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10 Articles in Volume 9, Issue #6
Cytokine Testing in Clinical Pain Practice
Effective Monitoring of Opiates in Chronic Pain Patients
Ethics, Pain Care, and Obama’s Policy Intentions
Interventions for Radiating Upper Extremity and Cervical Facet Pain
Long-Acting Opioids for Refractory Chronic Migraine
Need for More Accurate ER Diagnoses of ACL Injuries
Neural Therapy and Its Role in the Effective Treatment of Chronic Pain
Screening Blood Panel to Evaluate New Chronic Pain Patients
Spinal Pain and Neuromuscular Deficiency
Thermal Imaging Guided Laser Therapy: Part 1

Interventions for Radiating Upper Extremity and Cervical Facet Pain

Recent developments mean safer and better outcomes of therapy for radiating pain of the neck and shoulders.

The evaluation of patients complaining of upper extremity radiating pain must include examination of the head and neck. The first steps are to obtain a careful history and to conduct a systematic physical examination. History of onset, character and location of the pain, helpful medications and ones that aggravate the problem, movement limitation—as well as previous procedures done on the patient—are helpful in the evaluation, diagnosis, and formulation of a treatment plan.

The cervical nerve roots provide innervation to a significant portion of the head. The cranial nerves are also involved in painful conditions of facial structures. The three divisions of the trigeminal nerve innervate the eye and forehead (V1), mid-facial structures (V2), and the lower jaw area (V3). Pain in temporal structures may be referred from the upper cervical area or from injury to second, third, and possibly the fourth, cervical nerves and cervical spinal facet joints. The fourth and fifth cervical nerve roots supply the shoulder area. The thumb area is supplied by C6, and the median nerve which originates from C6-7 supplies the palm and middle fingers. The little finger side is innervated by C8, T1 nerve roots (see Table 1).

Table 1. Area of Referred Pain Elicited by Referred Distribution Palpatation
Nerve Referred Distribution
C1-2 Occipital region of head
C3 Temporal region of head
C4,5 Shoulder
C6, 7 8, T1 Arm and hand

Patient Examination

Examination of the patient to confirm which nerves are involved in the pain should concentrate on placing gentle pressure along the course of the nerves. Palpation of the second cervical nerve from a posterolateral direction can reproduce pain radiating to the back of the head. Pressure just below this from the side can elicit pain radiating to the temporal area from the C3 distribution. C4 and C5 will possibly refer to the shoulder as well as the side of the head. Spasm of the trapezius muscles and pain invoked by gentle pressure on the anterior border of the trapezius muscle as the examining physician palpates from behind the front edge of the muscle represents pain in the C4 distribution. Pain invoked by palpation a little more posteriorally indicates C5 facet joint distribution. Applying pressure gives a “jump sign” where the patient jumps when pain is elicited. The C6 distribution is more caudal and posterior. In many patients, discogenic referred pain coming from the C5-6 levels is elicited by palpation closer to the spine at a location level with the upper end of the scapula. Palpation behind and inferior to the sternocleidomastoid muscle in patients with cervicogenic facet injury can trigger significant scalene muscle spasm and elicit a jump sign.

Very commonly, physicians taking care of patients fail to examine the anterior and middle scalene muscles. Spasms of these muscles are caused by compression of the brachial plexus between the two muscle groups. The compression can produce significant pain radiating to the arm or shoulder. We have found this to be a useful evaluation, especially in patients who have already had treatment in the form of radiofrequency thermocoagulation of the facet joints but failed to respond. In these patients, the scalene muscle may still be in significant spasm and injection of the interscalene space to free the compression by the two muscle groups can result in significant pain relief and help regain cervical mobility. The interscalene block will reach both the brachial plexus and the cervical sympathetic ganglia.

