The guidelines established by the New York State Workers Compensation Board are designed to assist healthcare professionals in administering therapeutic injections for individuals with Neck Injuries. These directives aim to support physicians and healthcare practitioners in determining the appropriateness of therapeutic injections as part of the comprehensive care plan for neck injuries.
Healthcare professionals specializing in Neck Injuries can rely on the guidance provided by the Workers Compensation Board to make well-informed decisions about the use of therapeutic injections for their patients.
It is crucial to emphasize that these guidelines are not meant to replace clinical judgment or professional expertise. The ultimate decision regarding therapeutic injections for neck injuries should involve collaboration between the patient and their healthcare provider.
Therapeutic Spinal Injections
Spinal injections for therapeutic purposes might come into play after initial non-invasive treatments, like physical therapy, medication, manual therapy, exercise, or acupuncture, have been tried.
– Therapeutic injections should only be considered once imaging studies and diagnostic injections have identified the underlying issue.
– Given that injections are invasive and carry potential complications, it’s crucial to strictly follow clinical indications and contraindications.
The main goal of spinal injections is to support active therapy by offering short-term relief through pain and inflammation reduction.
Patients, regardless of injections, should keep up with appropriate exercises aligned with functional rehabilitation.
For those who have undergone active treatment before opting for injections, it’s common to repeat the sessions previously recommended.
Injections on their own aren’t likely to bring lasting relief. Instead, long-term relief is achieved through active rehabilitation and modified work, enhancing the active range of motion, strength, and stability.
When it comes to injections, it’s not advisable to repeat them if the initial one doesn’t result in:
– Improvement in function
– Temporary and sustained pain relief, measured by accepted pain scales (e.g., a 50% reduction on the Visual Analog Scale)
– Reduction in the use of prescribed analgesic medication
Medical management should be ongoing or adjusted based on ongoing patient assessments and responses.
Special Considerations:
For every injection, except trigger point and occipital nerve blocks, it’s essential to use multi-planar fluoroscopy during the procedure to accurately document the technique and needle placement.
– All injections, excluding trigger point ones, should be carried out by a physician with expertise in the specific procedure. Trigger point injections, on the other hand, can be administered by a physician or a Nurse Practitioner/Physician Assistant experienced in the procedure.
– Permanent images are necessary to record the precise needle placement.
– The physicians performing injections can come from various subspecialty disciplines, such as anesthesiology, radiology, surgery, or physiatry.
– The practitioner should have completed fellowship training in a relevant medical specialty like neurosurgery, orthopedic surgery, physiatry, pain management, etc., and should possess interventional training. Additionally, the practitioner must be well-versed in radiation safety for studies conducted under fluoroscopy.
Complications
Potential issues from spinal injections can encompass:
– Temporary nerve dysfunction (neurapraxia)
– Localized pain
– Nerve damage
– Risk of infection
– Headaches
– Vasovagal effects
– More severe complications like epidural hematoma, lasting neurologic damage, accidental puncture of the protective layers around the spine (dural perforation) leading to cerebrospinal fluid leakage, and spinal meningeal abscess may also occur.
– While uncommon, more serious complications can include spinal cord damage, quadriplegia, permanent lack of coordination (ataxia), and even death.
– In the case of steroid injections, there might be a dose-dependent suppression of the hypothalamic-pituitary-adrenal axis lasting for one to three months.
– Additionally, steroid injections can cause a temporary increase in glucose levels, particularly in individuals with diabetes.
Contraindications:
Absolute reasons to avoid therapeutic injections include:
– Bacterial infection, whether systemic or localized to the injection area
– Bleeding diatheses
– Hematological conditions
– The possibility of pregnancy
When it comes to diagnostic injections, potential reasons to be cautious (relative contraindications) may involve:
– Allergy to contrast
– Unstable control of Diabetes Mellitus
– Hypertension
Drugs that affect blood clotting, like aspirin, NSAIDs, anti-platelets, or anticoagulants, are often limited.
– Decisions regarding anticoagulation should be a collaborative effort between the provider administering the injection and the prescribing physician, along with other specialists if needed. This decision-making process should consider the patient’s specific underlying medical condition.
Cervical Epidural / Interlaminar Steroid Injections (ESI)
Cervical Epidural Steroid Injections (ESI) involve injecting corticosteroids into the epidural space to alleviate pain and inflammation, aiming to restore range of motion and enhance progress in more active programs. Like any treatment, it’s crucial to ensure patients have realistic expectations about the outcomes. For diabetic individuals considering ESI, it’s important to counsel them that a temporary increase in blood glucose may occur post-intervention.
Regarding needle placement, it’s imperative for cervical ESIs to be guided by fluoroscopy to confirm accurate needle positioning. Permanent images are necessary to document this placement. The use of contrast epidurograms is recommended to confirm the medication’s flow into the epidural space, with one epidurogram suggested per series of ESI injections as clinically needed.
ESIs are recommended for patients experiencing symptoms of cervical radicular pain syndromes. However, they are not recommended for those with cervical axial pain or non-radicular pain syndromes. Notably, the use of anesthetics is generally discouraged for cervical ESI.
