Cervical - Padda Institute Center for Interventional Pain Management

Migraine Headache: Our position on five medical treatment options that patients with migraines should avoid

Headache is among the principal reasons for physician visits and a common cause of emergency department visits. The costs of tests and treatments for headache are not insubstantial, and when unwarranted, they needlessly expose patients to potential harm. In a recent study of the treatments and procedures that contribute most to the $13 billion dollar annual cost of outpatient neurology visits, migraine alone was the diagnostic category with the second highest costs. For example, using data from the National Ambulatory Medical Care Survey, CT scans ordered at neurology visits (many of which were probably done to evaluate headache) resulted in costs of roughly $358 million dollars.

Five tests and procedures associated with low-value care in headache medicine according to the American Headache Society (AHS).  Listed are five things that “physicians and patients should question” in order to make “wise decisions about the most appropriate care based on the individual situation.”

 

[box] (1) avoiding neuroimaging studies with stable headaches that meet the criteria for migraine

(2) except for emergency situations, computed tomography should not be performed for headache when magnetic resonance imaging is available

(3) outside of a clinical trial, surgical deactivation of migraine trigger points is not recommended

(4) opioids or butalbital-containing mediations should not be prescribed as first-line treatment for recurrent headache disorders

(5) prolonged or frequent use of over-the-counter pain medication is not recommended for headache [/box]

(1) avoiding neuroimaging studies with stable headaches that meet the criteria for migraine

In clinical practice, it is common to encounter patients with headache who have undergone multiple imaging procedures. These often involve exposure to ionizing radiation. The reasons for these repeated and unnecessary scans are not well understood, but probably include physician fear of missing a dangerous cause of headache and a desire to allay patient anxiety over possible missed abnormalities, especially when treatment is unsuccessful. In some cases, duplicate scans may be ordered because the physician is unaware of previous testing. The risk of unneeded testing may be especially high in the emergency department, where physicians are unfamiliar with the patient and fear missing serious causes of headache.

In ordering diagnostic tests, though, the possible adverse effects of testing must be balanced against the likely benefits to the patient. In particular, the potential adverse health effects of radiation exposure should be taken into consideration when ordering diagnostic testing for headache. In many situations, it is very unlikely that a repeat imaging study of the head will identify any abnormality that will alter management. The radiation risks of CT scanning are not negligible. Younger people are at higher risk of radiation adverse effects than older people.

Numerous evidence-based guidelines agree that the risk of intracranial disease is not elevated in migraine. However, not all severe headaches are migraine. To avoid missing patients with more serious headaches, a migraine diagnosis should be made after a clinical history and an examination that documents the absence of any neurologic findings, such as papilledema.

The key element is a change in headache symptomology or a new diagnosis of severe headache.

(2) except for emergency situations, computed tomography should not be performed for headache when magnetic resonance imaging is available

When neuroimaging is needed for the evaluation of headache, good quality evidence supports the view that MRI is more sensitive than CT scanning to detect most serious underlying causes of headache. The exception is settings in which acute intracranial bleeding is suspected. A Canadian government health technology assessment group recently reviewed the evidence and cost-effectiveness of the use of CT and MRI scanning for the evaluation of patients with headache. The researchers found that when performed for the indication of headache, the diagnostic yield of CT scans was 2%, while that of MRI scans was 5%. Because MRI was better at detecting abnormalities, the cost per abnormal finding of CT scans was $2409 compared with $957 for MRI.

When neuroimaging for headache is indicated, MRI is preferred over CT, except in emergency settings when hemorrhage, acute stroke, or head trauma are suspected. MRI is more sensitive than CT for the detection of neoplasm, vascular disease, posterior fossa and cervicomedullary lesions, and high and low intracranial pressure disorders. CT of the head is associated with substantial radiation exposure that may elevate the risk of later cancers, while there are no known biologic risks from MRI.

(3) outside of a clinical trial, surgical deactivation of migraine trigger points is not recommended

The idea of a surgical “solution” to migraine is inherently attractive to patients. Interest in surgical approaches to migraine has been motivated by serendipitous improvement in headaches noted in patients who have undergone various plastic surgery “forehead rejuvenation” procedures. These procedures are based on the premise that contraction of facial or other muscles impinges on peripheral branches of the trigeminal nerve.

The procedures involved are often referred to collectively as “migraine deactivation surgery,” although a variety of surgical sites and procedures are involved. These include resection of the corrugator supercilii muscle with the placement of fat grafts in the site, “temporal release” procedures involving dissection of the glabellar area, transection of the zygomatical temporal branch of the trigeminal nerve, and resection of the semispinalis capitus muscle with placement of fat grafts in the area with the aim of reducing pressure on the occipital nerve. Finally, some surgeons also perform nasal septoplasty or otherwise attempt to address possible intranasal trigger points.

The value of this form of “migraine surgery” is still a research question. Observational studies and a small controlled trial suggest possible benefit. However, large multicenter, randomized controlled trials with long-term follow-up are needed to provide accurate estimates of the effectiveness and harms of surgery. Long-term side effects are unknown but potentially a concern

(4) opioids or butalbital-containing mediations should not be prescribed as first-line treatment for recurrent headache disorders

Primary recurrent headache disorders (of which migraine, tension-type, and cluster headache are the most common) are conditions of long duration for which such treatment will be used repetitively over many years. Risks and harms that are unimportant in treating a single attack can become important when treatment is used for long periods of time. Once established, medication overuse can be difficult to treat and recidivism is common. Thus, treatments such as triptans or nonsteroidal anti-inflammatory drugs, which are not associated with dependence or sedation, are preferred first-line.  However, there are many clinical situations in which the use of opiates and butalbital is appropriate, including some situations where they are first-line treatments. These include patients for whom triptans or nonsteroidal anti-inflammatory drugs are contraindicated or ineffective.

