Archives of Physical Medicine and Rehabilitation
Volume 88, Issue 3, Supplement 1 , Pages S18-S21, March 2007

Industrial Medicine and Acute Musculoskeletal Rehabilitation. 4. Interventional Procedures for Work-Related Cervical Spine Conditions

  • Robert W. Irwin, MD

      Affiliations

    • Department of Rehabilitation Medicine, University of Miami, Miller School of Medicine, Miami, FL
    • Corresponding Author InformationCorrespondence to Robert W. Irwin, MD, Dept of Rehab Med, Univ of Miami, Miller Sch of Med, PO Box 016960 (D-461), Miami, FL 33101.
    • ,
  • Joseph P. Zuhosky, MD

      Affiliations

    • Total Spine Specialists, Department of Physical Medicine and Rehabilitation, Carolinas Medical Center, Charlotte, NC
    • ,
  • William J. Sullivan, MD

      Affiliations

    • Department of Physical Medicine and Rehabilitation, University of Colorado at Denver and Health Sciences Center, Denver, CO
    • ,
  • Andre Panagos, MD

      Affiliations

    • Department of Rehabilitation Medicine, Weill Cornell Medical Center, New York–Presbyterian Hospital, New York, NY
    • ,
  • Patrick M. Foye, MD

      Affiliations

    • Department of Physical Medicine and Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey: New Jersey Medical School, Newark, NJ
    • ,
  • Aaron W. Sable, MD

      Affiliations

    • St. John’s Macomb Hospital, Warren, MI.

Article Outline

Abstract 

Irwin RW, Zuhosky JP, Sullivan WJ, Panagos A, Foye PM, Sable AW. Industrial medicine and acute musculoskeletal rehabilitation. 4. Interventional procedures for work-related cervical spine conditions.

This self-directed learning module outlines the use of interventional techniques in the treatment of neck pain with and without referred pain into the arm. It is part of the supplement on industrial rehabilitation medicine and acute musculoskeletal rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on interventions used to diagnose or treat the conditions commonly seen in patients with neck pain or referred pain into the upper limb. Techniques reviewed include the use of botulinum toxin injections in the treatment of myofascial pain, cervical zygapophyseal joint injections and radiofrequency neuroablation in the treatment of posterior column disorders, and epidural steroid injections in the treatment of cervical radicular and referred upper-limb pain.

Overall Article Objective

To give an overview of the current state of the art regarding diagnostic and nonsurgical invasive treatment procedures for neck pain with and without referred upper-limb pain.

Key Words: Botulinum toxins, Facet joint, Disk, herniated, Injections, epidural, Rehabilitation, Trigger points, myofascial

 

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4.1 Educational Activity: To discuss the use of zygapophyseal injections and the use of botulinum toxin to treat a 45-year-old Department of Transportation worker with upper-thoracic and neck pain related to a “whiplash” injury for whom conservative treatment has failed 

UPPER-THORACIC, PERISCAPULAR, and neck pain from myofascial and/or whiplash-like injuries present a potentially vexing challenge to the treating clinician. Prompt and specific diagnosis coupled with early treatment generally results in better clinical outcomes. Much of the literature addressing myofascial pain describes trigger points in the discussion of the pathogenesis of these disorders. Trigger-point injections are a commonly used therapeutic option for this problem. Variations of these injections include dry needling, local anesthetic injections only, and combined local anesthetics with corticosteroid injections. These variations appear to have comparable efficacy. However, anecdotal experience and the available literature on trigger-point injections suggest that the benefits achieved may not be sustained if performed in isolation. In general, pain relief lasts 1 to 3 weeks when trigger-point injections are given as stand-alone treatment. Administering trigger-point injections as 1 component of a comprehensive rehabilitation program may yield better results.

The pathogenesis of trigger points remains unknown. Electromyographic investigation1 has suggested that mini-endplate potentials found routinely in trigger points may be used to characterize this phenomenon. These mini-endplate potentials, however, are not pathognomonic and are not consistently found. Others1 have examined oxygen tension in trigger points and note consistently lower oxygen levels in these muscle fibers. The mechanism that permits creation and maintenance of this lower level of muscle fiber oxygenation remains unclear.

Another hypothesis of trigger points’ pathogenesis contends that uncontrolled acetylcholine release results in chronic muscle fiber contraction. In an attempt to address this possible pathogenesis in particular, clinicians have turned to botulinum toxin types A and B to break this cycle. A recent focused review2 has described the use of these agents in cervical dystonias, spasticity, headaches, myofascial pain, and chronic low back pain. Botulinum toxin’s mechanism of action is the reversible blockade of acetylcholine release at the neuromuscular junction, generally lasting 3 to 4 months. Several small prospective studies have yielded promising results; however, the variety of dosing schedules and the number, frequency, and pattern of injections prove somewhat problematic in evaluating this research area.

