Tag Archives: facet joint

Having an infiltration anesthesia test and probable Rhyzotomy

***** 1-30-14: Update #2, I had the test last week and it worked, I was pain free for the first time in 17 years, it was injected lidocaine so it only last 24 hours but it means I can have the Rhyzotomy that has not been scheduled for February 5th.  The doctor I work for is off the 6th and 7th so if I need those days to recover I can take them easier than if she is here.  The website said it may take a week to recover and it is considered a surgical procedure.  I will have more pain for the first week at least and it will provide about 6 months relief.  I have new insurance so that if I have it done at the hospital I work for there is no copay so nothing out of pocket, so much better than last year.  I will keep you posted but the test injections were nothing to be worried about, no pain after at all.Click below for a link for the description given by the practice I go to and who will do the procedure.

http://www.southeasternspine.com/procedures-treatments/rhizotomy/

*****Update 6-27-2013 These 2 procedures have been put on hold for financial reasons.  I had no idea how expensive they were and the practice wants me to pay me entire balance even though I have been making regular payments to them and really my insurance is excellent, they have collected tens of thousands from my insurance in the last 18 months I have been there.  So I have an appt with a PA (the same one I have been seeing who really doesn’t understand pain) on July 3rd at 230pm.  I will update more on what my other options are after that appt.  I was very disappointed by having to postpone this potential for relief.

Well I am so disappointed to report that the news at my spine doctor’s appt yesterday was not at all what I was hoping to hear.  I was really hoping they would say that I still have pain because I was originally told it would take a full year to recover completely and to expect it to taper off and in the meantime we can just treat it with medication albeit lower strength medication than before which is fine with me and actually preferable. I want to avoid all of the oxy-codones at all costs.

Instead, the PA took out my MRI report and told me something I didn’t know before I had the surgery back in October.  What I knew then was that I had 3 herniated discs L3, 4 and 5 as well as some facet joint damage from these discs being herniated and that L4 also had a tear in it.  I could only have 2 discs repaired in a surgery so they replaced the worst ones, L4 to S1 with titanium implants and told me that L3 was damaged but not as severely but I could expect it to cause pain in years to come and actually it is now with pain in my left thigh.  With all this being said, apparently I also have problems from L1 all the way down.  The vertebral joints all have arthritis (most likely from the years of having the injury putting more stress on them than would be normal for my age) and she used the term Spondylolysis: “A weakness or fracture between the upper and lower facets of a vertebra. If the vertebra slips forward (spondylolisthesis), it can compress the nerve roots causing pain.”   So, this is the reason I am still having pain all these months after surgery.  I have tried so hard to will it away, stay active (those of you that know me know that sitting still is not something I am good at) and was beginning to feel that this was a weakness in my character that I couldn’t rise above the pain and was still resorting to medicating it.

rhizotomy-chart

So here is the game plan, next Wed the 19th, I am having a procedure is called infiltration anesthesia  where local anesthesia is produced by injection of the anesthetic solution in the area of terminal nerve endings.  In my case L1-3 since they can’t do anything with the ones that have had surgical intervention.  If this produces pain relief, I am supposed to call the next day and tell them, if it does relieve my pain, then I am a candidate for a Rhizotomy.  This is the scary part; if it doesn’t relieve my pain at all then I don’t know what the Plan B is.  But the following is a description and indications for Rhizotomy as found on this website: 

http://www.espalda.org/english/divulgativa/dolor/como_tratar/informacion_paciente/rizolisis.asp

“Basis, indications and risk

 

Rhizotomy

It is the destruction of the nerves in the facet joints, normally by burning them with radiofrequency current.

Objective

To improve pain in instances of facet joint degeneration.

Theoretical base

There are no nerves in the cartilage of the facet joint. These are located in the bone placed underneath. This is why joint degeneration may not cause problems until the bone is affected. When this occurs, pain nerves are activated, with the subsequent onset of pain.

Conceptually, rhizotomy aims at destroying the nerves in the facet joint to eliminate pain sensation. It is usually performed by burning the joint nerves. Obviously, this procedure is only considered in those cases in which pain is due to activation of these nerves by facet joint disorders.

However, each facet joint enfolds nerves from two, and in some individuals three, different vertebral levels. Thus, for example, the facet joint between the fourth and fifth lumbar vertebrae may receive nerves that originate from, for example, the third, fourth and fifth lumbar level. Therefore, nerve destruction of only one of these levels may have no effect, or have a temporary effect until the remaining nerves take on its nerve field.