These medications impair alertness and may produce dependence or addiction syndromes, an undesirable risk for the young, otherwise healthy people most likely to have recurrent headaches. They increase the risk that episodic headache disorders such as migraine will become chronic, and may produce heightened sensitivity to pain. Use may be appropriate when other treatments fail or are contraindicated. Such patients should be monitored for the development of chronic headache.  This is not meant to imply that opioid or butalbital medications are always inappropriate treatments for recurrent headache treatments. Rather, it is meant to address the appropriate order in which medication classes should typically be used.

(5) prolonged or frequent use of over-the-counter pain medication is not recommended for headache

Over-the-counter (OTC) medications are appropriate treatment for occasional headaches if they work reliably without intolerable side effects. Frequent use (especially of caffeine-containing medications) can lead to an increase in headaches, resulting in “medication overuse headache” (MOH). To avoid this, OTC medication should be limited to no more than 2 days per week. In addition to MOH, prolonged overuse of acetaminophen can cause liver damage, while overuse of nonsteroidal anti-inflammatory drugs can lead to gastrointestinal bleeding.

 

 

Severe Head and Neck Pain

Caution:

If you’re having your worst migraine ever or symptoms that are unusual for you or frightening, see a doctor as soon as possible. You need to be sure this IS a Migraine and not something more serious such as a stroke. 

Caution:

Pregnant women should immediately alert their physician as many of the medications used to treat migraines can cause birth defects.

 

 

The goal of the Padda Institute Headache Section is to provide diagnosis and treatment that will help people who experience severe pain regain a better quality of life.  (The treatment needs of patients who have occasional mild headaches are significantly different from those patients whose attacks are frequent and completely disabling.)  If your quality of life is impacted from migraine, chronic head pain, or nerve pain in the face you need a plan of action from a team of highly experienced specialists. We provide a collaborative approach combined with the latest technology resulting in individualized care. Our goal is to provide effective, compassionate care to improve your quality of life.

Headaches are serious

Headache remains one of the most common health issues which challenge physicians and other health professionals, migraine is the 12th most disabling disorder in the United States..  The symptoms of head pain are a frequent cause of human suffering and disability.  According to a World Health Organization analysis, severe Migraine attacks are as disabling as quadriplegia (paralysis of both arms and legs).  Suicide attempts are three times more likely among people who have Migraine with aura than among people who do not have Migraine.  More than 1,400 American women with Migraine with aura die each year from cardiovascular diseases compared to women who do not have Migraine.

Migraines permanently affect your brain

Some 37 million Americans suffer from migraines, those incredibly painful and often debilitating headaches. While they’ve been known to knock a person out, migraines weren’t thought to permanently affect the brain – until now.  A study published in the journal Neurology suggests migraines permanently alter brain structure in multiple ways.  The risk of white matter brain lesions increased 68% for those suffering migraines with aura, compared to non-migraine sufferers. Those who suffered from migraines without aura saw that increased risk cut in half (34%), but they too could get lesions in the part of the brain that is comprised of nerve fibers.  Migraine affects about 10 to 15% of the general population and can cause a substantial personal, occupational and social burden.  According to the American Migraine Foundation, migraines cost the United States more than $20 billion a year in both direct medical expenses like doctor visits and medication and indirectly when employees miss work resulting in lost productivity.

For many patients with headache, an organized, multidisciplinary headache center environment is necessary to provide the entire spectrum of headache management.

 

  • Patients in whom comprehensive services are essential to address the multifunctional components of their headaches.
  • Patients who have not responded to medication and have a history of recurring acute care needs or progressive persistent headache.
  • Patients who have undergone multiple diagnosis and therapeutic interventions yet the diagnosis remains uncertain or questionable.
  • Patients who have had frequent emergency room visits, who have used hospital inpatient services excessively, and who have overused different oral analgesics, including opiates, or who have been treated repeatedly with intramuscular or intravenous medications.

 

 

The History of Headaches

The clinical entity of headache dates back to ancient times.  As early as the dawn of civilization, primitive headache remedies included procedures aimed at ridding the body of the “demons and evil spirits” that were believed to cause headaches.  As early as the Neolithic period dating back to 7000 BC, skulls have been found bearing man made holes (called trephination) presumably done for medical reasons which may have included the treatment of headache.  Skulls demonstrating trepanation have also been found in Peru dating back to the thirteenth century.  The writings of the early Greeks referred to headache as a serious medical condition.

Hippocrates (400 BC) may have been the first to describe the clinical symptoms of migraine.  In the historical Hippocratic books Hippocrates discussed what appears to have been the visual aura that can precede migraine.  The term “migraine’ itself is derived from the Greek word hemicrania. Throughout history, there have been famous individuals such as Plato, Thomas Willis, Erasmus Darwin (Charles Darwin’s grandfather), and others who have contributed to our understanding of headache. More recent scholars, such as Dr Harold Wolff, played an important role in our classification of different types of headache and their treatment. Following his classic 1948 publication of the first edition of Wolff’s Headache, it was Dr Wolff who introduced important scientific concepts which have served to modernize the study of headache.  Since that publication there has been an explosion in headache research which has resulted in our better understanding of this clinical condition.

