of chronic tension type headache. If at all, rather a 'pro-nociceptive' effect was observed.     

Botulinum Toxin Type‐A (BOTOX®) in the Treatment of Occipital Neuralgia: A Pilot Study

Objective.— To determine the efficacy of occipital nerve blocks using reconstituted botulinum toxin type‐A (BTX‐A) in providing significant and prolonged pain relief in chronic occipital neuralgia. Background.— Occipital neuralgia is a unilateral or bilateral radiating pain with paresthesias commonly manifesting as paroxysmal episodes and involving the occipital and parietal regions. Common causes of occipital neuralgia include irritation or injury to the divisions of the occipital nerve, myofascial spasm, and focal entrapment of the occipital nerve. Treatment options include medication therapy, occipital nerve blocks, and surgical techniques. BTX‐A, which has shown promise in relief of other headache types, may prove a viable therapeutic option for occipital neuralgia pain. Methods.— Botulinum toxin type‐A (reconstituted in 3 cc of saline) was injected into regions traversed by the greater and lesser occipital nerve in 6 subjects diagnosed with occipital neuralgia. Subjects were instructed to report their daily pain level (on a visual analog pain scale), their ability to perform daily activities (on several quality of life instruments) and their daily pain medication usage (based on a self‐reported log), 2 weeks prior to the injection therapy and 12 weeks following injection therapy. Data were analyzed for significant variation from baseline values. Results.— The dull/aching and pin/needles types of pain reported by the subjects did not show a statistically significant improvement during the trial period. The sharp/shooting type of pain, however, showed improvement during most of the trial period except weeks 3‐4 and 5‐6. The quality of life measures exhibited some improvement. The headache‐specific quality of life measure showed significant improvement by 6 weeks which continued through week 12. The general health‐ and depression‐related measures showed no statistical improvement. No significant reduction in pain medication usage was demonstrated. Conclusions.— Our results indicate that BTX‐A improved the sharp/shooting type of pain most commonly known to be associated with occipital neuralgia. Additionally, the quality of life measures assessing burden and long‐term impact of the headaches, further corroborated improvement seen in daily head pain.     

Analgesic Effect of Botulinum Toxin A in Myofascial Pain Syndrome Patients Previously Treated with Local Infiltration of Anesthetic and Steroids

The purpose of this study was to evaluate the analgesic effect of botulinum toxin A (BoNTA) injections in patients with myofascial pain syndrome (MPS) who were previously treated with the local infiltration of anesthetic and steroids (LIAS). The study included a retrospective phase and a longitudinal open-label prospective phase, which were conducted on consecutive patients with MPS previously treated with the local infiltration of anesthetic (levobupivacaíne 0.25%) and steroids (triamcinolone 40 mg). Eligible patients were treated with a single intramuscular injection of BoNTA (Botox; Allergan, Inc., Irvine, CA). The treatment efficacy was determined according to the degree of pain relief obtained. Eighty-two patients met the inclusion/exclusion criteria and were included in the study. Successful results were obtained for 32 (39.0%) and 30 (36.6%) patients, during treatment with BoNTA and LIAS, respectively. The mean (standard deviation) length of the analgesic effect was significantly longer with BoNTA (29.6 [SD = 17.7] weeks) than with LIAS (8.5 [SD = 6.4] weeks), P <.0001. As regards the side effects, 19 (23.2%) patients reported transient soreness at the injection site for 2 to 3 days with BoNTA. The MPS patients previously treated with a local infiltration of anesthetic and steroids who then received a single injection of BoNTA experienced significantly reduced pain for a relatively long time.     

Treatment of lumbar spinal stenosis with epidural steroid injections: a retrospective outcome study

OBJECTIVE: To determine patient satisfaction, relief of pain, frequency of injections, change of function, and subsequent surgical rate in patients who received epidural steroid injections (ESIs) for the diagnosis of lumbar spinal stenosis (LSS). DESIGN: Retrospective review conducted using a standard set of questions asked over the telephone, 6 to 36 months after the patient received an ESI. SETTING: An outpatient spine center. PARTICIPANTS: One hundred forty patients at or over the age of 55 years diagnosed with LSS who received ESI(s). INTERVENTION: Transforaminal or caudal fluoroscopically guided ESIs with 60 to 100mg of triamcinalone in combination with local anesthetic or normal saline.Main outcome measures Duration and amount of pain relief, change in functional status, patient satisfaction, and surgical rate, assessed by a 5-item questionnaire. RESULTS: Of the 140 participants, 32% reported more than 2 months of pain relief, 39% reported less than 2 months of pain relief, and 29% reported no relief from the injection(s). Twenty percent subsequently had surgery. Fifty-three percent reported improvement in their functional abilities. Seventy-four percent where at least somewhat satisfied with ESI as a form of treatment. CONCLUSIONS: ESI is a reasonable treatment for LSS, providing one third of our patient population with sustained relief and more than half with sustained improvement in function.     

