_________________________________________________________________________ Neck Pain in Adults
neurotomy should not be used, as it may result in incomplete denervation [50]. Precise positioning of the radiofrequency probe with fluoroscopic guidance is required [103]. A systematic review of cervical medial branch thermal radiofrequency neurotomy found most patients were pain- free at six months and more than 33% reported being free of pain at one year [257]. The evidence of effectiveness was rated as high quality. Side effects were reported in 12 studies; most were minor and temporary. Adhering to International Spine Intervention Society guidelines on fluoroscopic-guided cervical medial branch thermal radiofrequency neurotomy was stressed; when performed as described, cervical medial branch thermal radiofrequency neurotomy is effective for resolving chronic facet joint pain and carries only minor risks [257]. Repeat procedures may lead to atrophy of supportive spinal musculature from denervation of sensory and motor nerve inputs. Focused physical therapy may mitigate this risk [103]. Trigger Point Injections Trigger point injection with a local anesthetic (with or without corticosteroid) is widely used in treating myofascial pain. With trigger point injection, the trigger point in the taut muscle band is palpated, slightly stretched to prevent it from moving, and injected. The needle is redirected in the area to ensure injectate distribution. The fast-in/fast-out method is the most successful in eliciting a local twitch response (which helps confirm diagnosis) and reducing myofascial pain [57]. Sedation is not needed for trigger point injection [103]. The efficacy of this approach is enhanced when immediately followed by a myofascial intervention [57; 103]. There are two main approaches to trigger point injection. The first is the stretch and spray technique, in which areas around the trigger point and referred pain are stretched using parallel strokes in the same direction, and a vapocoolant spray is applied. A variant involves spraying first, then stretching, and repeating the spraying. The second is ischemic compression (myotherapy). With this approach, the affected muscle is placed in a fully stretched position and sustained pressure by thumb press is applied on the trigger point, with pressure gradually increased as the pain lessens. Specific soft tissue mobilization or physical modalities may be used with either approach. Rare trigger point injection complications include infection, pneumothorax, anaphylaxis, neurapraxia, and neuropathy. Corticosteroid injection carries a risk of local myopathy. Severe pain on trigger point injection suggests an intraneural injection, and the needle should be immediately repositioned [103]. Intradiscal Interventions A variety of different approaches have been used to address diskogenic pain. In the treatment of cervical diskogenic pain, thermal annuloplasty applies heat along the annulus fibrosus to denervate the annulus and/or reconfigure the collagen structure of the disk [258]. Coblation nucleoplasty applies
bipolar radiofrequency current to decrease the volume of disk tissue. Intradiscal electrothermal therapy places an electrode or catheter into the annulus of the disk and applies electrothermal energy to denervate the annulus. Percutaneous intradiscal radiofrequency places an electrode or catheter into a disk to apply alternating radiofrequency current. Diskography is used for identifying the disk as the axial pain source by placing contrast dye into the intervertebral disk under fluoroscopy before CT imaging. The validity of diskography remains controversial, and there is concern that the procedure may accelerate disk degeneration [259; 260]. Disk Decompression In treating radicular pain secondary to intervertebral disk herniation, percutaneous disk decompression is used to remove a portion of disk material in order to reduce intradiscal pressure and decompress the involved nerve [259; 261]. One study found that the use of percutaneous laser disk decompression reduced pain and disability in patients. The study included 30 patients (11 men and 19 women). The procedure decreased both pain and disability scores, with no statistical difference found between men and women [262]. Overall efficacy remains controversial [259]. Vertebroplasty consists of injecting polymethyl methacrylate cement into the vertebral body. Kyphoplasty involves inflating a balloon within the vertebral body before polymethyl methacrylate is injected. The proposed mechanism is the combination of thermal necrosis and chemotoxicity of intraosseous pain receptors [263]. Vertebroplasty did not show benefit over sham or placebo interventions in two large randomized trials [264]. One study compared vertebroplasty, kyphoplasty, and nonsurgical management of vertebral compression fractures among 7,290 patients. Outcomes assessed included reoperation rates, complications, and overall costs [265]. A total of 7,290 patients were included (75.5% women; average age: 78 years). Reoperation rates ranged from 6% to 17%, and complication rates ranged from 7% to 10%. Overall costs were significantly greater in both the kyphoplasty and vertebroplasty groups at one-year follow-up, but not at two-year and four-year follow-up [265]. Botulinum Toxin A Injections Botulinum toxin A reduces muscular contractions and spasm by inhibiting acetylcholine release into the neuromuscular junction. Compared with placebo, trigger point injections of botulinum toxin A into painful muscles significantly improved pain scores, reduced headaches per week, and improved general activity and sleep after 12 weeks in patients with severe shoulder girdle and chronic cervical myofascial pain [266]. Trigger point injections with botulinum toxin A for chronic cervical myofascial pain are now considered supported by the available evidence [267; 268]. Side effects with cervical botulinum toxin A injection include transient dysphagia, neck weakness, dry mouth, and vocal hoarseness [103].
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