There are now scientific mechanisms which more clearly define the pathophysiology of some headaches such as migraine.  This has also led to the development of new migraine specific medications, specialized pain management techniques, and ultimately more effective treatment opportunities.

Migraines have affected people for centuries and played an influential role throughout world history. Many famous and accomplished people have experienced severe headaches.  Julius Caesar, Napoleon, Ulysses S. Grant and Robert E. Lee; great painters Vincent Van Gogh, Georges Seurat and Claude Monet,; and famous authors Virginia Woolfe, Cervantes and Lewis Carroll all experienced migraines. Thomas Jefferson wrote the Declaration of Independence during an intense period of productivity after being bedridden for six weeks with a migraine.  The famous authors Virginia Woolf, Cervantes (best known for Don Quixote) and Lewis Carroll (Alice’ Adventures in Wonderland) had migraine. There is even evidence to suggest that at least some of Alice’s Adventures were based on Carroll’s personal migraine visual aura perceptions. As Cheshire Cat observed, “One pill makes you smaller; one pill makes you larger, the pills mother gives you do nothing at all”.  There has been literature which indicates that Thomas Jefferson’s headaches were so severe and debilitating that they often interfered with his ability to function.  As he wrote to Martha Jefferson in February 18, 1784, “Having to my habitual ill health….lately added an attack of my periodical headache; I am obliged to avoid reading, writing, and almost thinking”.  In March 1807, while still President, Jefferson wrote “…Indeed, I have but little moment in the morning in which I can either read, write, or think, being obliged to be shut up in a dark room from early in the forenoon till night, with a periodical headache”.

Headache sufferers constitute one of the largest groups of patients within a neurological practice.  More patients who visit doctors complain of headache than any other single ailment. Headache and migraine in particular, may be considered as a universal human condition which continues to be under diagnosed, misdiagnosed and/or mistreated.  Whereas in some individuals, headache may be an occasional episodic, sometimes nuisance, for others the symptoms of headache may be a manifestation of a disabling chronic disease.  In the latter group, headache disrupts daily routines and impairs quality of life.  The frequency, severity, and even life consequences of headache sufferers vary widely.  The causes of headache are different in different individuals.

 

Range of Disorders:

Each year, millions of Americans suffer from chronic headaches.  There are four main headache types: tension, cervicogenic, migraine and cluster.

  • Tension headaches are the most common and may be described as a mild to moderate constant band-like pain, tightness, or pressure around the forehead or back of the head and neck.

 

  • While cervicogenic headaches are slightly less common and are caused by any number of conditions in the neck, causing referred pain, most often the cervical facets or the cervical discs.  Some studies suggest that the trigeminal sympathetics and parasympathetics mediate pain from the region of the Occipital Nerve, such to the degree that the Occipital Nerve may be considered the “V4” of the trigeminal.  Cervicogenic pain can trigger Migraine headaches and Cluster headaches.

 

  • Migraine headaches are severe headaches that are described as a chronic, throbbing head pain that can cause significant pain for hours or even days.  Symptoms can be so severe that light or sound can cause exacerbation and most patients must find a dark quiet room to lie down.  The typical Aura of Migraines is only present in 25-30% of all cases.

Status Migrainosus: A rare, sustained and severe type of migraine headache, lasting more than 72 hours that is characterized by intense pain and nausea, often leading to hospitalization.

Chronic daily headaches occur frequently, usually more than 15 days per month. Chronic daily headaches are classified as either long duration (lasting more than four hours) and short duration (lasting less than four hours). The majority of people who experience chronic daily headaches have long-duration headaches.

Medication overuse headaches, sometimes called rebound headaches, occur when people who experience migraine or tension headaches take too much analgesic or anti-migraine medication. When the effect of one dose wears off, the next headache occurs and another round of medication is taken. A vicious cycle is created of ever-increasing headaches and more frequent medication use.  Taking Migraine abortive medications, pain relievers, or alternating them more than two or three days a week can cause medication overuse headache.

Menstrual migraine is a headache that occurs during the menstrual cycle. It can occur two days before and up to three days after the beginning of a woman’s period. Although the cause is not explicitly known, menstrual migraine may be triggered by changes in hormone levels. The most likely cause is the fall in estrogen levels that takes place just before the beginning of menses.  When women experience menopause naturally, 1/3 experience worse Migraines. When women experience menopause following a hysterectomy, 2/3 experience worse Migraines.

Studies have shown that 90% of what people think are sinus headaches are really Migraines. A sinus headache is very rare without an infection.

  • Cluster headaches, also known as suicide headaches, are excruciating unilateral headaches of extreme intensity. The duration of the common attack ranges from as short as 15 minutes to three hours or more. The onset of an attack is rapid, and most often without the preliminary signs that are characteristic of a migraine. They are marked by repeated, short-lasting attacks of excruciating, unilateral head pain of short duration.  A cluster headache may be accompanied by redness or tearing of the eye and nasal congestion or runny nose. Often mistaken for sinus or migraine headaches, cluster headaches are characterized by sharp, stabbing pain in or around the eye, temple, forehead or cheeks.
  • Atypical facial pain of all types including trigeminal neuralgia

To assure an accurate diagnosis, we collect an extensive medical history and conduct a comprehensive neurological exam. At times we request a specialized MRI of the brain and neck or blood tests that search for causes of headache including hormone levels, vitamin levels, or markers of an overactive immune system. After the evaluation, treatment options are discussed including medications, lifestyle modification, pain relieving procedures and alternative therapies.  Nearly 30% of patients with dental pain after dental procedures are actually a form of trigeminal neuralgia.