Also, it was traditionally believed that all pain nerves reached the medulla through the posterior root, which permitted the localization of the site where nerves had to be destroyed to eliminate the pain originated in the facet joint. However, recent studies show that, although there are individual variations, in some individuals up to 20% of pain nerves reach the medulla through the anterior root. Muscle nerves also pass through this root so it cannot be destroyed since, in doing so, it would cause paralysis of the innervated muscles.

It may only be indicated in cases that comply with the following criteria:

Indications

The existing evidence based recommendations do not recommend rhizotomy, essentially because they are focused on the treatment of acute cases and rhizotomy can only be considered in chronic cases.  It may only be indicated in cases that comply with the following criteria:

 Characteristics of pain:

    1. local pain with no radiated pain nor signs of nervous compression (such as loss of strength or reflex or sensibility alterations)
    2. Pain resistant to non-surgical treatments for more than 12 months.
  1. Pain origin:
    1. Rhizotomy should not be performed on patients whose other organic alterations of the spine may explain the pain.
    2. – It must be assured that pain results from alterations of the facet joint. This is the most important criterion to recommend rhizotomy and also the most difficult one to prove. The detection of signs of joint degeneration through radiological test is not enough, since many healthy persons have it. To verify it, a test with anesthetics is needed (see below).
  2. Test with anesthetics:
    1. – Before a rhizotomy treatment, an anesthetic infiltration test at the joint should be done. If pain is due to the activation of nerves at the joint, pain should disappear completely. Some authors recommend doing three infiltrations spaced out in time; two with anesthetics and one with a placebo (substance of similar appearance but with no effect), without letting the patient know which is which).
    2.  ***** this is what I described above and will be having the 19th (next week)
    3. – Rhizotomy should only be performed on those patients in whom pain disappears completely with the anesthetic injections and remains unchanged with the placebo shot.
  1. Patients:
    1. – An adequate selection of patients is the key criterion to assure that Rhizotomy has acceptable chances of success.
    2. – It should only be considered on patients whose pain complies with the above described characteristics, after discarding that it may be due to any alteration different from that of the facet joint and where pain disappeared with the anesthetic infiltrations.
    3. Technique:
    4. – The destruction of the root should be performed under radiologic control, to assure it is done in the right place.
    5. – The roots of, at least, two segments should be destroyed and two or three lesions should be made at each location, to accommodate personal variations in the course of the nerve.”

So knowing all of this, I am worried, I really had hoped I would have much less pain than I do at this point being 8 months post surgery and have done all I can do myself to try and alleviate and relieve it so apparently this is the next logical step and I will definitely let you all know how these tests really feel.  Of course, I was told that they were “easy” and “not any worse” than the epidural injections and the discography test that I had before surgery.  I will keep you posted 🙂  Thanks as always for reading and I hope that the information I share is helping someone out there going through similar situations with chronic back pain and injury.

Advertisements

Epidural and Facet Joint Pain Relief Injections

Over the course of my back injury I have had many epidural steroid pain relief injections in my back.  The very first one was in 2001.  Every doctor I have seen for this offers sedation for comfort.  I would not recommend that anyone try and have this done without the sedation because even with it, you can feel it.  Some doctors use IV sedation, others just give you a shot in the arm.  Almost always they use a medication called Versed.  “GENERIC NAME: MIDAZOLAM – INJECTION (mid-AZE-oh-lam)

BRAND NAME(S): Versed

Rapid intravenous (IV) use of midazolam can cause severe breathing problems which could cause brain damage or be fatal if left untreated. Therefore, when using this medication IV it must be used only under close medical supervision. Children, infants, elderly or weak patients are more sensitive to the effects of midazolam. Thus, lower doses should be used for these patients or when other sedating drugs are used with midazolam.

USES: Midazolam is used before operations or procedures to relax you, make you sleepy and to decrease your memory of the event.”

http://www.medicinenet.com/midazolam-injection/article.htm

 

This is also used during colonoscopy.  You are not completely asleep with this medication but it’s very hard to remember what happened the next day and that is a good thing.  The memory is vague and fussy but at no time are you unaware of what is going on around you.  You can respond to commands and right after the shot they help you up and you can walk over to wherever they will have you recover for about 15-20 minutes before sending you home.  Below is a description from Spine Health of the procedure itself:

