Written by Dr Willem-Johan Steyn, Spinecentre Paarl
It is a common misconception that if conservative management of spine pain i.e. medication and physiotherapy, has failed that surgery is the next option. This could not be further from the truth as there are excellent non-invasive treatment modalities available to manage spine-related pain, especially for degenerative spine conditions. Certain interventional spine procedures are also of great diagnostic value in determining whether spine surgery would be of benefit to a specific patient – especially given that surgical changes are irreversible. These non-invasive procedures are easily replicable and cause no irreversible damage or long-term complications. They are even appropriate in patients who have already undergone spine surgery. Using radiofrequency ablation, pain relief can often be experienced for years. Below, some of the common non-invasive procedures that can be performed for spine-related pain will be outlined.
Facet-type back and neck pain
The spine is made up of a column of bones called vertebrae. Each vertebra is connected to each other through a disc and two facet joints. This tripod design is very strong and allows the spine to be able to move and bend. Inside these facet joints is synovial fluid, encased in a joint capsule. When healthy, this allows the facet joints to slide smoothly without giving way. As wear and tear occurs – known as degenerative changes – the capsule starts to thin, the cartilage inside the joint breaks down and bony spurs start to form. This leads to inflammation in the joints (known as facet-arthritis) which causes pain.
Facet-type back pain is often described as a diffuse dull ache in the lower back often radiating into the buttocks. Facet-type neck pain is often felt in the back of the skull or in the shoulders/shoulder blades.
Bending or twisting or standing for too long often causes the pain to worsen, whilst sitting down, leaning forward or changing position often relieves the pain.
For back and neck pain caused by facet-arthrosis or facet joint syndrome we often make use of facet blocks, or facet joint infiltrations. The infiltration involves injecting local anaesthetic and anti-inflammatories – such as cortisone – into the facet joint. For long term pain relief from facet arthrosis, radiofrequency ablation of the nerves supplying these joints can be performed.
Radiofrequency ablation/Rhizotomy
During radiofrequency ablation (also known as rhizotomy), special insulated needles are placed near the medial branch sensory nerves as can be seen in the images below. The placement is confirmed with an Xray. A probe, connected to a radiofrequency generator, is inserted into the cannulated needle. This probe allows us to make certain that we are in the correct anatomic position and not too near or too far from the targeted nerves. Two types of rhizotomies are available: either a low temperature or a high heat. At low temperatures the pulsed radiofrequency emitted from the radiofrequency generator re-programs the nerves to alleviate pain – usually decreasing the sensitivity of the nerve from 100% to around 20%. This low temperature does not cause any damage to the nerve itself. With high heat rhizotomy, usually reserved for more resistant cases, the nerve undergoes a burn lesion.
Epidural steroid injection
The epidural space is the sheath around which the main spinal cord is situated. Cortisone is often infiltrated into this space to help with nerve pain (neuropathic pain). Epidural steroid injections are often performed near the tailbone and is also called a caudal epidural injection.
Extraforaminal blocks
When there is a specific nerve root that is being compressed – which is experienced as a burning pain that shoots down the arm or legs – one can perform a nerve root block (also known as an extraforaminal block). This is often employed as a diagnostic block that is performed before considering spinal surgery. Radiofrequency ablation of the nerve root can also be performed to potentially provide longer relief.
Occipital nerve blocks for headaches
Chronic neck pain is often accompanied by headaches (although the above block is often performed to provide relief for primary headache disorders). The occipital nerves arise from the neck and transverse across the scalp to the temple area and behind the eyes. The spot where this block is performed is often felt as two trigger points at the point where the base of the skull meets the neck as shown in the photo below. Using an ultrasound machine, the greater occipital nerve, the lesser occipital nerve and the third occipital nerve can be identified and blocked using local anaesthetic and cortisone. Radiofrequency ablation of these nerves can also be performed to provide long term relief.