Upper-thoracic, periscapular, and neck pain may emanate from the cervical zygapophyseal joints, commonly referred to as facet joints. The patterns of pain provocation mapped out in zygapophyseal-joint injections of symptomatic and asymptomatic people have significant overlap with the patterns seen in myofascial and whiplash-associated disorders.3, 4 The prevalence of cervical zygapophyseal-joint pain has been estimated at greater than 25% in neck pain patients and, after whiplash-like injuries, the prevalence is increased to greater than 50%, most often affecting the C2-3 and C5-6 joints.5, 6

On physical examination, neck pain reproduction with the Spurling maneuver without referred pain into the arm and with cervical extension or rotation, with reduced, painful range of motion, may suggest a cervical zygapophyseal-joint disorder. History and physical examination alone, however, have proven to be unreliable predictors of zygapophyseal-joint pain. Increased radioactive uptake in the zygapophyseal joint on bone scan may provide further diagnostic confirmation. Comparative local anesthetic blocks of the medial branches of the dorsal ramus, commonly referred to as medial branch blocks, as a diagnostic tool have been established as a current criterion standard.7 The dual innervation of the cervical zygapophyseal joints is shown in figure 1. Many clinicians also use cervical intra-articular zygapophyseal-joint blocks as part of a diagnostic regimen with or without medial branch blocks. Cervical zygapophyseal-joint intra-articular blocks can also provide short-term relief but may be less effective for chronic pain states.8, 9

Studies3, 4, 5, 6, 7, 8 for cervical zygapophyseal-joint pain initially focused on intra-articular blocks but more recently have included medial branch blocks not only for diagnostic benefits but also for potentially therapeutic benefits. Medial branch blocks have several advantages, including safety of the injection. There is less risk of a needle passing through the joint into the spinal cord, compared with zygapophyseal-joint intra-articular injections, because the articular pillars serve as an effective bony backstop, preventing needle penetration into the spinal canal. They may be technically easier to perform than intra-articular injections, especially in older patients where osteophytes may preclude needle entry into an arthritic joint.

Analysis7 of dual comparative, local anesthetic, medial branch blocks shows variable duration of response, with some patients reporting pain relief longer than the duration of the local anesthetic used. The injections have predictive validity, with pain relief after medial branch blocks corresponding quite favorably to pain relief after radiofrequency neuroablation.7

Radiofrequency neuroablation has proven to be safe and effective, with a greater than 70% response rate for cervical zygapophyseal-joint pain when performed after appropriately diagnostic, comparative, local anesthetic, medial branch blocks. Workers’ compensation patients did statistically as well as patients treated from the general population. Although the medial branch of the dorsal ramus nerve typically regenerates in approximately 90 days, the relief achieved may last 7 to 9 months, or longer. If the pain returns, repeat radiofrequency neuroablation can produce similar beneficial effects.10, 11 It is unclear how many times the procedure may be repeated with achievement of the same results.

Pulsed radiofrequency neuroablation has been investigated as a treatment of zygapophyseal-joint pain partly in an effort to increase the safety of these procedures. This procedure allows lower levels of heating (42°C vs 80°C), and the subsequent risk of deafferentation pain is theoretically decreased. Animal models show cellular changes and an increase of immunoreactive cells with the pulsed techniques when compared with a sham procedure.12 Very few trials have looked critically at pulsed radiofrequency neuroablation. One suggested a positive response with greater than 50% relief sustained for 1 to 5 months in about 60% of patients.13 Further research is needed before this procedure can be widely recommended for clinical practice.

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4.2 Educational Activity: The above Department of Transportation worker has persistent pain in the neck and posterior shoulder and now has arm pain despite botulinum toxin injections and facet injections. Discuss other nonsurgical interventions that may be considered, including their potential risks and benefits 

Upper-limb pain associated with spinal pathology is considered synonymous with cervical radiculopathy in some settings; however, referred pain into the upper limb may in fact emanate from other somatic sources (eg, cervical zygapophyseal joint, myofascial) and does not always represent irritation or injury of the nerve root. Although pain related to a clear-cut radiculopathy is generally perceived along the affected dermatome, pain patterns from other causes often overlap dermatomes, sclerotomes, or myotomes, as well as peripheral nerve innervation patterns. Patients may also suffer with referred pain from an irritated nerve root without having associated neurologic deficits. Some clinicians refer to this as radiculitis, but others use the term radiculitis to denote inflammatory involvement (whether associated with neurologic deficits or not). Unfortunately, there is no consensus in differentiating the etiology of radicular pain patterns in the upper limb. Hence, the literature evaluating upper-limb referred pain remains confounded by a heterogeneous patient population with likely multiple underlying etiologies contributing to radicular pain. The distinction between truly radicular and referred upper-limb pain is important. A patient who has referred pain that is not clearly the result of radiculopathy might not benefit from an epidural steroid injection (ESI); however, treatments including zygapophyseal-joint injections and botulinum toxin injections might be more helpful. Conversely, if a physician fails to recognize a clear-cut radicular pain pattern, an inappropriate zygapophyseal-joint injection or trigger-point injection might be performed. A recent study suggests that tender points can be associated with radiculopathies and/or with myofascial pain. Various shoulder pathologies may also create periscapular, shoulder, and upper-limb pain. The importance of a detailed history, thorough physical examination, and correlation with appropriate advance imaging studies to arrive at a specific diagnosis cannot be overstated.

