1. When Interventional Injections and Nerve Blocks Can Help
Christopher Rumery, MD

3. Source of Pain Cervical Spine pain generators
Lumbar spine pain generators
When a patient is sent to us for consideration of an injection, we need to determine the source of the pain.
For pain originating from the spine, first determine if the pain is radicular (caused by a bulging disc) or non radicular (caused by facet joints, SIJ or myofascial)

4. Treatment Pathways Non-radicular pain Radicular pain
Cervical Epidural Steroid Injection
Lumbar Epidural Steroid Injection
Radicular pain
Medial Branch Nerve Blocks
Radiofrequency Neurotomy
Non-radicular pain

5. Cervical Epidural Steroid Injection
Indication
Rationale
Indication- Patient presenting with neck pain and typically worse pain, numbness, weakness, radiating to one of both upper extremities. MRI shows bulging disc or stenosis
Rationale – to deliver a caricosteroid in the epidural space, in close proximity to the source of the pain.

6. Cervical Spine Anatomy
There are two approaches for the CESI – both require fluroscopy
Intralaminar – requires loss of resistance technique, minimal or no sedation – very needle location & contrast.
Transforaminal – always use if the patient has had surgery using the posterior approach
Quineke needle anterior/lateral approach – minimal or no sedation – verify needle position & contrast.
Generally considered more risky due to relationship of vertebral artery, radicular artery and the spinal nerve.
Recommend non patrulate steroids

7. Pg 194 - Images from the book “ Practice Guidelines for Spinal Diagnostic and Treatment Procedures
Second edition, Edited by Nikolai Bogduk, MD, PHD, DSc

8. Images from the book “ Practice Guidelines for Spina Diagnostic and Treatment Procedures
Second edition, Edited by Nikolai Bogduk, MD, PHD, DSc

9. Contraindications & Risks for Cervical and Lumbar Epidural Injections
Blood Thinners
Infection at the needle entry site
Canal stenosis
Risks
Bleeding
Infection
Nerve damage
Headache

10. Efficacy 60% had good or excellent relief
Slipman CW, Lipetz, JS, et al. Arch Phys Med Rehabil 2000; 81:
The literature on the effectiveness or efficacy or cervical transforaminal injection of steroids is limited in quantity and quality.
60% had good or excellent relief – defined as pain reduced to 4 out of 10 or less, with resumption of work and no need for medications for radicular pain

11. Lumbar Spine Anatomy

12. Lumbar Epidural Steroid Injection
Transforaminal access
Deposit steroid close to pain generator
Lower incidence of dural puncture
More effective
Intralaminar access
May be necessary if transforaminal access is difficult
Efficacy- lacking for interlaminar

13. Pg 447- Images from the book “ Practice Guidelines for Spinal Diagnostic and Treatment Procedures
Second edition, Edited by Nikolai Bogduk, MD, PHD, DSc

14. Z-Joint
The Z joint is a possible source of non-radicular lumbar and cervical pain
Clinical Signs of Z-joint Pain
Increased pain with standing
Pain decreased with lumbar flexion and support
Increased pain with lumbar extension
More likely in the elderly

15. Why MBBs? “Z” joint pain Which joint to workup?
Never by imaging studies
Most prevalent
Cervical – C2-3 or C5-6: Lumbar L5-S1 or L4-5

16. Cont’d – Why MBB’s Palpation under fluoroscopy - Questionable
Cervical – Start with single most likely. You can always add another.
Lumbar – Single best. Pragmatic: L4-5 + L5-S1

17. Diagnostic MBB Review
Contrast required: Isovue or Omnipaque (~.02cc)
To assure no venous uptake (>50% false negative)
To assure coverage of target nerves with LA
Local anesthetic:
Low volume ( cc), therefore want
High concentration (Lidocaine 4%; Bupivacaine 0.5 or 0.75%)
No Corticosteroids!!
Corticosteroid = presumptive therapeutic
Injection of steroid onto MB has no concept validity
The pathology is intra-articular somatic not neuropathic

18. Lord et al. clinical Journal Pain 11:208-213. 1995.
Benefit of MBBs
Post procedure Assessment
Significant relief (80-100%) with provocative movements, for expected duration of local anesthetic
High false positive (30%)
Therefore, a 2nd confirmatory injection is required
If 1st injection negative, no 2nd injection warranted and
If 2nd injection is negative RFN is not appropriate
Best practice – Comparative LA blocks + Placebo
*Bogduk. On the use of diagnostic blocks for spinal pain. Neurosurgery Quarterly 19:88-100, 2009.
Bogduk. Practice Guidelines for Spinal Diagnostic and Treatment Procedures. 2013
Lord et al. clinical Journal Pain 11:

19. Reasons for False Positives
Placebo response
Observer bias
Minimal pain at the time of block
Single block
Myofascial pain generator

20. Radiofrequency Neurotomy
“That which cannot be healed by heat cannot be cured” – Hippocrates, 400 BCE
Temperature lesions > 70C cause irreversible lesions via protein denaturation with indiscriminate large and small fiber cell destruction
16 gauge needle, 85C degrees, 90 seconds

22. Efficacy of Thermal RF Neurotomy
Duration of relief
13-15 months
Only if:
100% dual dx blks
Meticulous technique
MacVicar et al. Pain Medicine. 2012

23. Conclusion
For radicular cervical or lumbar pain, do cervical or lumbar epidural steroid injection
For non-radicular cervical or lumbar pain, do medial branch block, possibly followed by radiofrequency neurotomy.