Musculoskeletal 4

How can facet injections and Botox be used to treat a worker with upper thoracic and neck pain related to whiplash injury, with failure of conservative treatment?
• Trigger point injections commonly used for whiplash, with pain relief for 1-3 weeks
• Hypotheses behind trigger point injections: MEPPs at trigger points, uncontrolled ACh release resulting in chronic muscle fiber contraction (--> Botox useful?)
• Cervical facet pain estimated to be present in 25% of neck pain patients and 50% whiplash injuries (most often C2-3 and C5-6)
• Facet pain suggested by neck pain with cervical extension and rotation, but history and physical alone are unreliable --> can do medial branch block as diagnostic tool
• Advantages of medial branch blocks: safer than intra-articular blocks, technically easier to perform
• Radiofreq neuroablation: safe and effective --> 70% response rate for cervical facet pain when performed after diagnostic block
• Medial branch of dorsal ramus regenerates in 90 days but relief may last 7-9 months
• Pulsed radiofreq ablation investigated --> lower levels of heating and lower risk of deafferentation pain --> few trials

After failure of Botox and facet injections in the above patient, who is now having neck, shoulder, and arm pain, what are other possible interventions?
• Cervical transforaminal ESI has shown promising results for clear-cut cervical radiculopathy
• Complications of cervical ESI: infection, nerve root injury, vertebral artery dissection, paralysis, stroke, high spinal block
• Interlaminar ESI may provide less availability of steroid anteriorly, but has less risk of inadvertent arterial particulate steroid deposition --> complication rate of 16.8% although most are minor
• Cervical transforaminal injection should be performed under live fluoro to avoid intravascular injection