Evaluation of pain patients with arm pain radiating from the lower cervical nerve roots, C6 and below, is done with a stretching maneuver. The patient’s shoulder and arm are extended horizontally, the shoulder is pushed forward, and the head is tilted in the opposite direction while the patient stabilizes himself/herself by firmly holding on to a structure such as a doorway. This procedure often reproduces the patient’s pain, such as pain radiating to the thumb, the middle of the palm and the little finger along the above outlined dermatomal innervation pattern.

Causes of Cervical Pain

Chronic compression of nerve roots produces radiating pain as will acute, intense compression of normal nerves or compression of injured nerves. Sources of compression include muscle groups in spasm or a bulging intervertebral disc inside the spinal canal, bony outgrowths such as osteophytes due to degenerative processes and spinal lateral recess stenosis near the neuroforamina.1 Other significant causes of pain are degenerative processes of the disc. Leakage of nucleus pulposus material, the soft inner structure of the cervical disc, into the spinal epidural space can produce an inflammatory reaction leading to scar formation similar to scar formation produced by surgery.2-4

Nerve roots move as the human body moves. If the nerves cannot move freely, flexion of the head and neck and movement of the upper extremity often leads to severe radiating pain due to traction in the nerve root. Movement is three times more likely to cause pain when nerve movement is restricted.5

Anterior and middle scalene muscle spasm can lead to significant radiating pain. Interscalene blocks can have rather remarkable long-lasting effect when there is scar formation of the nerve root and spasm of the scalene muscles.

Injury to a nerve can change its normal role of transmitting messages from the periphery to the central nervous system (CNS) and from the CNS to the periphery. An injured nerve may spontaneously generate impulses which produce pain. A cycle develops from the triad of injury leading to pain, leading to muscle spasm and more injury, more pain, and more spasm.

“The challenge for the examining physician is to differentiate pain originating from the different structures of the spinal canal, the muscles or the lateral and anterior structures of the facet joints and discs, or pain due to other pathological processes.”

The challenge for the examining physician is to differentiate pain originating from the different structures of the spinal canal, the muscles or the lateral and anterior structures of the facet joints and discs, or pain due to other pathological processes. Training and experience lead to remarkably accurate presumptive diagnosis but additional diagnostic tools such as flexion-extension x-rays, CT scans and MRIs are important in the complete evaluation.

Physician Credentials

For interventional pain physicians, there is no substitute for properly supervised training where basic principles must be taught. The training must provide a foundation of clinical experience where supervised procedures are performed with predictable safety and efficacy.

The only way to evaluate the training of a physician is to verify his/her credentials. Optimally, physicians who practice pain medicine will have Board certification in a primary specialty (eg, anesthesiology, neurosurgery, orthopedic surgery, neurology, physical medicine and rehabilitation) and subspecialty certification (added qualification) in pain medicine. On completion of the added qualification examination, those physicians who are interventional pain procedure-oriented should avail themselves of the examination offered by the World Institute of Pain, the FIPP (Fellow of Interventional Pain Practice) examination, and also the American Society of Interventional Pain Physicians that offers the ABIPP (American Board of Interventional Pain Practice) examination (see section titled ‘Certification And Membership Information’). The ABIPP examination has two parts: Part I is an examination in coding, compliance and use of pain medications while Part II is the FIPP examination.

Noteworthy is that all other tests and examinations available to physicians are simply written examinations, with or without an oral component, that do not evaluate and test the skills required to perform the very exacting and precise procedures that interventional pain physicians perform. The FIPP (ABIPP Part II) examination requires the examinee to perform four procedures on cadavers. Two examiners observe and evaluate the examinee’s skills. Examinees must also pass an oral examination where clinical case information is discussed in detail. The format is very similar to the oral part of ABMS examinations. The need for improving physicians’ level of training and fund of knowledge is founded on the simple basic principle that better education leads to better patient care and outcome from therapy. Complications that are very rare—but inevitable—are reduced through better training, better understanding of the cause of complications and through the use of the best equipment available to reduce the sometimes disastrous but completely unintended complications that may occur in the hands of caring and compassionate physicians.

