Cervical Medial Branch Blocks for Chronic Cervical Facet Joint Pain
Prevalence of chronic neck pain is thought to be 60 percent in persons five years or longer after an initial episode. Thirty nine to 67 percent of chronic neck pain is thought to be from facet joints. Facet joints are rich with nerves, pain receptors, and mechanoreceptors. Facet joints can also refer pain to the head and upper extremities.
Various techniques have been employed to treat chronic neck pain from facet joint origin. These include intraarticular injections, medial branch blocks, and radiofrequency neurotomy. Reviews of the literature for treatment of cervical facet joint pain show limited evidence for intraarticular injections, moderate evidence for medial branch blocks, and strong evidence for radiofrequency neurotomy.
The authors chose to study the effectiveness of local anesthetic cervical medial branch blocks with and without steroids. Subjects had to have non-specific neck pain of at least six months duration. Diagnosis of facet joint involvement was verified with diagnostic blocks in a two step process.
One hundred twenty subjects were assigned to one of two groups. Each group was further divided into those that received Sarapin mixed in with the injection, and those without. Group one subjects received medial branch blocks with injection of bupivacaine. Group two subjects received medial branch blocks with bupivacaine and betamethasone, a steroid. All medial branch blocks were performed under fluoroscopy. They were repeated based on the response when increased levels of pain were reported by greater than 50 percent, or relief had deteriorated to below 50 percent.
Outcomes were measured using the Numeric Pain Scale, Neck Disability Index, work status, and opioid intake. These were assessed at three months, six months, and twelve months after treatment.
Improvement in the Neck Disability Index was 50 percent or greater in 63 percent of group I, and 68 percent in group II. Of the subjects eligible for employment, total employed changed from ten persons at baseline to 22 at the end of twelve months in group I, and changed from eleven to 18 in group II. Eighty three percent of patients noted significant pain relief at one year after the study. Duration of pain relief per procedure ranged from 14 to 16 weeks. Subjects noted 46-48 weeks of significant pain relief during the twelve month period.
The authors feel that there is equal effectiveness of local anesthetic with or without steroids. There was also equal effectiveness with or without Sarafin. Therefore, they suggest that it is not necessary to add steroids to the anesthetic during cervical medial branch blocks.
L. Manchikanti et al. A randomized, double-blind, controlled trial with one year follow up. SPINE August 2008. Volume 33, Number 17. Pp. 1813-1820.
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