Facet Nerve Block after cervical ADR - questions

[SandyW]

Yesterday I had my very first appointment with a PM doc. Am 1 yr. post-op from 4C ADR's.

Have daily pain while taking tramadol/muscle relaxant, can't ride in car for long, can't sit in movie or at computer or walk rapidly (slow is ok) without considerable increase in pain. Lying flat is most comfortable, so not able to do what I would like and am tired of the constant pain. I know, no different than many, but better that lots of you.

I can ask for stronger pain meds and will, but want to know what is causing my pain. My x-rays show the placement of the disc's is very good and I have good movement. Was hoping for better results.

I had diagnosed my problem as being musculature and thought that trigger point injections might help. Had massage therapy on Wed and this was my report. Muscles found taunt: Trapezius. Rhomboids (bilateral, I feel these were taut due to the bilateral infraspintus tautness & trps pulling the shoulder blade laterally). Suboccipitals (especially right side). Right Levator Scapula (probably producing pain on left side and pulling on suboccipitals). The sports med therapist thought I wouldn't get better until I stretched the muscles manually or with injections since they were locked.

However, the PM doc feels that my muscular pain has snowballed from the facets and has scheduled me for a Facet Nerve Block. What would make him believe this?

I've searched the ispine site and understand that this procedure is more diagnostic. If the block stops the pain then facets are the problem. But how can the block alleviate my musculature pain? Should have had the block before ADR surgery??

Also read here that a facet nerve block may cause an infection if you have ADR's, not good. Cleveland Clinic PM has not done nerve blocks on ADR recipients, but the doc didn't seem concerned - he did raise his eyebrows when he asked me how many ADR levels and I answered 4. I asked him if there would be a problem treating me. He said "No, we are just more conservative." Yea, I have learned this the hard way!

My 2007 MRI refers to C3-4 as having some degenerative changes in the facets and overall spinal canal is small suggesting congenital stenosis and degenerative foraminal stenosis here and there. 2009 x-ray's say nothing about facets. Also read here in the February 2009 annual meeting of AAOS on the comparison of MRI and CT in predicting facet arthrosis in the cervical spine that MRI's were not accurate.

I understand that Dr. Bertagnoli cleaned up bone spurs, but to my knowledge nothing was said about facets. If I had facet problems wouldn't he have seen it and discussed this with me after the surgery??? I also have read that ProDisc is not facet friendly, but can't imagine a deterioration from them in a few months. I had the muscle knots/spasms before surgery.

Any suggestions? I am confused?? Should I go ahead with the facet nerve block and then go from there? Would greatly appreciate your thoughts even though you are not PM doc's and I understand that all your suggestions would be "IMHO".

Thank you, Sandy

[Terry Allen Blackburn]

Sandy:

Even though they use the injections for diagnostic testing of the facets you may still benefit from the medicine that they use in the injections. I had facet blocks and SI joint injections prior to my 4 level ADR that did not help in the least. After my ADR surgery I had facet blocks or SI joint injections every three months for the first year. Then a year lapsed before I needed another set of two SI joint injections that I had this past December. I still feel really good since this last set of injections. So I am telling you that it may be worth having this done to see if you get any relief. It took about up to three weeks to get relief after each set of injections in the past.

Hang in there as you are still in recovery. It took me all of twenty months to start feeling really top shelf after such major surgery.

Terry Newton

[mmglobal]

facets are the $500,000 question. If the facets are the main problem, ADR may not be indicated. Some doctors will consider grade II facets a contra-indication, while others will usually do grade II, and sometimes do grade III facets.

I reality, some with minimal facet degeneration will have their facets go south with ADR. It's not magic and if there is some other reason for your facets to go, they may still go bad. Some doctors will do grade III facets and I've seen many films of facets that have actually recovered after ADR. Not that ADR is designed to halt facet degeneration, but in some configurations, restoring the disc height, more normal facet loading and kinematics; may actually allow the facets to recover. I wish there was some way to tell who is who in advance. If we could do that, spine surgery wouldn't be so exciting.

[SandyW]

Terry and Mark,

Thanks for responses. After more googling, maybe I understand this??

I had two choices, since my diagnosis was surgery not elective because of spinal cord impingement. I needed fusion or ADR. Chose ADR for more movement. Dr. B thought ADR was appropriate even though Dec '07 MRI showed "some degenerative changes in facets at C3-4". Was beginning to doubt Dr. B's decision, silly me! ADR may provide enough height to actually improve facet problems, maybe not. ProDisc-C or deterioration from aging, 16 mos. since last MRI, may be the culprit in facet pain.

Correct or close so far, even though stated in layman's language?