Therapeutic Principles

The therapeutic principles center around regaining function, reducing pain and reducing swelling. These objectives are addressed first by the use of nonsteroid anti inflammatory drugs (NSAIDs), possibly by the use of oral steroids such as a Medrol Dosepak® and by the use of heat, exercise, and massage to reverse muscle spasm and increase blood flow to nerves. The increased blood flow reduces neural swelling and helps to regain nerve root mobility. Minimal reduction in nerve size can lead to large space gain in the neuroforamen. Recall that cross sectional area of a nerve changes geometrically with radius (πr2).

Shoulder Pain

Shoulder pain may originate from the cervical spine but the shoulder also is subject to parallel degenerative processes, injuries, secondary myofacial spasm, and inflammatory and entrapment neuropathic processes. One inflammatory process that is often overlooked is biceps tendonitis. To detect biceps tendonitis, face the patient and place your thumb in front of the upper end of the arm then roll the thumb from medial to lateral, while applying firm but gentle pressure to roll the biceps tendon laterally and posteriorly. This will elicit a rapid pain response if there is biceps tendonitis. Injection of a small amount of local anesthetics and steroid under fluoroscopic guidance into the insertion of the longhead of the biceps tendon at the coracoid process and injection of local anesthetic and steroid along the upper end of the arm, medial and lateral to the biceps tendon is a very useful technique. The total injection is 6-8 ml of 0.2% ropivacaine and 4 mg of dexamethasone or 40 milligram of triamcinolone. Care must be exercised to avoid injecting into the tendon at the coracoid process on the medial and lateral side of the insertion of the tendon and on the upper arm along the course of the biceps tendon.

“Shoulder pain may originate from the cervical spine but the shoulder also is subject to parallel degenerative processes, injuries, secondary myofacial spasm, and inflammatory and entrapment neuropathic processes.”

Common Cause of Shoulder Pain

A common cause of shoulder pain is entrapment of the suprascapular nerve as it travels through the suprascapular notch. One can elicit this pain by applying straight downward pressure on the suprascapular notch with the index finger. The notch is just anterior on the lateral aspect of the spine of the scapula, close to the shoulder joint. We prefer to use fluoroscopic guidance to place a blunt Coude 20- or 22-gauge needle in the notch through an introducing cannula. The goal is to free the seriously compressed nerve as it travels through the notch. The first step is to perform a diagnostic block with local anesthetic. If the block gives pain relief of significant duration but is not lasting, injection of local anesthetic and steroid may give longer lasting pain relief. If the pain subsequently returns, pulsed radiofrequency (PRF) may be applied by placing a blunt curved RF needle through the supracapular notch. According to a recent report, PRF produced pain relief lasting over a year in a 6-months series of patients.6

Subacromial bursitis is another com-mon cause of shoulder pain. Injecting local anesthetic and steroid underneath the acromioclavicular joint using a simple posterior approach can be an effective treatment. Torn rotator cuff injuries requiring surgical repair can cause shoulder pain. But, in the presence of clinical findings described above, a simple injection may lead to good pain relief. Diagnostic studies, such as MRI of the shoulder, can be used if there is no response or if one has clear-cut evidence of rotator cuff injuries.

Cervical Facet Pain

The examination for facet pain secondary to referred muscle spasm in the trepezius has been described above. It is important to understand this because even relatively small whiplash type injuries can produce injury to the structures surrounding the cervical facet joints that may not show up on diagnostic studies such as CT scan and MRI. This was demonstrated by Jim Taylor7 who performed a large number of post-mortem facet joint dissections of patients who were victims of fatal motor vehicle injuries. At the time of postmortem dissection, direct visualization of the facet joints was the only way to show that tears and lacerations were caused by the fatal accidents. Dissection of one patient who survived a motor vehicle accident developed cervical facet joint pain and subsequently died from medication overdose. The postmortem evaluation confirmed the presence of the small tears and injury to the facet joints that did not show up on diagnostic studies.