Cervicogenic Headache: Evidence That the Neck is a Pain Generator

This review was developed as part of a debate, and takes the “pro” stance that abnormalities of structures in the neck can be a significant source of headache. The argument for this is developed from a review of the medical literature, and is made in 5 steps. It is clear that the cervical region contains many pain‐sensitive structures, and that these are prone to injury. The anatomical and physiological mechanisms are in place to allow referral of pain to the head including frontal head regions and even the orbit in patients with pain originating from many of these neck structures. Clinical studies have shown that pain from cervical spine structures can in fact be referred to the head. Finally, clinical treatment trials involving patients with proven painful disorders of upper cervical zygapophysial joints have shown significant headache relief with treatment directed at cervical pain generators. In conclusion, painful disorders of the neck can give rise to headache, and the challenge is to identify these patients and treat them successfully.     

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.     

Cephalalgia Alopecia or Nummular Headache With Trophic Changes? A New Case With Prolonged Follow‐Up

Cephalalgia alopecia is a rare and recently described headache syndrome in which recurrent, burning head and neck pain is associated with hair loss from areas of scalp affected by the pain. We here report the case of a 33‐year‐old woman with continuous unilateral occipital pain and colocalized alopecia, only responsive to onabotulinumtoxin A injections. We hypothesize whether this clinical phenotype may correspond to either cephalalgia alopecia or nummular headache with trophic changes, conditions that might represent 2 manifestations of the same spectrum of disorders.     

Botulinum toxin type A for the treatment of nummular headache: four case studies

OBJECTIVE: We assessed the efficacy and safety of botulinum toxin type A (BoNTA; BOTOX): Allergan, Inc., Irvine, CA, USA) in patients with nummular headache who did not respond to other treatments including nonsteroidal anti-inflammatory drugs (NSAIDs), local anesthetics, and/or gabapentin. BACKGROUND: Nummular headache is characterized by circumscribed round or elliptical areas of fluctuating mild-to-moderate head pain in a chronic or remitting pattern. It is a relatively rare primary headache disorder that responds poorly to adequate treatment trials with local anesthetic, migraine, or neuropathic pain agents or NSAIDs. METHODS: Four patients aged 35-58 years with intractable nummular headaches were given 25 units of BoNTA divided among 10 injection sites in and around the circumscribed affected areas of pain, paresthesia, and allodynia. All patients had 2 sets of injections approximately 14 weeks apart. RESULTS: All patients met the International Headache Society criteria for nummular headache (International Classification of Headache Disorders, A13.7.1). Patients were female; mean age of onset was 42 years. Average disease duration prior to BoNTA treatment was 3.75 years. One patient reported concurrent episodic migraine and another reported concurrent tension-type headache. Patients reported round-shaped (n = 2; 6 and 3 cm in diameter), oval (n = 1; 4 x 2 cm), and elliptical (n = 1; 6 cm in length) areas of pain. Painful symptoms were reported in the right parietal convexity (n = 2) and the posterior frontal, unilaterally (n = 2). All patients experienced spontaneous or stimuli-triggered exacerbations and variable combinations of sensory disturbances, including allodynia, tenderness, and paresthesia. The temporal pattern was continuous in 3 patients and intermittent in one. Both the size and shape of the pain remained unchanged in all patients since the onset of nummular headache symptoms. Six to 10 days following BoNTA treatment, all patients experienced a reduction in nummular headache symptoms, which lasted approximately 14 weeks on average. Repeat injections gave the same degree of improvement. No treatment-related adverse events were reported. CONCLUSIONS: BoNTA appears to be a well-tolerated effective treatment for intractable, persistent nummular headache in patients with an inadequate response to other treatments including NSAIDs, gabapentin, or local anesthetics.     

