The authors of this blog recommend that interventional pain procedures should be reserved to cases where “lower level of care” has been exhausted and/or if the pain is becoming a daily debilitating burden, even early on after the initial insult. In addition, we believe the patient has the right to decide and ‘go directly’ to interventional procedures. We also promote considering pain procedures in patients with high risk of development of chronic pain syndrome, such as chronic pain patients with pre-existing pain syndromes, chronic smokers (or vapers), patients with degenerative spondylosis, and other chronic complicated cases. These procedures must be performed by an experienced interventional pain clinician with skills not only to master the procedure under fluoroscopy but also address any untoward potential immediate or late complications and/or side effects.
In the United States, in the arena of motor vehicle collisions, due to “other party” payors and for litigation purposes, for non-radicular neck pain, the authors recommend performing Zygapophyseal joint injections under fluoroscopy, with 3 levels done on each side at a time, 2-3 weeks apart, rather than diagnostic medial branch blocks leading to radiofrequency ablation (RFA). RFA remains a good option and is indicated after whiplash injuries once you establish relief from 2 diagnostic medial branch blocks. It is also indicated for neck pain unrelated to whiplash injury. It typically will last about 6-9 months before the pain starts to recur. At that time, another RFA is indicated without subsequent diagnostic blocks. The second and subsequent RFA will be performed under insurance rather than personal injury, in case of a collision, since most likely the litigation would have resolved, and it will then be up to the patient’s health insurance to decline or approve the procedure.
Identification of the patient is essential. “Time out” to confirm the actual procedure and side is important to avoid mishaps. Patient must sign an informed consent. The clinician must explain what the patient is to expect from these injections. Thorough and detailed explanation of the risks, benefits, alternatives, pros, and cons should be established. Using a spine model to explain the procedure is beneficial.
It is preferable to perform the injections in a monitored suite, either at an outpatient surgery center or office-based with monitoring. Experienced staff must be present 19 .
Authors promote the use of at least heart and blood pressure monitoring, but full monitoring is also advised. Patient will decide whether to receive oral or intravenous (IV) sedation or not. Authors do not see a need for IV access if no sedation is to be administered.
Sedation will not create outcome bias since these injections are considered therapeutic injections. Sedation will control anxiety related to the procedure.
Patient positioning involves a prone position with slight neck flexion. Pillows should be placed under the chest to support the shoulders and convey a relaxing posture.
Once the patient is comfortable and ready to start, the skin is thoroughly prepped with Chlorhexidine, in an aseptic fashion using sterile gloves. Sterile draping of the site ofinjections is then carried out. Visual identification of the cervical facet joint of interest is then performed using fluoroscopic guidance (Figure 4). A Quincke spinal needle, 3.5-inch long or 5-inch for obese patients, with gauge range 22 to 25 gauge is gradually introduced towards the facet joint. A small aliquot of 0.3 ml of contrast material is then slowly injected to confirm needle location. Images will confirm intraarticular access with linear streaks between articular surfaces. Lateral imaging is then obtained to confirm the location of the needle. Prior to injecting the Decadron (typically 1-2 mg per joint), aspiration is carried out to confirm negative heme and CSF. Then either sterile, preservative free local anesthetic or sterile, preservative free normal saline is then injected slowly along with the Decadron with a total volume of no more than 1 cc in each level, to avoid facet capsule rupture. Needles are removed and the patient is given a quick motor and sensory examination. Patient will then be transported to recovery area.
Once intraarticular access is confirmed, a combination of local anesthetic and steroids may be injected. It is recommended that the volume injected be between 1 to 1.5 mL as larger volumes may rupture the joint capsule.
In our practice, in the field of motor vehicle collisions and the arena of litigation, considering the frequency of whiplash injuries, we opine cervical facet joint injections have been a very good alternative to regular cookie-cutter cervical epidural injections and RFA.
We have performed a significant number of these procedures and found a high percentage of patients carry on with their lives with no chronic cervicalgia. We recognize the superiority of RFA for long term relief but also recognize the majority of these personal injury patients will eventually be discharged and will again need subsequent RFA sessions.
Many do not have health insurances and with the changes in health care, many RFA many be denied. Facet joint injections can always be repeated.
In the personal injury clinical practice world, WAD pain is a common syndrome and often refractory to physical therapy and chiropractic. NSAIDs have limited role and may have untoward effects related to chronicity of pain and systemic side effects. We opine cervical intra-articular facet joint injections using a steroid of choice, may serve as an alternative and safe management option for whiplash-related cervical facetogenic pain.
Outside personal injury and motor vehicle collisions, in the realm of health insurances, we feel positive diagnostic medial branch blocks followed by RFA may provide adequate longer-term relief.
The authors are optimistic that in the future, researchers will continue to conduct non-biased high-quality prospective comparative clinical research to answer many of our curious questions.