 

Outpatient Treatment

For many people, medication is required to control their headaches. Avoiding the triggers which initiate headache onset is the most important step. There are two categories of headache medication: abortive and prophylactic.

 

  • Trigger Management

Trigger management is key to preventing a migraine attack, migraines don’t just happen; they have triggers.  Trigger factors are those circumstances or influences that can cause a migraine. Trigger factors vary from person to person; if recognized and avoided, a person may prevent a migraine from developing.

Examples of triggers include changes in weather or air-pressure, bright sunlight or glare, fluorescent lights, chemical fumes, menstrual cycles, and certain foods and food products, such as processed meats, red wine, beer, dried fish, fermented cheeses, aspartame and MSG.

  • Preventive or Prophylactic Medication Therapy

Prophylactic drugs are taken daily to prevent headaches. They may be prescribed for people who experience frequent severe headaches, usually two or more per month. These drugs may be taken until a person’s headaches are under control. Generally, the lowest effective dose is used for the shortest period possible. Examples of prophylactic drugs are anti-depressants, beta blocker and calcium-channel blockers.

Many people who take preventive or prophylactic medications will also need to take attack-aborting medications to relieve pain and other symptoms.

  • Abortive Medication Therapy

Attack-aborting medications can relieve the severity and/or the duration of migraine headaches and their related symptoms. In general, most attack-aborting medication should be taken as early as possible in an attack.

Many people who experience migraines or other severe headaches can recognize their early symptoms, allowing them to intervene early with the attack-aborting medication. This may allow them to avoid a more severe, prolonged episode. Attack-aborting medications include cerebral vascoconstrictor abortive agents and non-vasoconstrictive abortive agents.

Specialized Treatment Options for Headache, Migraine and Facial Pain

Our team cares for many patients each year which empowers countless people to achieve substantial improvement. Some of our specialized treatments offered include peripheral nerve injections, which numb the nerves of the scalp to shut off chronic migraine. On average, the injections can give patients weeks to months of benefit. In rare cases, our team provides occipital nerve stimulation by a surgically implanted device that delivers an electric charge to nerves in the back of the scalp to treat migraine, cluster headache, and other types of facial pain that doesn’t respond well to other treatments. This is a treatment few other centers offer.

We also offer a number of alternative therapies with special focus on nutraceuticals – nutritional supplements – and vitamin therapies that have anti-pain or anti-migraine suppressing properties. Also available is pain psychology which uses relaxation strategies and biofeedback to reduce migraine. Our clinic embraces a specialized hormone therapy, called bioidentical hormone replacement therapy. This is where a patient’s hormonal status is monitored and individualized hormonal therapy is provided to normalize the body’s natural cycle and reduce migraine or head pain associated with hormonal dysfunction. We also offer acupuncture.

 

Advanced therapies

  • Spenopalatine Block

The Sphenopalatine Gangion Nerve Block (SPG Nerve Block) is both a  preventative and abortive technique, and may infact prevent trigger activation altogether.

The Sphenopalatine ganglion (SPG) nerve block and the Trigeminal Nerve Block is a fast, highly effective, non-invasive treatment option for migraines and headaches without the use of pills or injections. This treatment uses a unique transnasal catheter to eliminate the pain in a safe and painless way. Aside from migraine and headache, It has been providing successful relief to a variety of painful conditions including trigeminal neuralgia.

Technical:

The sphenopalatine ganglion (pterygopalatine, nasal, or Meckel’s ganglion) is located in the pterygopalatine fossa, posterior to the middle nasal turbinate. It is covered by a 1- to 1.5-mm layer of connective tissue and mucous membrane. This 5-mm triangular structure sends major branches to the gasserian ganglion, trigeminal nerves, carotid plexus, facial nerve, and the superior cervical ganglion. The sphenopalatine ganglion can be blocked by topical application of local anesthetic or by injection.

  • Trigeminal Blockade

Trigeminal neuralgia is an extremely painful condition that affects the trigeminal nerve in the face, which is also called the fifth cranial nerve.  The Trigeminal Nerve is often called the Dentist’s Nerve because it goes to the teeth, jaw muscles, jaw joints (TMJ),and periodontal ligament. Trigeminal innervation of the sinuses, eustacian tubes, tensor of the ear drum (tensor tympani), soft palate, tongue and meninges of the brain explain why there are so many disorders associated with jaw function, TMJ and TMD. The trigeminal nerve plays a very important role in the face, being responsible for sensing touch, pressure, pain and temperature in the jaw, gums, forehead and around the sensitive eye area. Since it controls sensation in almost the entire face, pain in the trigeminal nerve can affect many different parts of the face.  Many people speculate that most atypical facial pain, most dental pain, most sinus induced headache, and most headache originating from the base of the skull results from trigeminal activation.

 

Stellate Ganglion Block

 

 

 

 

Stellate Ganglion Block

Your body has special nerves known as sympathetic nerves in your neck which ,control blood supply and sweating to your arms and hands . These nerves can be anesthetized to change the blood flow to a limb and to decrease the pain which is mediated by these sympathetic nerves:

 

 

 

 

Reflex sympathetic dystrophy (RSD), also called Complex Regional Pain Syndrome (CRPS) typically involves a nerve injury involving the sympathetic nervous system.