In patients with a clear-cut cervical radiculopathy, direct application of corticosteroids to the site of inflammation is a well-recognized treatment option. This can be achieved by means of a cervical transforaminal or interlaminar ESI. No prospective, randomized controlled trials have compared these injection techniques. A handful of prospective studies14, 15 evaluating cervical transforaminal ESI have shown promising results in patients with cervical radiculopathy for whom conservative treatment protocols had failed. One theoretic advantage of this injection is the low volume of injectate yielding a high concentration of corticosteroid directly to the site of inflammation. The cervical transforaminal ESI, in particular, is technically demanding because even small deviations in needle placement may have profound deleterious effects. It is important that the physician performing this procedure know the anatomy of the cervical spine, be familiar with the use of live fluoroscopic images, and be well aware of the potential injection complications. Transforaminal ESI complications include infection, nerve root injury, vertebral artery dissection, paralysis, and stroke.16 It has been postulated that particulate steroid deposition into an artery or arterial watershed zone has resulted in spinal cord and brain infarction, culminating in tetraplegia and death in some patients.17, 18, 19, 20, 21, 22 There is also a risk of a high spinal block with respiratory compromise with inadvertent subarachnoid injection of anesthetic.

Compared with transforaminal ESI, the interlaminar ESI theoretically may have a disadvantage of less availability of corticosteroid anteriorly at the site of inflammation. Cervical interlaminar ESIs may present less risk of inadvertent arterial particulate steroid deposition but are not without complications.23, 24 Risks of interlaminar ESI include delayed injury to the spinal cord, which may occur because of mass effect from either a hematoma or epidural abscess.24 One may also sustain direct spinal cord injury as a result of needle puncture of the spinal cord itself. High spinal block may occur with injection of local anesthetic into the subarachnoid space, and for this reason interlaminar ESIs with local anesthetic are typically performed at C6-7 or below. To minimize complications, interlaminar ESI should not be performed at stenotic levels.

There exists a relative paucity of literature to support the routine use of cervical ESI in the treatment of cervical radicular pain. To our knowledge, no study exists to date directly comparing the efficacy or safety of transforaminal ESI versus interlaminar ESI, and thus this choice rests with the injecting physician. The current debate as to which of the 2 injections may be more advantageous revolves more around the perceived safety of each injection and the potential complication of serious central nervous system (CNS) injury. Several studies have addressed the possible complications in retrospective analyses. In 1 study,23 the overall complication rate from cervical interlaminar ESI was 16.8%. Most of these complications were characterized as minor and resolved within 24 hours. However, there was 1 (0.3%) serious complication of a dural puncture.23

A 2003 study of cervical transforaminal ESI found that 19.4% of patients had intravascular injection on installation of contrast medium under real time fluoroscopy.18 These intravascular injections did not always correlate with blood in the hub of the needle on withdrawal of the syringe.

There have been several case reports of CNS complications resulting from cervical transforaminal ESI.19, 20, 21, 22, 25 Magnetic resonance imaging studies after these complications have shown injury or infarction to either the spinal cord or the brainstem. Only 1 study,22 which used computed tomography guidance during the procedure, showed evidence of arterial needle placement. In this study, the needle was placed in the vertebral artery before the injection.22 The other studies did not have fluoroscopic guidance or image documentation of needle placement listed in their reports. The available literature and hypotheses of CNS injuries suggests, at a minimum, that cervical transforaminal ESI procedures should always be performed with fluoroscopic guidance with live fluoroscopic images during contrast installation to minimize the risk of inadvertent intravascular injection. Some clinicians have suggested a further safeguard of digital subtraction analysis of the fluoroscopic images to further decrease this risk.

In summary, cervical ESI remains a treatment option for cervical radicular pain; however, little literature exists to support the clinical efficacy of these injections. It is important to recognize and inform the patient of the potentially disabling and life-threatening CNS complications that may occur with these injections. Appropriate use of fluoroscopic guidance in the performance of these injections may reduce, but certainly do not eliminate, the risks associated with these injections.

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 No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated.

 Reprints are not available from the author.

PII: S0003-9993(06)01566-8

doi:10.1016/j.apmr.2006.12.011

Archives of Physical Medicine and Rehabilitation
Volume 88, Issue 3, Supplement 1 , Pages S18-S21, March 2007

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