Pain coming from the joints can be elicited by range of motion evaluations. If a “yes” nodding motion produces pain, it usually indicates the pain is originating from the atlanto-occipital joint. Pain originating from the atlanto-axial joint, on the other hand, usually can be elicited by a lateral “no” shaking movement. The lower cervical joints show limitation of range of motion towards the origin of pain but those joints are best evaluated by lateral pressure on the joint. Credit must be given for the beautiful dissections and clinical, therapeutic and diagnostic studies by Bogduk and his team regarding the cervical facet joints.8 C3 involvement leads to pain in the temporal. However, pain originating from the third occipital nerve can be blocked with local anesthetic injected just above the C2-3 lateral facet joint that usually leads to resolution of posterior-lateral occipital and midline inferior occipital pain.

The evidence is very solid for the therapeutic value of cervical and lumbar facet diagnostic blocks followed by radiofrequency thermo coagulation. The issue may very well be one-to-three diagnostic and/or therapeutic blocks but, in the absence of prolonged pain relief, radiofrequency lesioning is the best therapeutic approach we have for pain related to facet joint disease. The procedure must be done by fluoroscopy guidance by an appropriately-trained physicians.9-17

Radiofrequency lesioning of the C2-3 facet joint may produce long-lasting pain relief in patients suffering from intractable severe pain. At times, the posterior approach is used to target the third occipital nerve just above the C2-3 facet line together with injecting the C3 medial branch. If the lateral fluoroscopic view is not parallel to the tip of the needle and if a sharp needle is used, the tip of the needle may enter the C3 nerve near the spine. An intraneural injection can be followed by injury to the spinal cord. Injection into nerves close to the spinal cord is a hazard due to using needles with sharp tips. This hazard first became evident during the use of sharp-tipped needles for transforaminal injections.18 The lead author has seen four of these cases. Results of a survey led to the recommendation to use blunt needles to reduce the incidence of injury to the spinal cord.18,19 We now prefer to use blunt needles inserted through an introducing cannula when doing C3 facet and also when doing other nerve root blocks. If the cervical facet diagnostic block, followed by local anesthetic and steroid injection, relieves the pain only for a short duration, radiofrequency lesioning can be done. This may produce pain relief that can last about 250 days.

Lysis of Adhesions: Site-Specific Injection

Cervical spinal canal nerve involvement secondary to a bulging disc, degenerative disc disease, an osteophyte, or surgery can lead to scar formation which has been the area where cervical lysis of adhesions has been very useful.20 A common problem in the cervical area is that epidural steroid injected by the interlaminar route remains in the posterior epidural space and does not reach the nerve in the spinal canal. Cervical epidural injections are useful in new onset acute cervical radiculopathies where the radiating pain can be elicited by stretching the arm and bending the head away from the painful side.

The alternative technique to interlaminar epidural steroid injection is placement of an x-ray visible soft tip steerable catheter anterolaterally where the painful nerve root originates. We use this technique for site-specific injection of contrast, saline, and hyaluronidase (Hylenex 150 units). This is followed by injection of local anesthetic and steroid. A paramedian approach at a segment and one-half below the target site is used. For placing a 21-guage Versacath Epimed, the site usually is T1, T2. An 18-gauge RX-2 Coude needle (see Figure 1) is inserted into the epidural space using the loss of resistance technique. Prior to moving the tip of the needle after it is epidural, the regular needle stylet is replaced by a second stylet. This blunt stylet extends approximately 1mm beyond the epidural needle tip and pushes the dura away from the needle tip to protect the dura from laceration or puncture when the needle tip is rotated towards the desired direction. The technique for the three injection series of the lysis of adhesion is done through the 16- or 15-gauge RX-2 Coude needle using a similar technique as described above. The catheter used for the repeat injections is larger diameter (19 gauge) and is longer (24-inches) for better fixation and prevention of migration of the catheter tip. The tip of the catheter is very soft and is not known to migrate into vessels, nerves, or through the dura. Sterility is maintained by the use of a bacterial filter for the second and third injections. The steerability to the target site is enhanced by putting a three-fourth inch bend near the tip. The catheter (24XL Epimed Catheter) can also be used for identifying painful nerve roots through electrical stimulation due to the uninsulated spring tip construction. Steroids will not pass through the bacterial filter and are only injected on day one. If a one-day injection is utilized and electric stimulation is desired, the Brevi Excel Catheter can be utilized.

