Neck Pain in Adults _________________________________________________________________________
ALTERNATIVE AND COMPLEMENTARY APPROACHES Acupuncture
INTERVENTIONAL AND SURGICAL THERAPIES Interventional modalities involve injection or ablation approaches in the treatment of spinal pain. They are considered minimally invasive, in contrast to spinal surgery, which is invasive. Cervical epidural, spinal nerve root, facet joint, and sympathetic injections serve diagnostic and therapeutic roles. These procedures can be instrumental in identifying the anatomic pain generator (e.g., nerve root, facet joint) and providing aggressive treatment [51]. Cervical Epidural Injections For cervical radiculopathy, epidural steroid injections place a corticosteroid and anesthetic (lidocaine or bupivacaine) into the epidural space (interlaminar) or along the nerve root (transforaminal) under radiographic guidance. Epidural steroid injections are thought to reduce pain by interrupting the inflammatory cascade, blocking C-fiber transmission, increasing microcirculation around ischemic areas, and/or modulating pain transmission in the dorsal horn [250; 251]. Rare but catastrophic neurovascular complications following cervical transforaminal steroid injections have resulted from particulate matter in corticosteroid preparations. Only the nonparticulate steroid dexamethasone should be used in cervical transforaminal injections. All epidural steroid injections should be performed under radiographic guidance to avoid serious CNS injuries [252]. Epidural steroid injections can induce dose-dependent suppression of the hypothalamic-pituitary-adrenal axis lasting one to three months. Steroids provide no additional benefit to local anesthetic (bupivacaine) alone in pain, function, or disability. Considering local and systemic risks versus negligible benefit, adding a corticosteroid to local anesthetic is not recommended. Aside from cervical radiculopathy, epidural injections are not indicated for other neck pain conditions [2; 253; 254]. Cervical Facet Joint Interventions Facet joint interventions identify and treat facet-mediated pain. To identify facet joints as the pain source, inter-articular injections of local anesthetic are placed into facet joints or along their innervating nerve fibers (sensory medial branch). A separate comparative block is performed on a different date to confirm the level of involvement and reduce placebo response. Pain relief from both medial branch nerve blocks confirms facet origin, and radiofrequency ablation is indicated for extended pain control [50; 255]. Radiofrequency neurotomy applies a radiofrequency current with heat sufficient to ablate the afferent nerve supply of the facet joint. Denervating these joints is effective in relieving pain and restoring function in these patients. Nerve regeneration occurs 9 to 12 months post-radiofrequency neurotomy, but repeat radiofrequency neurotomy is usually successful and longer-lasting [103; 256]. Continuous radiofrequency neurotomy is the preferred method; pulsed radiofrequency
Acupuncture therapy is one of most popular complementary approaches and has become a widely accepted treatment for diverse pain-related conditions [245]. Acupuncture therapy involves insertion of needles into the skin and underlying tissues at specific sites, known as acupoints, to reduce pain or induce anesthesia. Needles may be manipulated manually or through electrical stimulation [2; 8]. The persistence of therapeutic effects following a course of acupuncture was evaluated in a meta-analysis of 29 randomized controlled trials of diverse chronic pain. Depending on the control group (no-acupuncture versus sham acupuncture), 50% to 90% of acupuncture benefit was sustained 12 months after treatment and did not seem to decrease importantly in chronic pain [246]. Patients can generally be reassured that treatment effects persist. Questions of acupuncture cost-effectiveness can take these findings into account. Acupuncture is not without risks. Deaths and serious nonfatal complications of acupuncture are reported, with pneumothorax the most frequent fatal and non-fatal cause. All deaths were avoidable with proper acupuncture technique and sufficient anatomic knowledge. Most reports originated in East Asia, but some came from the United States and Western Europe [226]. Yoga, Qigong, and Tai Chi Iyengar yoga involves a range of classical yoga poses adapted to patients with neck pain with the use of supportive props. Emphasis is placed on muscle strengthening, stretching, joint mobility, and proper posture [8]. A systematic review found evidence for significant short-term benefits in neck pain intensity, neck pain-related disability, quality of life, and mood, suggesting that yoga might be a good treatment option in chronic nonspecific neck pain [247]. With origins in traditional Chinese medicine, qigong and tai chi are gentle, focused exercises for the mind and body that aim to increase and restore the flow of qi energy and encourage healing [8]. In one study, patients with chronic nonspecific neck pain were randomized to 12 weeks of group tai chi, sessions of conventional neck exercises, or to a wait- list control group. Tai chi and exercise intervention did not differ, and both significantly improved pain on movement, functional disability, and quality of life compared with the wait-list group [248]. Of 89 patients with chronic neck pain randomized to 8 weeks of Jyoti meditation or self-care exercise program, meditation training significantly reduced pain and pain-related bothersomeness compared with the exercise group. Researchers suggest that mediation may support patients with chronic pain in pain reduction and pain coping [249].
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