Cluster headache and the sympathetic nerve

OBJECTIVE: To determine the effect of a sympathetic block at C7 on cluster headache. BACKGROUND: Eleven patients presenting to a pain control unit with cluster headache were included in the study after giving informed consent. METHODS: In all patients, a mixture of 5 mL of 0.5% bupivacaine hydrochloride and 1 cc of methylprednisolone acetate was injected onto the base of the C7 transverse process. RESULTS: The injection was applied during the acute phase of headache in 6 patients and all experienced immediate and complete relief. The other 5 patients received the injection between attacks. Of the 11 patients treated, 8 went into remission by aborting the cluster. In some patients, repeated injections were given before the cluster was aborted. Three patients did not respond to treatment. One patient with chronic paroxysmal hemicrania experienced pain relief of the acute attack after treatment, but the procedure did not abort the subsequent attacks. A surgical sympathectomy removing the stellate ganglion rendered him pain-free for 15 months after which he was lost to follow-up. CONCLUSION: Blocking the sympathetic nerve aborts an acute attack of cluster headache and may play a major role in aborting the cluster. Although only one patient with chronic paroxysmal hemicrania responded to surgical sympathectomy, this procedure may be considered as an alternative if there is poor response to oral medication or a sympathetic block.     

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.

5. Cervical Facet Pain

More than 50% of patients presenting to a pain clinic with neck pain may suffer from facet‐related pain. The most common symptom is unilateral pain without radiation to the arm. Rotation and retroflexion are frequently painful or limited. The history should exclude risk factors for serious underlying pathology (red flags). Radiculopathy may be excluded with neurologic testing. Direct correlation between degenerative changes observed with plain radiography, computerized tomography, and magnetic resonance imaging and pain has not been proven. Conservative treatment options for cervical facet pain such as physiotherapy, manipulation, and mobilization, although supported by little evidence, are frequently applied before considering interventional treatments. Interventional pain management techniques, including intra‐articular steroid injections, medial branch blocks, and radiofrequency treatment, may be considered (0). At present, there is no evidence to support cervical intra‐articular corticosteroid injection. When applied, this should be done in the context of a study. Therapeutic repetitive medial branch blocks, with or without corticosteroid added to the local anesthetic, result in a comparable short‐term pain relief (2 B+). Radiofrequency treatment of the ramus medialis of the cervical ramus dorsalis (facet) may be considered. The evidence to support its use in the management of degenerative cervical facet joint pain is derived from observational studies (2 C+).     

Ultrasound‐Guided Paravertebral Neurolytic Block: A Report of Two Cases

Paravertebral block is commonly used in the treatment for acute and chronic pain. The duration of paravertebral block could theoretically be prolonged with neurolytic agents. We report two cases of ultrasound‐guided neurolytic paravertebral blocks in patients suffering from intense cancer‐related thoracic pain. Ultrasound was used to identify the space and plane of injection at the mid‐thoracic level. Absolute alcohol was used to block the nerves at different segments. The two patients had great pain relief. Neurolytic paravertebral block can be a useful technique in patients with intractable cancer pain. Because of the risk of complication, it is recommended that this technique should be limited to relief of intractable pain in cancer patients with a poor prognosis.     

Facet joint pain and the role of neural blockade in its management

Chronic spinal pain is a common medical problem with serious financial and social consequences. Among the various structures with potential for producing pain in the spine, facet joints as sources of chronic spinal pain have attracted considerable attention and controversy. Significant progress has been made in precision diagnosis of spinal pain with neural blockade, in the face of less than optimal diagnostic information offered by imaging and neurophysiologic studies. Research into the role of facet joints in spinal pain has shown that cervical facet joints are the cause of chronic neck pain in 54% to 60% of patients, whereas lumbar facet joints cause pain in 15% to 40% of patients with chronic low back pain. Local anesthetic blocks of medial branches have proven to be a reliable diagnostic test; they are target-specific when used appropriately with control blocks, either with two local anesthetics with different durations of action or with the addition of an inactive placebo injection. The literature is replete with reports on uncontrolled studies, case reports, and documentation from a few controlled studies, all of which offer supporting information on the rationale and effectiveness of facet blocks and neurotomy. Facet joint injections and medial branch blocks are considered to be of equal value. Lumbar intra-articular steroid injections have been proven effective to a certain extent, but evidence indicates that cervical intra-articular steroids are ineffective. The role of repeat medial branch blocks is not known. Radiofrequency neurotomy remains the only practical and validated treatment for cervical facet joint pain; however, its role in management of either lumbar or thoracic facet joint pain awaits validation.