The facet at C3-4, where the PM doctor will administer a facet nerve block, might be causing pain. So will have the block. Since they are only temporary, don't want the block to work since that would mean facet problems exist. I am just hoping it's musculature. Won't worry until later!

And yes Terry I'll try to be more patient since I'm 69 yrs. young and only 1yr post op from 4 cervical ADR's, 15 mos post-op from knee surgery, 9 mos from gall bladder surgery, 4 mos cataract surgery. Know these are mickey mouse surgeries, but all take a toll.

Sandy Wade

[Terry Allen Blackburn]

Originally Posted by SandyW

And yes Terry I'll try to be more patient since I'm 69 yrs. young and only 1yr post op from 4 cervical ADR's, 15 mos post-op from knee surgery, 9 mos from gall bladder surgery, 4 mos cataract surgery. Know these are mickey mouse surgeries, but all take a toll.

Sandy Wade

Oh My God Sandy; You've gone through hell and back in the last couple of years. I hope the facet blocks work as they will help you be more pain free while your body continues to heal. I had them every three months for the first year and then needed none for a year. I had my last injections in December so it has been over 4 months ago. I still feel good.

Terry Newton

[Justin]

Originally Posted by SandyW

And yes Terry I'll try to be more patient since I'm 69 yrs. young and only 1yr post op from 4 cervical ADR's, 15 mos post-op from knee surgery, 9 mos from gall bladder surgery, 4 mos cataract surgery. Know these are mickey mouse surgeries, but all take a toll.

Sandy Wade

Sandy, I'm going to echo what Terry said: you've been through hell. The facet injection sounds like a good next step. Did the sports med therapist offer to manually work on your tight muscles or give you exercises that you can do on your own? Muscular dysfunction can be significant after surgery and can take quite a while to "work out."

I would not question your surgery, as you had to do something in the face of spinal cord impingement. It's hard not to second guess yourself. Here's to hoping this is just a prolonged bump in the road and that it will be a distant memory soon. Good luck!

[Cindylou]

I could not agree more with the above responses Sandy. Hard not to second guess, but big waste of time and energy. Don't go there. The nerve block will prove valuable indeed. All is certainly not lost. You had major, major surgery that definitely produces musculature ironing out, over time. Yes, facets are the elephant in the room, but the fact that you had Dr. B do such an invasive surgery is very encouraging indeed. You had the master of multi-levels, so take great hope in that. Are the trigger injections helping? Regular massage therapy maybe?? Hang in there. Let us know how the nerve block goes.

My best,

Cindylou

[SandyW]

Hi all,

Had my first injections last Wednesday. Doctor gave me three, one each at C3, C4, C5. Had very little pain in recovery and the "fellow" told me to enjoy the next few hours. I did! first time in years I have had so little pain.

Normal pain returned that evening. I will return May 6 for the second set of injections.

The sports therapist suggested manual myofascial and said my massage therapist was only doing trigger point releases.The references to myofascia and trigger point releases seems to overlap, so it's all very confusing, I'm reading Wikipedia and in a 2008 review I thought OK a recent study. BUT it makes no sense to me. . .

"A 2008 review in Arch Phys Med Rehabil. of two recent studies, concludes they present groundbreaking findings that can reduce some of the controversy surrounding myofascial trigger points (MTrPs). The integrated hypothesis is the most credible and most complete proposed etiology of MTrPs. However, the feedback loop suggested in this hypothesis has a few weak links, and studies by Shah and colleagues in particular supply a solid link for one of them. The feedback loop connects the hypothesized energy crisis with the milieu changes responsible for noxious stimulation of local nociceptors that causes the local and referred pain of MTrPs. Shah's reports quantify the presence of not just 1 noxious stimulant but 11 of them with outstanding concentrations of immune system histochemicals. The results also strongly place a solid histochemical base under the important clinical distinction between active and latent MTrPs. [6] Subjects with active MTrPs in the muscle have a biochemical milieu of selected inflammatory mediators, neuropeptides, cytokines, and catecholamines different from subjects with latent or absent MTrPs. [8]"

What I wanted to ask you guys before I talk to the doctor - The nerve block or a possible ablation may take care of the nerves, if that what's causing the pain, but what should be done with the muscle pain, or Will muscle pain go away if the nerve block works? If not, can they do trigger point injections along with nerve blocks? Should I try manual myofascial release during the nerve blocks. I'm going to the massage therapist tomorrow, Will that cause a problem while the nerve blocks are being done. You always think of questions after you leave and even if you have questions it's hard to get them to answer - your on your tummy with your face in a hole and nobody listens to you - I could hear the doctors talk and tried but no luck.

