[exercise453]

#6838

Hello Dr Corenman
Sorry for the length. My symptoms are diffuse (c2-3 – t1-2), from a variety of trauma. There is both facet and nerve pain. Left side neck pain is the dominant, diffuse symptom, especially above the base of the neck, but downward and in the arm as well. There is no cord involvement or symptoms I am aware of. The traumatized c2-3 facet is a particular nightmare. The mri is normal, the area tender, with trigger points and what feels like some atrophy. You have suggested the inflammation or a severely degenerated facet may affect the nerve.

Originally (1 year ago) I went to a Beckers list/Castle Connally (like our Vail, Colorado hero) pain management doctor. After receiving a thorough examination and questioning by the physicians assistant (who might have been too young to vote), she took the mri report and left to present the case to the doctor. The doctor soon arrived, coffee container in hand, only visible from the waist up as he leaned in the doorway. (He was not going to do any doctoring…today). His recommendation was to medial branch block the entire side. I was somewhat taken aback as they advertise the meticulous search for the pain generator. I asked how he would know which nerves to radiofrequency if the block successfully produced pain relief. He responded, “I burn ’em all, they’re all involved” and vanished. He was including c1-2 and possibly even c0-1 (not sure).

I went elsewhere to a pm doc with identical credentials who did the procedure in-office, sparing surgical center, anesthesiologist and even procedure expense (just co-pay) . The radiofrequency was c3-t1. A couple of months later I forced him to do c2-3. All results were minimal.

The odd part is this doctor started with only c3-4 (the opposite of the burn ‘em all doc). The short acting, 30 minute block weirdly produced 3 days of wonderful relief. Encouraged he next did a 4 hour marcane block adding c4-5 to the c3-4. No relief at all. Zero! Zilch! This morphed into the c3-t1 radiofrequency. Months later I convinced him to do c2-3. He first did a marcane block and there was 4 hours of great relief. Again the radiofrequency results were minimal. (there was an epidural in the middle which did little for pain but did reduce irritation, burning, tingling type symptoms for a couple of months. You have replied about out of position nerves, anesthetic spread vs needle width and capsule tear (although these were medial branch)

I am going to try pm again and am seriously contemplating the burn ‘em all doc this time for simplicity sake and his credentials.

Questions:
1-Do you approve of any radiofrequency at c1-2 (headaches are not a symptom)????

2-Because this facet is surely enflamed, would it make sense for the block to be into the facet with anesthetic and cortisone vs medial branch (at least once). The injury and symptoms are years old????

3-In my case c2-3 and c4-5 must be done together this time and I would approve adding c4-5. Is there any downside to including all the way to t-1 as he seems to routinely do????

4-The common denominator to the relief I got twice on blocks seems to be c-3. Again the mri at c2-3 is normal but the facet is bad news. There are posterior discs (mild) with lateral extension also producing left foraminal stenosis at c3-4 and (c4-5) termed moderate but look and feel worse than that to me. C5 nerve root was +1 fib ans psw on nerve test -no weakness-but certainly sensory symptoms. Any idea why these blocks are so successful????

Thank you for everything Dr Corenman ( I read the forum daily and frequently re-read parts)

[Donald Corenman, MD, DC]

#6841

Medial branch rhizotomies at C1-2 are somewhat risky. There is this small structure called the vertebral artery at that location. I imagine that an excellent physician can perform that procedure but I would be very cautious.

It might make sense at this point to obtain a CT scan of the cervical spine. MRIs are notorious for underdiagnosing facet degenerative disease and CT scans can reveal pathology that MRIs will not.

Some insurance companies require two different facet blocks before they will allow a rhizotomy (an intracapsular block and then a medial branch block). I am not sure that this is needed but there are experts that would know better than me.

There is some price to be paid for these rhizotomies. The medial branch also innervates the small muscles of the back of the neck and these muscles loose some or all function after rhizotomy. There seems to be no significant ill effects after rhizolysis that I have seen but you should be aware of all the potential side-effects.

Don’t forget that these medial branch blocks can also aestheticize the exiting nerve root if some of the liquid seeps down onto the nerve root (which is not uncommon). You then might try a selective nerve root block of the C3 nerve to determine if the root itself is the pain generator.

If you had your nerve test after the rhizotomy, the small posterior muscles of the neck will test positive during the EMG even if there is no nerve root involvement.

Consider asking your doctor for a CT scan and a SNRB of the C3 root. This might give you more information.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[exercise453]

#6861

Thanks Doc….I hope this will put this thread to bed

Messages received:
No c1-2 radiofrequency
No whole side radiofrequency……No unnecessary levels
The atrophy I feel at this level is likely due to the c3 medial branch nerve being radiofrequencied twice (once in the c3-8 and later c2-3)

I do believe the c3 root might be symptomatic but the facet surely is and it just seems to something treatable that might make a significant difference. It was readily felt and identifiable by a chiropractor and pm doc upon palpation as you said you did when you were a chiropractor. From a pain management perspective I am not opposed to having c2-3 and c3-4 redone, together this time (assuming blocks work well again and the doctor is alerted to do his best to avoid “dripping”). My only concern would be any further atrophy that the medial branch being “wacked” again might cause. I had always assumed a nerve root was causing this, never seeing anything in any literature about rhizotomies causing atrophy

1-Am I correct that this same c3 medial branch nerve has been “wacked” twice already (c3-8 and then c2-3)???? With atrophy in that area already should it even be done again??? Does this scenario make the potential gain worth the risk???

2-Would a selective nerve root block with both anesthetic and cortisone have any potential long term therapeutic value where the nerve is irritated over 5 years???

3-I have read surgeons do not readily operate on this c2-3 level except for life threatening trauma or spinal cord compression which this is certainly not. If a selective nerve root block will not give long term or curative value to a long time irritated nerve, and it is a pain management/medication issue, do I even need to know…(given other pathologies below)???

4-On a very recent thread the writer said her neurosurgeon said axial views are not as reliable as sagittal views for stenosis. Is that true???

Thanks Dr Corenman

P.S. I’m not sure pm doctors that perform cervical selective nerve root blocks are easily found…even anesthesiologists. The doctor I am no longer with was part of a pain group of 6 accomplished interventional anesthesiologists and they only did general epidurals in the neck (in thru c7-t1). I will of course seek one out.

[Donald Corenman, MD, DC]

#6864

The medial branches at C2-3 have been “wacked” twice before (I prefer the term ablated so it does not sound so mafia related). Atrophy of some of the posterior muscles can occur but there should be no greater atrophy than has occurred before. I do not know what patients results are for a third ablation.

If a nerve root inflammation or compression problem has been present for five years, it is unlikely that an epidural or SNRB injection would yield long term relief but I have seen stranger things happen.

Surgeons normally do not operate on the C2-3 level as this is the least likely level to need an operation. However if needed, operating on this level is not significantly different than other levels.

Axial views are generally better to determine stenosis than sagittal views but this fact depends upon the quality of the study and the angulation of the cuts.

SNRBs are quite common with my injectionists. The technique requires great care but is not out of the ordinary.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[SpinelessWench]

#6867

My apologies for replying in this thread, but “exercise453”, if you’d like to privately talk about the conversation I had with a second surgeon (lovely guy ) about the “axial view” comment, I can email you? My axials seemed to show the stenosis clearly, but he totally dismissed it.

Sorry for the interruption, Dr. C…

S.W.

[Donald Corenman, MD, DC]

#6870

That is no problem. I encourge discussions on each thread as long as the purpose is to educate and share experiences.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

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