 

 

  • Reflex sympathetic dystrophy  (RSD), also called Complex Regional Pain Syndrome (CRPS) typically involves a nerve injury involving the sympathetic nervous system.  Patients who suffer crushing or partial nerve injury develop excruciating burning pain accompanied by changes in blood supply to the area of the injury.   People with CRPS may exhibit abnormal sensation throughout all or part of the affected area. This often includes increased sensitivity to stimuli such as touch, pressure, or temperature.
  • Patients with severe ischemic limb pain have sharp, aching pain as a result of circulatory insufficiency.  Patients in end-stage PVD (peripheral vascular disease) will complain of rest pain with or without ulcers.
    1. Severe pain (claudication and rest pain)
    2. Decreased pulse in the limb
    3. Abnormal skin temperature
    4. Abnormal skin color
    5. Nonhealing ulcers
    6. Other trophic changes

Common types of PVD

  • Arteriosclerosis
  • Diabetic arteriosclerosis
  • Raynaud’s disease
  • Buerger’s disease

What is the purpose of Stellate Ganglion Block?

The Stellate Ganglion Block is an injection procedure used to block or decrease pain located in the head, neck, chest, or arm. It also helps increase circulation.

The Stellate Ganglion is a group of nerves located in the upper neck and is part of the sympathetic nervous system. After an injury or illness, the sympathetic nervous system may not function properly, causing pain. Some of the more common conditions are: complex regional pain syndrome (CRPS) also known as reflex sympathetic dystrophy (RSD), causalgia (nerve injury), and herpes zoster (shingles) of the head and face. The Stellate ganglion block is also used to treat intractable angina (severe pain caused by heart disease) or severe peripheral vascular disease (PVD).

 

If this treatment relieves your pain, the doctor will perform a series of blocks at another time in an attempt to break the pain cycle and provide long lasting pain relief. The number of blocks you will need depends on how long the pain relief lasted between injections. Usually you will get more and longer pain relief after each injection.

 

Some patient’s get short-term relief with Stellate blockade, but the series of blocks fails to provide long-term relief.  These individuals are usually considered candidates for Dorsal Column Stimulation (DCS).

 

What does the procedure involve?

The nerves going to the arm can be anesthetized in one of two place; the low neck which is known as a stellate block, or the upper chest area known as a T2 sympathetic block.

 

The Stellate Ganglion Block is an outpatient procedure, usually done in the Operating Room or a Procedure Room. For your safety and comfort, you will be connected to monitoring equipment (EKG monitor, blood pressure cuff, and a blood-oxygen monitoring device). The doctor or nurse may start an intravenous line and give some medicine to help you relax. You will also have skin temperature monitors placed on your hands.

 

The procedure is performed with you lying on your back. A rolled-up sheet or other support is placed between your shoulder blades, which may be a little uncomfortable.

 

After cleansing your neck with an antiseptic solution, the doctor will inject numbing medicine into the skin and tissue. This may cause a burning sensation for a few seconds. The doctor will also apply some pressure on your neck to determine exactly where to place the needle. It is very important that you do not talk, swallow, or cough. If you have to swallow or cough, raise your hand to let someone know.

 

After the numbing medicine takes effect the doctor will insert another needle, and with the assistance of a special X-ray machine called a fluoroscope, inject a radiopaque dye (contrast solution) to confirm correct needle position. When satisfied with the needle position, the doctor will inject a small mixture of numbing medicine (anesthetic) and anti-inflammatory medicine (cortisone/steroid).

 

Although it takes about 10 to 20 minutes for the medication to take effect, you will remain at the Clinic until the doctor feels you are ready to leave.

 

If the block works, then your hand will warm up and (depending upon the source of your pain) your pain may improve.  When utilized for CRPS (RSD), stellate blocks are used as a way of getting you to work with physical \ occupational therapy to desensitize your arm or hand.

 

Can I go to sleep for the procedure?

It is not necessary for you to go to sleep for this procedure; you must be awake and communicate with the physician during the procedure.

 

 

How long will the procedure take?

Normally, a Stellate ganglion block procedure takes no more than 30 minutes.

 

 

What should I do before the procedure?

• Since you will be receiving medication, it is recommended that you do not eat within four or five hours before the procedure. If you are a diabetic, be sure to discuss your eating and medication schedule with the doctor.

• You may need to stop taking certain medications several days before the procedure. Please remind the doctor of all prescription and over-the-counter medications you take, including herbal and vitamin supplements. The doctor will tell you if and when you need to discontinue the medications.

• It is very important to tell the doctor if you have asthma, had an allergic reaction (i.e. hives, itchiness, difficulty breathing, any treatment which required hospitalization) to the injected dye for a previous radiology exam (CT scan, angiogram, etc) or if you have had an allergic reaction to shellfish (shrimp, scallops, lobster, crab). The doctor may prescribe some medications for you to take before having the procedure.

• Tell the doctor if you develop a cold, fever, or flu symptoms before your scheduled appointment.

 

 

Is there anything special that I need do after the procedure?

You need to be aware of several potential side effects. These side effects, which usually disappear four to eight hours after the block may include: • A droopy eyelid on the side of the block; Redness and blurred vision in the eye on the side of the block; A feeling like a lump in your throat; Difficulty swallowing; Hoarseness of your voice; Warmth and weakness of the arm on the side of the block.

•          Drink plenty of clear liquids after the procedure to help remove the dye from the kidneys and do not eat solid food until you are comfortable swallowing.

•          Do not drive for the remainder of the day. Please have an adult drive you home or accompany you in a taxi or other public transportation.