Figure 1. RX-2 Coude needle. Upper needle with standard stylet. Bottom standard stylet replaced by plastic stylet with round tip.

The needle is rotated in the direction where the catheter needs to be threaded. Once the catheter is at the target site, there usually is evidence of pain originating from the nerve root when the tip of the catheter comes in contact with it. A small volume of contrast is injected, 0.5 to l ml, and then 2-3 ml of saline with hyaluronidase is injected slowly while observing the dye spread. The contrast will spread cephalad and caudal in the epidural space. However, scarring and resistance will prevent the desired lateral spread and so pressure can build up in the lateral epidural space compressing the blood supply to the cord.21 Because of the small amount of space available in the cervical epidural space, the contrast may spread during injection from one side to the other, following the course of the ventral epidural veins since fluids take the path of least resistance. This spread is known as PVCS (perivenous counter spread; see Figure 2). PVCS is evidence that pressure is increasing in the injected lateral side and contrast is unable to spread in the direction of the nerve root. It spreads to the opposite side of the spinal canal instead. If pressure increases, the spinal cord may be compressed by pressure from both sides. When this occurs, rapid action is required to prevent damage due to ischemia and pain from compression of the blood supply to the cord.22

Figure 2.Cervical epidurogram shows PVCS (perivenous counter spread).). If this occurs, flexion and rotation to enlarge the neuroforamin should be done quickly to allow fluid to exit from the spinal canal via the intervertebral foramen.

Rotation and flexion of the neck will alter the outlet from the spinal canal. The neuroforamen gets larger as the inferior pars slides forward over the superior pars.23 The patient is instructed to flex the neck and turn the chin from left to right towards the shoulders. The anesthesiologist at the head of the table helps the patient do this. It is remarkable how this flexion rotation movement enlarges the neuroforamina and allows the rapid exit of the fluid from the spinal canal through the enlarged neuroforamina. The cervical spine is a dynamic structure where the neuro foramina can be enlarged by the above procedure and open up a lateral run off for the injected solutions and prevent ischemic cord injuries (see Figures 3-a,b,c).

Figure 3a.18-gauge RX-2 Coude needle is in the epidural space. The second protruding stylet was used to rotate the needle to the desired direction. The catheter, a 21-gauge Versacath, was passed through the needle to C4 on the left side. Injection of contrast failed to spread laterally. Because of loculation and pressure buildup, the dye spreads toward the opposite side on the right around the ventral cervical epidural veins. (PVCS) The dye partially is coming out on the right side at C4-5.

Figure 3b.Flexion rotation of the head and neck opens up the left-sided epidural space. Also the neuroforamina get larger and the dye is spreading out on the painful left side laterally from the epidural space.

Figure 3c.The flexion rotation from left to right allows the dynamic spread of epidural injection up and down and laterally. Pressure build up is therefore prevented. The needle is placed at C7 T1 or T1 T2. Flexion rotation with the catheter threaded through the needle is possible because the dura is pushed away by the catheter. The upper thoracic spine moves very little during the rotation maneuver.