I want to be more prepared before I see the doctor again and will request to see him or his "fellow" before the injection.

Well thanks for any advice, not sure I make a lot of sense. Sandy

[Kathy]

Originally Posted by SandyW

You always think of questions after you leave and even if you have questions it's hard to get them to answer - your on your tummy with your face in a hole and nobody listens to you - I could hear the doctors talk and tried but no luck.

Sandy, Made me think of some funny things I have experienced on this journey.
First, I went to a dr and he and the nurse shared the same last name. I had kinda though they were maybe married; but wasn't really sure. He was real laid back, nice man and she was high sturng, didn't listen to a word you said and rude; so I thought surely they weren't a match. Well, before an office procedure, while the drugs are running into the IV, I decided to ask. Indeed, they were married. I was being sedated and shouldn't remember anything after this point; but being hard to sedate, I do remember. I listened as the other nurses went on and on about how much they disliked her and all the office politics. Kinda funny!

Next, when I had my ADR surgery, I had an idiot nurse miss my vein. No one misses my veins, they are huge. After she dug the large needle in my are for several minutes, I was in tears crying. She left and got an anesthiologist to try for a vein. I insisted this lady give me the numbing shot before putting the IV in. Well, this lady was even worse, digging and still not getting a vein. They finally put it in my hand (don't know why they didn't do that in the first place, I had huge bruises on my arm for weeks). I was crying and begging for drugs, thought I was going to puke. They start giving me the drugs, I don't remember this part; but hubby says I sat up, pointed at them and said "I'm mad at you, I can't believe you missed my vein, that hurt and on and on" They wheeled me back and proceded to try and knock me out. Hubby said the first thing the surgeon told him when surgery was over was that it was like knocking out a horse and that I just wouldn't quit talking about them missing my vein! I thought that was hilarious; because I am so not the confrontational type.

Anyway, your post reminded me of this.

[SandyW]

Read my post at L4-5 Charite ADR Stenum for my bad and funny. We should send excerpts to Reader's Digest. Maybe make some money .

[Kathy]

Originally Posted by SandyW

Read my post at L4-5 Charite ADR Stenum for my bad and funny. We should send excerpts to Reader's Digest. Maybe make some money .

Wow, sounds like your after care was as shitty as mine. I like the prisoner of war analogy, as I felt the same way. I had this nurse, who I swear, got joy out of being mean to me and withholding my meds (that my surgeon ordered). I thought about checking out of the hospital, while I was still in ICU. I couldn't even walk and would have had to convince my husband to do this, against medical advice. The nurse who did this to me was fired after myself and the dr made complaints about her. I don't know why some people go into nursing? Seems like if you aren't the compassionate type, then you should go into another line of work!

[Terry Allen Blackburn]

Originally Posted by SandyW

What I wanted to ask you guys before I talk to the doctor - The nerve block or a possible ablation may take care of the nerves, if that what's causing the pain, but what should be done with the muscle pain, or Will muscle pain go away if the nerve block works? If not, can they do trigger point injections along with nerve blocks? Should I try manual myofascial release during the nerve blocks. I'm going to the massage therapist tomorrow, Will that cause a problem while the nerve blocks are being done. You always think of questions after you leave and even if you have questions it's hard to get them to answer - your on your tummy with your face in a hole and nobody listens to you - I could hear the doctors talk and tried but no luck.

Sandy:

I think that the facet blocks can take care of the muscular pain if the pain is referred. I had a lot of symptoms like fibromyalgia that went away after my ADR surgery. A lot of that pain was referred pain from the injury that transferred in to my muscles and myofascial area. I have also noticed the same thing with the facet blocks that pain I had in the surrounding muscles went away when the injections started to work. Just to be on the safe side they can always pop a few trigger point injections in to the muscles that are aching.

Terry Newton

[Justin]

Originally Posted by SandyW

The sports therapist suggested manual myofascial and said my massage therapist was only doing trigger point releases.The references to myofascia and trigger point releases seems to overlap, so it's all very confusing, I'm reading Wikipedia and in a 2008 review I thought OK a recent study. BUT it makes no sense to me. . .

Hi Sandy, myofascial release is a very basic manual therapy modality that is widely used by many health professionals (Physical Medicine and Rehabilitation Physicians, Doctors of Osteopathic Medicine that have been board certified in Osteopathic Manipulative Medicine, Physical Therapists, etc.).

I'll PM you the name of a great physician that does manipulative therapy in your area.