•          Depending on how you feel, you may resume normal activities and return to work the following day.

•          If the doctor prescribes physical therapy, it is very important that you continue with the physical therapy program.

•          Although you may feel much better immediately after the injection (due to the numbing medicine), there is a possibility your pain may return within a few hours. It may take a few days for the steroid medication to start working.

•          You must participate in physical therapy, in order to get long-term control of symptoms.  Desensitization physical therapy can be an effective way to treat hypersensitivity, especially when used in combination with other medical and/or therapeutic interventions.

 

The stellate blockade is both diagnostic (helps diagnose the cause of your pain) and therapeutic (treats the cause of your pain).  You may need a series of injections in order to achieve long-term pain control.  Please keep track of your symptoms after the block.

 

What are the risks of a Stellate Ganglion Block?

The risks, although infrequent, include:

  • Collapsed lung
  • Numbness of an arm that may last for hours
  • Temporary weakness or numbness from the neck down
  • Allergic reaction to the medication
  • Nerve damage
  • Bruising at the injection site
  • Infection at the injection site
  • Injection of medication into a blood vessel with possibility of stroke or seizure
  • Post-injection flare (nerve root irritation with pain several hours after treatment, which may last days or weeks)
  • Depigmentation (a whitening of the skin)
  • Local fat atrophy (thinning of the skin)
  • Destruction of a motor or sensory nerve in the path of the needle
  • Bleeding, nerve injury, organ injury and death are rare but possible

Note: If you experience new shortness of breath 24 – 48 hours after the injection or any signs of infection in the area of the injection you should go to your nearest emergency room immediately.

 

 

 

 

 

 

Selective nerve root block (cervical, thoracic or lumbar)


Nerve roots exit your spinal cord and form nerves that travel into your arms or legs. These nerves allow you to move your arms, chest wall, and legs. These nerve roots may become inflamed and painful due to irritation, for example, from a damaged disc or a bony spur.

A selective nerve root block provides important information to your physician and is not a primary treatment. It serves to prove which nerve is causing your pain by placing temporary numbing medicine over the nerve root of concern. If your main pain improves after the injection then that nerve is most likely causing your pain. If your pain remains unchanged, that nerve probably is not the cause of pain.

 

By confirming or denying your exact source of pain, it provides information allowing for proper treatment, which may include additional nerve blocks and/or surgery at a specific level.  Selective nerve root blocks are similar to epidurals, but instead of putting medication in to cover all of the nerve roots, selective blocks are done so as to cover just one or two nerve roots.

The membrane that covers the spinal cord and nerve roots in your spine is called the dura membrane. The space surrounding the dura is the epidural space. Nerves travel through the epidural space before they form the nerves that travel down your arms, along your ribs and into your legs. These nerve roots may become inflamed, for example, due to irritation from a damaged disc or contact with the bony structure of the spine. A selective epidural injection places anti-inflammatory medicine over the nerve root and into the epidural space to decrease inflammation of the nerve roots therefore reducing your pain. The epidural injection may assist the injury to heal by reducing inflammation. It may provide permanent relief or provide a period of pain relief for several months while the injury/cause of your pain is healing.

The selective nerve root block (SNRB) is a procedure that anesthetizes an individual nerve root, either within the neck (‘cervical’), or in the back (‘thoracic’ or ‘lumbar’), thought to be responsible for the patient’s pain. The nerve root sheath is injected and anesthetized with the intent of relieving this pain.  This procedure is sometimes referred to as a ‘Foraminal Block.’  The SNRB procedure delivers a low volume of concentrated medication directly into the affected nerve root sleeve.

Back Pain is often multifactorial and difficult to diagnose because the symptoms overlap considerably with those of other degenerative disorders of the spine.  The SNRB is useful in both the diagnosis and the treatment of back pain; therefore, it is both a diagnostic as well as a therapeutic procedure. In other words, if we inject a medication within the suspected nerve root sleeve and the pain improves, we are fairly confident that this nerve root is responsible for the pain; conversely, if we inject a medication and the pain is no better, this implies that this nerve root is likely not responsible for the pain.

 

Nerve Root Impingement

Patients with pain from nerve root irritation often have an anatomic cause, which is usually the result of a nearby structure pushing on, or impinging on the nerve, causing irritation of that nerve.

The most common causes of this are either a disc abnormality or an adjacent bone spur, either of which, when in close proximity to the nerve, can irritate it and cause pain in the distribution of that nerve.

 

Radicular Pain

If there is irritation of a nerve in the back or neck, it may cause symptoms of pain, and usually this pain is in the distribution of that particular nerve, referred to as radicular pain.

Dermatomes

 

Patient Selection

SNRB is most effectively used in patients with radicular pain.

These patients should have recent imaging studies (CT or MRI scan), which in many instances help to identify the cause of pain. Not all patients will have an identifiable cause for the pain on imaging, but all should have radicular symptoms.  Electrodiagnostic studies such as EMG are useful in distinguishing peripheral neuropathy, entrapment and radiculopathy.

 

Procedure

The procedure is explained to the patient, questions are answered and informed consent is obtained.

The patient is placed prone (stomach down) for lumbar or thoracic injections, or supine (face up) for cervical injection on the fluoroscopic table, and the area is sterilely cleansed with povidone-iodine (Betadine) and alcohol.

The exact level is located with the fluoroscope, and the skin overlying this area is anesthetized (numbed) with lidocaine. This is either to the right or left of midline on the back.

