Lumbar and Cervical Pain Management Procedures: When And How to Do Them

Yair Safriel, MD

Disclosures

Appl Radiol. 2010;39(12):14-23. 

In This Article

Abstract and Introduction

Introduction

Pain of spinal origin is a significant public health concern in the United States and is among the most common reasons people seek medical care.[1–4] It is the also the second leading, medically related reason for missed work, resulting in 40% of lost workdays annually.[2] Between 1997 and 2006, the use of interventional pain management procedures increased by 235% in the Medicare population.[2] The cost-per-injection also doubled, from $115 to $227, between 1994 and 2001.[1] While clinical trials are difficult to perform due to the multiple factors that can influence a patient's perception of pain, evidence is building that early imaging and intervention result in better outcomes.[1–9]

Conservative approaches to pain management utilize medication, rehabilitative therapies and behavioral approaches. Interventional pain management approaches employ diagnostic and therapeutic techniques to assist in identifying and relieving pain. Compared to traditional pain management methods, which have shown mixed outcomes,[10–12] interventional therapies that rely on injection procedures have demonstrated promising results.[5–22]

Degenerative back and neck pain is most easily classified into 3 broad categories according to its anatomical origin: disc degeneration, disc protrusions/herniations and facet degeneration. The primary role of imaging is to exclude causes of nondegenerative pain (e.g., compression fractures, tumors, neural disorders and traumatic injuries) and indicate which of the above three categories may be the primary pain generator.

This article describes procedural techniques developed through extensive experience, a thorough literature review, and feedback from spine and neurosurgeons. It is important to recognize that the techniques outlined here are among many possible options.

This paper will first review the safety profile of injection procedures as a guide to obtaining informed consent and outline the pertinent differences between lumbar and cervical injections. Then, epidural, nerve block and facet injections will each be examined separately, with a particular focus on outlining the differences between lumbar and cervical therapy.

The arsenal of interventional pain management includes many other injection procedures, such as stellate ganglion blocks and trigger point, sacroiliac joint, synovial cyst rupture, and intradiscal steroid injections. A complete review of all these procedures is beyond the scope of this article.

But by initially focusing on epidural injections/nerve blocks and facet injections—the most common procedures—the interventional musculoskeletalor neuroradiologists can subsequently expand their practices to include other procedures.

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