What I wanted to ask you guys before I talk to the doctor - The nerve block or a possible ablation may take care of the nerves, if that what's causing the pain, but what should be done with the muscle pain, or Will muscle pain go away if the nerve block works? If not, can they do trigger point injections along with nerve blocks? Should I try manual myofascial release during the nerve blocks. I'm going to the massage therapist tomorrow, Will that cause a problem while the nerve blocks are being done. You always think of questions after you leave and even if you have questions it's hard to get them to answer - your on your tummy with your face in a hole and nobody listens to you - I could hear the doctors talk and tried but no luck.

The muscle pain should improve secondary to the nerve block. However, I personally believe that you are going to have to address those muscles as well. The massage therapist (in my opinion, of course) will not cause a problem when your nerve blocks are done. If anything, the massage will help remove waste that is "sitting" in the fibrotic, chronically inflamed muscles. Essentially, the massage will be a good thing because it will "prep" the area and hopefully decrease inflammation, improve lymphatics to remove waste products and set up a more favorable environment in which the block will be located.

I want to be more prepared before I see the doctor again and will request to see him or his "fellow" before the injection.

Fellows have a lot of training under their belts. They've been through medical school, their residency training and now are pursuing additional training through a fellowship. If it makes you feel better, you could request to have both the attending and the fellow in the room and ask all of your questions and concerns, so you are all on the same page and you feel absolutely comfortable in your care and treatment.

Well thanks for any advice, not sure I make a lot of sense. Sandy

Good luck Sandy...I'll send you a PM as well. BTW, these are all very good questions to be asked.

[SandyW]

Terry and Justin,

I know you both are busy and not always feeling well, but your suggestions and concerns mean alot. So a big hug and best wishes and thank you so much.

Sandy

[treefrog]

Terry, thanks for describing your fibromyalgia like symptoms, that went away after ADR. When I lay down at night to go to sleep, I sometimes feel like I might have fibro. But, I keep hoping that it is just an effect of not moving normally, and referred pain, that will hopefully go away after surgery.

[SandyW]

An update since April: The Pain Management doc felt that my muscle pain was secondary to the arthritis in my facets and recommended the facet nerve block.

His explanation made sense. Due to my age and the length of my DDD the cartilage between my facets (spoon shape bone) and the vertebrae was gone. The bone on bone action was impinging on the nerves that branch out of that area. To make matters worse, my successful 4-level ADR were contributing to the problem. The ADR's were successful in correcting the impingement of my discs on the spinal cord and therefore a necessary surgery. BUT because the ADR's allowed normal movement, more movement than fusion, I was irritating the nerves from the bone on bone movement.

Fixed things successfully (thank you Dr. B) and kept my mobility, but created a monster.

The PM doctor was fairly sure he could help me. In April I had nerve blocks at facets 3, 4, and 5 left side only. Since nerve blocks are diagnostic and used to locate pain I was fascinated and thrilled to have no pain for about 4 hours. However after the anesthetic wore off, a week of greater pain made be wonder "what did you get yourself into this time." The next week was "Hey, I feel much better, can get up out of bed, off the sofa and do more." I had the second set of injections in May, the after pain was shorter and the pain level way down.

The problem if you want to look at it that way was: I can ride in a car for longer periods of time, I can work outside in the flower beds for more than a few minutes, I can sit thru a movie - but with more movement I still had to take pain meds - just Tramadol with a seldom used Percocet for break thru pain. I felt like I had a life again, one I could accept.

These blocks got rid of the debilitating pain in my traps, but they don't last forever. I must decide whether to continue nerve blocks or go for a longer, but not forever, RFA (radio frequency nerve ablation) procedure.

I've been back to the PM doc, since I fell in love with him for giving me a life that I could tolerate, to fix the other pain.The #2 facet was affecting the occipital muscle pinching the nerves causing migraine type headaches (not 24/7) and my head to itch excessively 24/7 uggh. I had the first injection last week, the headaches are not as severe and the muscle is not as sore, the itching is as bad. I go back for second round the middle of September.

I hope this may help some of you who might be experiencing more pain after surgery than before. Since I had thought my new ADR's would fix me, I was dismayed with my worsening pain. Dr. B and two other spine docs said my ADR's were perfectly placed and had not moved 1 year post-op and my spinal cord was not in trouble. No one except Terry and Justin suggested looking at the facets - THANK YOU . Understanding the role arthritis of the facet/vertebrae and the movement the ADR's allow, plus finding a good PM doc who suggested nerve blocks has been a life saver.

I'll be back in several months to let you know what my next step will be. If you have any questions would be glad to answer.

Sandy

[dshobbies]

Sandy,

Glad you found a key to your pain and can do something about it. The spine is a complicated mechanism and when working properly, we think nothing of it but when it causes pain, our lives are ruined. You have compounding problems and fortunately, you're able to deal with them. Keep up the good work and I look forward to future updates.

Dale