A needle is sterilely advanced along the nerve root sleeve, which typically elicits a mild degree of radicular pain in the distribution of that nerve. It is important for us to know whether the pain elicited is similar to the patient’s pain (concordant response), or dissimilar (discordant response).

Typically, as small amount of water-soluble contrast (dye) is injected to confirm proper needle tip position.

Once this is confirmed, a mixture of anesthetic (lidocaine or bupivacaine) and anti-inflammatory medication (steroid) is injected.

The needle is slowly withdrawn

This procedure may be performed with either CT or Fluoroscopic guidance.

 

 

What will happen after the procedure?

Immediately after the procedure, you will get up and walk around and try to imitate something that would normally bring about your usual pain. You will then report the percentage of pain relief and record the relief you experience during the next week. We ask that you remain at the Clinic until you feel you are ready to leave.

You may not be able to drive the day of your procedure. Your legs or arms may feel weak or numb for a few hours. You may be referred to a physical therapist immediately afterwards while the numbing medicine is still working. If the doctor prescribes physical therapy, it is very important that you continue with the physical therapy program.

Although you may feel much better immediately after the injection (due to the numbing medicine), there is a possibility your pain may return within a few hours. It may take a few days for the steroid medication to start working.

You may experience some weakness and/or numbness in your legs a few hours after the procedure. If so, do not engage in any activities that require lifting, balance and coordination.

Drink plenty of clear liquids after the procedure to help remove the dye from the kidneys.

 

 

General Pre/Post Instructions:

You should eat a light meal within a few hours before your procedure. If you are an insulin dependent diabetic, do not change your normal eating pattern prior to the procedure. Please take your routine medications (i.e. high blood pressure and diabetic medications).  Do not take pain medications or anti-inflammatory medications the day of your procedure. You need to be hurting prior to this procedure. Please do not take any medications that may give you pain relief. These medications can be restarted after the procedure if they are needed. If you are on Coumadin, Heparin, Plavix or any other blood thinners (including Aspirin), or the diabetic medication Glucophage you must notify this office so the timing of these medications can be explained. You will either be at our clinic facility for approximately 1-3 hours for your procedure. You may need to bring a driver with you. You may return to your normal activities the day after the procedure, including returning to work.

 

Risks of nerve root injection?

Increased localized back pain, neck pain, arm pain or leg pain can be expected from several days to several weeks and rarely several months. There is a rare risk of permanent injury to nerve tissue with weakness or loss of sensation.  There is also a rare risk of complication from anesthesia used to make you feel more comfortable during the procedure.

As with any procedure, there is a risk of significant complications. The most common side effects from the nerve root block can include (but are not limited to):

  • Allergic reactions to medications
  • Infection (occurs in less than 1 per 15,000 injections)
  • Post-injection flare (nerve root irritation with pain several hours after treatment, which may last days or weeks)
  • Depigmentation (a whitening of the skin)
  • Local fat atrophy (thinning of the skin)
  • Destruction of a motor or sensory nerve in the path of the needle
  • Bleeding, nerve injury, organ injury and death are rare but possible

 

 

Facet Joint Injection (zygapophyseal joint injection)

What are facet joints and why are facet joint injections helpful?

The spine is designed to bend and turn. Along with the intervertebral discs, facet joints (also referred to as Z joints or zygapophyseal joints) enable the spine to bend and twist. Each vertebra has two sets of facet joints. One set of facet joints is located at the top and a corresponding set is at the bottom.

Facets joint are small joints a little larger than the size of your thumbnails located in pairs on the back of your spine. They provide stability and guide motion in your back. If the joints become painful they may cause pain in your neck, shoulder, low back, abdomen, buttocks, groin or legs.   The pattern and location of pain helps to determine the likely facet joints involved.

 

Working like a hinge, the articulating surfaces of each facet joint are coated with smooth cartilage allowing friction free movement. Although the facet joint bones fit snugly together, there is a lubrication system. The lubricating ‘oil’ is called synovial fluid and resembles uncooked egg whites. This fluid also nourishes the cartilage tissues.

A block that is performed to confirm that a facet joint is the source of pain and decrease pain and inflammation in a facet joint or joints.

 

I. Introduction

 

  • The Facet Joint injection (FJI) procedure targets the facet joint thought to be responsible for a patient’s back pain. The joint is injected and anesthetized with the intent of relieving this pain.
  • The facet injection procedure delivers a low volume of concentrated medication directly into the affected joint.
  • Back Pain is often multifactorial and difficult to diagnose because the symptoms overlap considerably with those of other degenerative disorders of the spine.
  • The FJI is useful in both the diagnosis and the treatment of back pain; therefore, it is both a diagnostic as well as a therapeutic procedure. In other words, if we inject a medication within the suspected joint space and the pain improves, we are fairly confident that this joint is responsible for the pain; conversely, if we inject a medication and the pain is no better, this implies that this joint is likely not responsible for the pain.

 

II. The Facet Joints

 

  • The Facet Joints are the joints of the spine (cervical, thoracic, and lumbar). They contain joint fluid and are lined by cartilage. There are two facet joints at each level of the spine, one on the right and one on the left.
  • The function of the facet joints of the spine is to allow movement (flexion, extension, bending side-to-side) and rotation.
  • Like any other joint in the body, facet joints can become diseased, and thereby become painful.
  • By far the most common disease affecting the facet joints is arthritis. This is a degenerative, inflammatory condition that over time results in loss of joint cartilage, bone overgrowth (‘osteophytes’ or ‘spurs’), erosions of the joint, and ultimately instability of the joint itself.  Facet joints are also damaged by trauma, and frequently are the source of pain after whiplash type injuries.  Facet injury can also occur with disc height loss, in front of the disc.
  • The facet joints and their surrounding tissues are lined with nerves. As this degenerative, inflammatory condition progresses, the nerve endings become irritated and inflamed; this produces the sensation of pain. Any and all of this degenerative process may be painful.
  • The primary role for imaging studies prior to the procedure is to evaluate for other possible causes of back pain.