Rotation and flexion rotation of the head allows the spread of medications along multiple nerves. The medication and increased blood flow reduces the size of the swollen nerve roots. This allows passage of the catheter in the lateral ventral epidural space past the previously firmly-adhered nerve roots. Saline and hyaluronidase injection is followed by local anesthetic and steroid injection. The injection usually is done under mild sedation in a sterile environment. In the post-operative area, the patient is observed to be sure there is no spread of local anesthesia to the subdural space. Subdural spread, which is certainly possible—especially in the failed neck surgery patient population—may produce delayed onset motor block and respiratory depression. It is not uncommon to produce a partial tear through the dura during surgical procedures. As fluids take the path of least resistance, they can find the opening in the dura and spread into the subdural space. For this reason, it is very important to wait prior to the injection of 10% sodium chloride or, in some instances, 5% sodium chloride, using volumes equal to or less than the volumes of local anesthetic used. The hypertonic saline injection can be very painful if not proceeded by local anesthetic. The hypertonic injection usually is injected 30 minutes after the local anesthetic and steroid. It is infused over 15 minutes so that the painful swollen nerve roots are slowly bathed in the hyperosmolar solution to draw the fluid out of the painful nerve root. This is also helpful in reducing post-procedure pain. The hypertonic saline is injected through a bacterial filter so that the indwelling catheter that has been placed into the painful area remains completely sterile. The patient is then instructed and started on neuroflossing exercises. This exercise puts sustained stretch on the nerve root to try to regain nerve mobility. Hypertonic injection, preceded by local anesthetic injection, is repeated at least six to eight hours apart for a total of three injections. After the third injection—which, again, is local anesthetic followed 30 minutes later by hypertonic saline—the catheter is removed. The hypertonic saline infusion usually is done with the painful side down and the patient is kept in this position for 30-45 minutes. The patient is instructed to continue the neuroflossing exercise program at home, two to three times per day, stretching on both sides for 30 seconds each (see Figure 4, page 18). Holding the position for a sustained period of time converts the stretching of the nerve to a pulling force at the nerve root.

Figures 4a, 4b and 4c. Neuroflossing exercise for the cervical space nerve roots. (Figures courtesy of Epimed Corp.)

The results have been remarkably effective for radiating pain. The longest follow-up we have is on one of our professors who had an osteophyte in the neck causing severe radiating arm pain. The lysis procedure was done in 1984. In 1986, he developed severe radiating pain on the opposite side and the procedure was repeated using the sequence of three series of injections as described above. The patient has not had any additional procedures since those done 23 and 25 years ago, respectively.

The explanation for this result is that a nerve root irritated by osteophytes becomes swollen and the resulting enlarged nerve root is then continuously injured by the osteophyte. Once the nerve root is freed and its size reduced, the nerve may settle down next to the osteophyte and the nerve root mobility can be maintained if the patient continues to do the neuroflossing exercises. Once reduced in size, the nerve root, at times, may be able to remain pain-free for very long periods of time.

A more typical scenario with post traumatic or degenerative or failed neck surgery patients is that the lysis of adhesions procedure produces a very nice reduction in the radiating pain. It usually takes a month post-procedure to produce maximum benefit. However, examination of the neck and shoulder pain at this point may reveal the pain originating from pathologically-changed facet joints. One detects the painful joints from lateral pressure as well as by the jump signs when pressure is applied over the trapezius area. At this point, we address the facet joints with diagnostic nerve blocks. We reduce the muscle spasm in the trapezius without touching the myofascial component. A successful block indicates that the muscle spasm is not coming from the muscles but from where the muscles insert on the pathologically-changed facet joints.

