Diagnostics Procedures

Facet Joint Blocks and Medial Branch Nerve Blocks

About 40% of neck and back pain are from facet joint diseases. To successfully relieve the pain, having an accurate diagnosis is the key. Facet joint blocks are the deliverance of local anesthetic mediation to a particular facet joint to determine if the pain is gone, and to determine if the pain returns when the medication wears off. Facet joint blocks are used for the diagnosis of pain originated from facet joint diseases, such as arthritis and injury.

All pain is felt with nerves. The nerves that sense the facet joint problems are called medial branch nerves. Medial branch nerve blocks are the use of local anesthetic medication to numb the medial branch nerves. They are as equally effective as facet joint blocks for the diagnosis of facet joint pain syndrome.

Facet joint blocks or medial branch nerve blocks are very simple and safe procedures. They are done under x-ray guidance and with light sedation. Patients are generally released after 1-2 hours and can return to their normal work and activities the next day if sedation is used.

Spinal Probing: A New Diagnostic Technique for Back Pain

Introduction

Low back pain is a major health and economic issue. Diagnosis and treatment of low back pain are extremely difficult. With the application of modern diagnostic tools such as CT scan, MRI, myelogram, and nerve electric diagnostic tests, the accuracy for low back pain diagnosis has improved. However, it is a common belief that 80% of the low back pain sufferers still can not have accurate diagnoses. Inaccurate diagnosis of pain sources is a key cause for treatment failure, including physical, medical, and surgical means.

Recently, provocative discography becomes popular for the diagnosis of discogenic pain. However, discography is ineffective for diagnosis of non discogenic pain. It has been found that many pain sources are from intervetebral formainal structures, such as osteophytes, bone spurs, scar tissue, inflamed tissues, and facet joint hypertrophy. To confirm the pain sources in the foraminal area, current image studies including CT, MRI, and myleography are ineffective neither.

Recently, Martin Knight in UK and Anthony Yeung in the US have applied a new technique, namely spinal probing, for the diagnosis of pain sources in the formainal structures. Furthermore, after removal of the pain sources endoscopically, the patients have had significant pain relief and improved functional status and life quality. The patients who have been benefited from these pioneering studies include those with severe degenerative diseases, spinal stenosis, foraminal stenosis, slippage of vertebrates, disc herniations, and failed back surgery syndrome.

Technique

Under the light sedation, the patient is positioned in prone on to standard pain management table. Under fluoroscopic guidance, an introducing cannula is inserted to target foraminal entrance. A blunt probe is inserted through the cannula for reproducing pain by gentle probing. The introducing cannula is repositioned to different locations but will be parked in the foraminal entrance. The foraminal contents located at superior foraminal notch, subarticular zone, and inferior foraminal notch are tested. Anterior facet margins and posterior disc annular tissues are probed as well. During entire testing, the patient will be competent to report pain response under gentle sedation. Each pain response will be recorded in situ. The risk and complications theoretically include infections, bleeding, spinal nerve injury, spinal cord injury, and other injuries.

Publications

1. M.T.N. Knight: Endoscopically Determined Pain Sources; in Lasers in the Musculoskeletal System, eds: B.E. Gerber, M, Knight, W.E. Siebert; page 267-276
2. A, Yeung, C. Yeung: In-vivo endoscopic visualization of patho-anatomy in painful degenerative conditions of the lumbar spine. Surg Technol Int. 2006;15:243-56

Spinal Discography

Spinal discography or discogram is a test used for the diagnosis of pain related to spinal disc diseases. It is very useful when a patient has many problems with his or her spinal discs, and the doctor is not sure where the pain is coming from.

The test is simple and safe. It is done under x-ray guidance with sedation. Tiny spinal needles are inserted into the spinal discs while the patients are sedated. These discs include normal ones and pathological ones based on MRI or CT images. The patients are woken up from the sedation while the needles are well positioned. A dye (contrast) is injected into each disc and the patient is asked if the contrast provokes his or her typical pain. A normal disc usually does not produce pain whereas a pathological one typically reproduces the pain. At the same time, the flow of dye in the disc is visualized under X-ray to determine if the patients have disc tears or disruptions. The details of disc problems are determined with a CT scan that follows the test.

With discogram test, an experienced physician can distinguish between the pathological ones and the healthy ones and determine whether or not the pain generators are related to spinal disc diseases. As with any other medical test, the discogram test has false positive and false negative results. One should never rely on one test result to make decisions. To make a sound clinical judgment, a good doctor always knows how to collect and analyze a patient's history, physical exams, and test results together with knowledge, skill, experience, and confidence.

Intradiscal Injection

Back pain generated from spinal discs is very common and called discogenic pain. Disc tears, degenerations, and herniations are typical causes. Successful treatment of disogenic pain depends on accurate diagnosis. However, it is often challenging, because problems of every structure in the back can cause the pain.

In addition to history, physical exams, and image studies, doctors some times use intradiscal injection of steroids and anesthetic medications for differential diagnosis of discogenic back pain. Typically, steroid could relieve pain for about 2 to 3 weeks, but injection of anesthetic medications only relieves pain from a few hours to 1 or 2 days. This difference helps doctors confirm if the pain is from disc problems (discogenic).

The injections are very much the same as discography studies. The patient is given local and intravenous sedative anesthesia during the procedures. A needle is inserted to a disc under X-ray guidance. The steroid or anesthetic medications is injected to the same disc but on a different day, with a gap after the pain returns from each injection. Based on the predictable results, doctors will be able to tell if his or her back pain is from disc problems (discogenic).

Atlantic spinal care is a leader in minimally invasive and endoscopic spine surgery. We try everything possible to make an accurate diagnosis of your pain before you are treated.