 

 

III. Facetogenic Pain (‘Facet Syndrome’)

 

Just as imaging studies demonstrate typical patterns of facet joint degeneration, patients with facetogenic pain often have a typical history and physical examination suggestive of this disease. This is sometimes referred to as “Facet Syndrome”.

The exact definition and what constitutes the ‘Facet Syndrome’ is somewhat controversial, but includes the following:

 

Cervical

  • Unilateral or bilateral neck pain
  • Decreased range of motion
  • Tenderness over the affected facet joint(s)
  • Headaches
  • ‘Referred’ pain, or pain which is referred to other areas, such as the shoulder, or upper arm

Lumbar

  • Unilateral or bilateral low back pain, often worsened by rest in any position
  • Deep pain which may radiate to the hip, thigh and upper leg
  • Pain worsened by twisting or rotation, and exacerbated by moving from sitting to standing
  • Improvement of pain by standing, walking, or repeated activity
  • Morning stiffness
  • Pain directly over involved facet joint

 

 

IV. Patient Selection

 

  • Oftentimes more than one facet joint is inflamed or degenerated. In addition, there are other factors, which may be contributing to a patient’s back pain, including disc disease, referred pain, as well as psychological factors. This can make the exact site and level responsible for the facet pain more challenging to localize and diagnose.
  • Unfortunately, while imaging studies (X-RAYs, MRI and CT scans) are helpful in screening the spine for potential causes of back pain, they are often unreliable in determining whether or not a given facet joint may be the source of pain.
  • They help in identifying and characterizing the extent of facet degeneration, but like any other joint in the body, the extent of degeneration doesn’t necessarily correlate with the amount of pain. In other words, some patients may show severely degenerated facet joints on imaging studies, but be relatively asymptomatic.
  • Conversely, some patients experiencing severe pain from the facet joints (facetogenic pain) may show relatively mild degenerative findings on imaging studies. For this reason, the patient’s history and physical exam are very important in helping to clarify the source and level responsible for pain.

 

 

V. Procedure: Lumbar, Thoracic or Cervical Facet Joint Injection

 

What will happen to me during the procedure?

The procedure is explained to the patient, questions are answered and informed consent is obtained.

 

You will be placed on the x-ray table on your stomach in such a way that your doctor can best visualize these joints in your back using x-ray guidance. The skin on your back will be scrubbed using a sterile scrub (soap). Next, the physician will numb a small area of skin with numbing medicine. This medicine stings for several seconds.

 

After the numbing medicine has been given time to be effective, your doctor will direct a very small needle using x-ray guidance into the joint. A small amount of contrast (dye) is then injected to insure proper needle position inside the joint space. Then, a small mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) will be injected.

 

One or several joints may be injected depending on the location of your usual pain.

 

 

What will happen after the procedure?

Immediately after the procedure, you will get up and walk and try to imitate something that would normally bring about your usual pain. You will then report the percentage of pain relief and record the relief you experience during the next week.

 

You should not drive the day of the procedure. Your legs may feel weak or numb for a few hours.

 

General Pre/Post Instructions

  • You should eat a light meal within a few hours before your procedure. If you are an insulin dependent diabetic, do not change your normal eating pattern prior to the procedure. Please take your routine medications (i.e. high blood pressure and diabetic medications).
  • Do not take pain medications or anti-inflammatory medications the day the day of your procedure. You need to be hurting prior to this procedure. Please do not take any medications that may give you pain relief or lessen your usual pain. These medications can be restarted after the procedure if they are needed.
  • If you are on Coumadin, Heparin, Plavix or any other blood thinners (including Aspirin), or the diabetic medication Glucophage you must notify this office so the timing of these medications can be explained. You will be at the clinic for approximately 1-3 hours for your procedure.
  • You will need to bring a driver with you. You may return to your normal activities the day after the procedure, including returning to work.

 

 

What if I don’t get any relief from the facet joint injections?

If you don’t get relief from the facet joint injections, it is unlikely that this is a source of your pain.  You should then consider with your physician the other possible sources of your pain.  This may include other diagnostic blocks or imaging studies.

 

What happens if I get relief from the injection, but my pain comes back after a few hours or days?

This is the most common scenario with facetogenic pain.  Typically the local anesthetic wears off over the next six hours and the pain may return.   After a series of successful diagnostic facet blocks, the next step is usually to proceed with a Radiofrequency Neurolysis (RF).

 

Potential Risks of  Joint Injections

 

As with any procedure, there is a risk of significant complications. The most common side effects from the joint injection include (but are not limited to):

 

  • Allergic reactions to medication or dye used
  • Infection (occurs in less than 1 per 15,000 injections)
  • Post-injection flare (joint swelling and pain several hours after the corticosteroid injection)
  • Depigmentation (a whitening of the skin)
  • Local fat atrophy (thinning of the skin)
  • Rupture of a tendon or capsule located in the path of the injection
  • Bleeding, nerve injury, organ injury and death are rare but possible