Physical Therapy

Post-procedure physical therapy is of great interest but it needs to be appropriate physical therapy. We reviewed 100 cervical lysis procedures where an uninvolved third party did the follow up evaluation on the role of physical therapy.24 The patients that were evaluated were randomly pulled from a group of 240 cervical lysis of adhesions population. We failed to prescribe physical therapy for one-third of the patients. In another third, physical therapy was prescribed but the therapy was not actually delivered—either because the patient did not feel inclined to participate, there was a scheduling conflict, or the therapy was never given for other reasons. The third group did get physical therapy but the prescribed therapy was chosen by the therapist consisting of heat, massage, and some range of motion. On statistical analysis the three groups had no statistically-significant outcome difference. This led us to reevaluate the physical therapy that we order. We now prescribe the neuroflossing exercises previously described (stabilizing the outstretched arm horizontally, pushing the shoulder forward, tilting the head to the opposite side and rotating the head forward so that the chin touches the shoulder). Pushing the shoulder forward puts a pulling force on the brachial plexus. Maintaining this pulling force for 20-30 seconds leads to mobilization of the nerve root. An additional benefit is stretching the scalene muscles that may also be involved in pain generation when in spasm. It is surprising how well patients can be motivated to continue with the exercise program for prolonged periods doing the exercise two to three times per day, bilaterally.

One example of a patient who benefited from the exercise program had failed neck surgery and severe pain radiating to the fingers. Following the lysis procedure and (the predictable) facet pain with radiofrequency thermocoagulation, the numerical rating score was reduced from 7-8 to 3-5 (VAS 0-10 scale). The patient elected to continue the neuroflossing exercises. Two years after the procedure, the patient reported that after the sensation of a pop the trapezius muscle spasm disappeared, and the upper cervical radiating pain completely disappeared. The patient has remained pain free for the last five years.

Similarly, patients who suffer from multi-level bulging disc disease have done remarkably well following the same approach: site-specific ventro-lateral catheter placement followed by the three daily injections for the radiating pain, and post-procedure physical therapy including muscle lengthening, massage, myofascial release, and facet block, if necessary. Surprisingly, disc bulging has not been a major issue so long as there is no spinal cord compression and the MRI shows spinal fluid surrounding the spinal cord. Following the use of the neuroflossing exercises, flexion, rotation, and the three-daily injections, the radiating pain is reduced.25,26

The site-specific injections are carried out as single injections in the surgi-center outpatient model. The injections are repeated 2 to 3 times in a span of 2 to 4 weeks, if there is significant improvement.

Limited duration physical therapy is ordered, but the main emphasis is teaching the patient and making the patient become involved in his or her own recovery by the continued use of neuroflossing exercises.

Electrical Stimulation Neural Mapping

It is not uncommon for us to see patients where surgical fusion results in no improvement in the pain. We believe this is because surgery is performed where the bulging disc is located but the pain may, in fact, be referred from a different site. This has been studied rather nicely27 where pre-surgery site-specific catheter placement to the painful lateral cervical epidural space was used. Electric stimulation to the point of paresthesia located the nerve root involved in the pain. In some instances, the nerve root was a level below where the degenerative changes were. The leaky disc causes inflammation and scaring of the nerve root and the best-intended surgery is, in fact, at the wrong level. EMG, commonly done prior to surgery, does not show pain. Diagnostic nerve block can spread to multi segments and may not accurately describe the painful area. When patients have had multi-level fusion without pain improvement, it is important to consider the diagnostic workup that was done prior to surgery. Electrical stimulation with neuromapping for pain generators is a useful procedure.

Mapping by electric stimulation prior to surgery may prevent surgery being done at the wrong location. Furthermore, the use of contrast, local anesthetic, hyaluronidase or hypertonic saline may prevent surgery if the injections are followed by neuroflossing exercises. One of our patients, referred to us from Europe, had a three-level fusion plus an artificial disc but continued to have severe radiating pain for several years. The first lysis of adhesions resulted in significant pain reduction for over a year’s duration but the pain persisted. A second lysis of adhesions procedure with mapping revealed the pain to be a level below the multi level surgical fusions. Together with the facet procedures—especially above and below the surgery—and neuroflossing exercises, the patient has done very well and is very satisfied with the outcome.