  • The patient lies flat on an x-ray table or with a small pillow under their stomach to slightly curve the back. If this position causes pain, the patient can be allowed to sit up or lie on their side in a slightly curled position.
  • The skin in the low back area is cleaned and then numbed with a local anesthetic similar to what a dentist uses.
  • Using fluoroscopy (live x-ray) for guidance, a needle is inserted into the skin and directed toward the epidural space. Fluoroscopy is considered important in guiding the needle into the epidural space, as controlled studies have found that medication is misplaced in many (> 30%) of epidural steroid injections that are done without fluoroscopy1.
  • Once the needle is in the proper position, contrast is injected to confirm the needle location. The epidural steroid solution is then injected. Although the steroid solution is injected slowly, most patients sense some pressure due to the amount of the solution used (which in lumber injections can range from 3mL to 10 mL, depending on the approach and steroid used). The pressure of the injection is not generally painful.
  • Following the injection, the patient is monitored for 15 to 20 minutes before being discharged home.”

 

You need to bring someone with you to drive or they won’t even do the shot, they are not kidding, they ask to speak to your driver and have them sign in next to you.  Of course this is only if your doctor uses sedation but as I said, I would never recommend anyone have this done without it. 

I try and schedule these in the late afternoon so that afterwards I can just go home and take it easy.  You should not bend, lift or do anything strenuous for at least 24 hours after a shot, it can make the steroid migrate away from where it needs to be and then it won’t help you at all.  Your pain can be worse for several days afterward, this is something they don’t want to tell you but I have had times where I thought “Why did I do that? This is much worse now than before the shot”  The longest that I had increased pain was for a whole week after my last one.  It was pretty bad.  You can put ice on the area and I find that helps a lot but never ever put heat, no heating pads, no hot shower water on it, just no heat. 

If you have no relief at your 2 week follow up, they will recommend you have another shot.  Many times it does take 2 of them to produce any relief.  They always make an appointment for you to come back 2 weeks after every shot.  There a few different schools of thought about how many of these a person can have.  Some doctors will not do more than 3 in a year others will just keep doing them as often as you need them.  I went to a doctor who gave me 13 shots in a 7 month period.

http://www.spine-health.com/treatment/injections/epidural-injection-procedure

 

Many times, there is more than one reason that a person is having back pain.  It can be due to herniated or bulging disc but along with that, you can have pain in the joints of the vertebrae called “facets”  I have injections in the facet joints and also my hip at the same time as the epidural shot.  I think I actually had better relief when they did this than when they only did the epidural space.

Cervical, Thoracic and Lumbar Facet Joint Injections

 

Facet joints are small joints at each segment of the spine that provide stability and help guide motion. The facet joints can become painful due to arthritis of the spine, a back injury or mechanical stress to the back. A cervical (neck), thoracic (upper back) or lumbar (lower back) facet joint injection involves injecting a steroid medication, which can anesthetize the facet joints and block the pain. The pain relief from a facet joint injection is intended to help a patient better tolerate a physical therapy routine to rehabilitate his or her injury or back condition.Facet joint injections usually have two goals: to help diagnose the cause and location of pain and also to provide pain relief:

  • Diagnostic goals: By placing numbing medicine into the joint, the amount of immediate pain relief experienced by the patient will help confirm or deny the joint as a source of pain. If complete pain relief is achieved while some of the facet joints are numb it means those joints are likely to be the source of pain.
  • Pain relief goals: Along with the numbing medication, a facet joint injection also includes injecting time-release cortisone into the facet joints to reduce inflammation, which can often provide long term pain relief. The procedure may also be called a facet block, as its purpose is to block the pain.

Anatomy of the Cervical, Thoracic and Lumbar Facet Joints

The facet joints are paired joints in the back and neck, one pair at each vertebral level (one joint on each side of the vertebrae). These joints have opposing surfaces of cartilage (cushioning tissue between the bones) and a surrounding capsule that is filled with synovial fluid, which reduces the friction between bones that rub together.

 

 

It is important to try all of your options for pain relief and be open to them.  You may need to do a combination of these things to get relief.  They are combined with physical therapy, heat, ice, core exercise, walking and wearing of back braces when lifting or bending.  It is only when all of these things fail to provide relief that your doctor will consider surgery.  I do not take having surgery lightly, rather, I have suffered with this for so long and have honestly tried everything without long term success.  For me, the time has come for surgical intervention.  I hope this information helps you, if you have any questions, feel free to post them as a comment here on this post.

 

http://www.spine-health.com/treatment/injections/cervical-thoracic-and-lumbar-facet-joint-injections