The cervical lysis procedure clearly has a number of contraindications. These include syrinx formation within the cervical spinal cord or serious spinal stenosis where there is no spinal fluid around the spinal cord on MRI examination. Also, any chronic infection and bleeding or clotting problems should be evaluated and appropriately treated prior to the procedure. Even lateral pressures in the cervical epidural space are transmitted centrally. The nerve roots act like a stay cable on a sailboat, preventing the full pressure from being exerted on the spinal cord as it would be if mid-line posterior injection were given. The patient must not have any platelet active substances onboard such as aspirin, mobic, cumadin, plavix, gingko, ghinsang, vitamin E, and so on (the list of these medications is growing).

We realize through clinical experience that extra caution is required when doing injections in the upper thoracic area where the venus plexus is abundant in the posterior epidural space. Placing a needle there is more likely to encounter a high-pressure vein. Patients who have platelet-active substances can continue to bleed thus leading to pressure build up equal to the intravenous pressures compressing the thoracic spinal cord below the level where the procedure is performed. These patients need to have an MRI and rapid surgical evaluation and possible decompression. This complication is extremely rare but knowing about it means that the appropriate therapeutic interventions can be carried out. Patients who have chronic untreated infections should be treated for the infections before any form of steroid is administered since steroids inhibit the immune system and chronic infections can become rampant.

CPT Codes

The procedure known as lysis of adhesions (aka epidural neuroplasty, the Racz procedure) was taken to the CPT Committee of the AMA by the representative of neurosurgery. The CPT committee of the American Medical Association, after considering the evidence, assigned the three-day adhesiolysis Code #62263.28-30 Subsequently, because of new evidence based on prospective randomized double blind trial of the one-day procedure, the CPT committee assigned the one-day CPT Code #62264.21 The additional evidence was based on an over 12-month follow-up from a multi-center prospective randomized trial comparing physical therapy with lysis of adhesions. The outcome clearly was significantly in favor of the lysis of adhesions.31 The lysis procedure CPT code is for cervical to sacral.

The most recent evidence of the efficacy of epidural neurologies was presented by L. Gerdesmeyer at the WIP 5th World Congress March 2009 in New York City.32 The paper is in preparation at the time of writing this article.


Certification and Membership Information

FIPP (ABIPP Part II) Certification
James Heavner, FIPP Registrar
Paula Brashear, FIPP Secretary
3601 4th Street, MS: 8182
Lubbock, TX 79430
Phone: 806-743-3112
Fax: 806-743-3965

ABIPP Certification
Mark Boswell,
Executive Director of ABIPP
Melinda Martin
81 Lakeview Drive
Paducah, KY 42001
Phone: 270-554-9412 #215
Fax: (270) 554-5394
mmartin@Asipp.org and http://www.abipp.org

WIP Membership, journal (Pain Practice) and website
Dianne Willard, WIP Executive Secretary
145 Kimel Park Drive, Suite 310
Winston-Salem, NC 27103
Phone: 336-714-8385
Fax: 336-760-2981


Patients suffering from cervical radiating pain need to be approached in a systematic manner. Patient evaluation, diagnosis and treatment plan are all important. The use of interventional pain procedures has a very good, logical basis. Pain relief is remarkably long-term, especially for the treatment radiating pain going to the upper extremity. The education of the interventional pain physician must be directed to an increasingly higher level where self-evaluation is no longer good enough. Specialty fellowship training and passing the ABMS-approved board examinations is the minimum requirement for entering the examination of FIPP and ABIPP. The utilization of evaluation by a higher-level examination such as the FIPP and ABIPP will lead to improved care in these very complex groups of patients.

Facet joint-induced pain needs to be addressed separately. The best long-term results come from the use of lysis of adhesions procedure as outlined. In addition, patient education, continued neuroflossing exercises and a critical review of type of physical therapy used in these patients is essential. The neuroflossing exercises done by the patients are effective in the long term and result in patient involvement and a significant savings to our health care system. n


The authors wish to express gratitude to Epimed, International for their permission to reprint pictures of the neuroflossing exercise and the RX-2 manufactured by Epimed, Int. The authors also wish to thank Paula Brashear for the secretarial work that made this manuscript possible.

Last updated on: August 12, 2019
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