Regarding frequency:
– Up to three injections can be administered in a 12-month period for each spinal region, depending on how the patient responds in terms of improved function and reduced pain. It’s important to limit injections to one level per treatment session.
– It’s suggested to schedule each injection separately and assess the effects individually, focusing on patient response in terms of improved function and pain reduction rather than planning a “Series of Three.”
– If the initial injection doesn’t bring about a response with temporary and sustained pain relief (lasting at least 2 weeks), supported by accepted pain scales like a 50% reduction on the Visual Analog Scale (VAS) and improved function, repeating injections is not recommended.
– A positive outcome, marked by functional improvement, should include measurable progress in physical activity goals and a return to baseline function or work duties. After each injection, patients should be reassessed for improvement in function, temporary and sustained pain relief (50% reduction on VAS), and/or a reduction in the use of prescribed analgesic medication. Medical management should be adjusted based on ongoing patient assessment and response.
Regarding discontinuation:
– Discontinuation is appropriate when symptoms resolve, decrease to a tolerable level, or if there’s no response.
– Epidural glucocorticosteroid injections are not advised for acute or non-acute neck pain without significant radicular symptoms.
– They are also not recommended as a treatment for non-acute axial neck pain without a radicular component.
Cervical Transforaminal Injections
Not recommended.
Cervical Diagnostic and Therapeutic Medial Nerve Branch Blocks / Facet (Zygapophyseal) Joint Injections
Facet joint injections, which involve injecting a combination of an anesthetic and a steroid into the intra-articular facet joint space or blocking the medial nerve innervation of the facet joint, are recommended for cases of acute neck pain. This is particularly applicable when there’s persistent axial neck pain following an injury, such as post-whiplash, that hasn’t responded to conservative management.
Regarding the frequency of these injections, up to three injections are allowed for acute pain within a 12-month period, as clinically indicated.
However, it’s not recommended to use diagnostic medial branch block injections with only anesthetic or diagnostic facet joint injections with only anesthetic for acute neck pain.
For select patients with non-acute neck pain, it’s recommended to use medial branch block injections. This helps determine whether specific interventions targeting the facet joint by blocking medial nerve innervation to the facet joint should be carried out.
Medial Branch Block Injections
Suggested for individuals with suspected facet-related pain based on examination findings, like non-radicular pain worsened by extension or facet loading. Also recommended for those displaying facet findings with pain extending to the axial/cervical thoracic or occipital area, provided they have:
– Documented evidence, such as imaging, confirming facet disease (facet arthropathy/hypertrophy at the targeted level(s))
– Completed a documented course of conservative management, as outlined in the Neck Injury Medical Treatment Guideline, which includes medications, modalities, and active exercises.
For these patients, medial branch block injections can help pinpoint pain sources, potentially alleviate pain, and support progress in a rehabilitation program. After each injection, patients should be reassessed, aiming for a documented 50% improvement in pain measured by accepted pain scales and evidence of functional enhancement lasting at least four to six weeks.
These injections need to be guided by fluoroscopy. Let me break down the details:
– Cervical medial nerve branch blocks can have both a diagnostic and a therapeutic part.
– The diagnostic section involves using an anesthetic, while the therapeutic part involves a corticosteroid.
– For non-acute pain, the diagnostic part (anesthetic only) can be used alone or combined with a steroid in a single diagnostic/therapeutic injection.
– A medial nerve branch block is recommended for diagnosing pain suspected to originate from the facet joint.
– It’s emphasized that facet joint injections aren’t suitable diagnostic tools for deciding on the necessity of radiofrequency ablation.
– The history and physical examination should thoroughly document the reasoning behind the suspected diagnosis.
– A positive response to the diagnostic part of a medial nerve branch block includes an initial temporary improvement, which could last as briefly as one to four hours. This involves a significant reduction in pain (at least 50%, according to accepted pain scales) and an improvement in function throughout the local anesthetic’s duration.
Repeat Medial Branch Block Injections
If a patient shows a positive response to a diagnostic medial branch block injection, regardless of whether steroids are used or not, it’s advisable to repeat the medial branch block injection to confirm the diagnosis. This second comparative injection should be conducted on a different date to ensure accuracy in identifying the level of involvement.
Should there be a positive response to the repeated diagnostic medial branch block injection, further assessment is needed to decide on more definitive treatments, like radiofrequency ablation. When delivering a diagnostic injection, it’s worth considering combining the anesthetic agent with a steroid to potentially extend pain relief.
However, if there’s no positive response to the initial diagnostic injection, it’s essential to reassess the diagnosis. If the first injection doesn’t yield a positive response, it’s not recommended to repeat diagnostic injections.
To enhance therapeutic benefits, steroids may be introduced with the aim of providing longer-lasting relief. The ultimate goal is to reduce pain, improve function, and enable participation in an active rehabilitation program that might have been challenging before the injection.
After each therapeutic injection, patients should be reevaluated to ensure a documented 50% improvement in pain, measured by accepted pain scales, and evidence of functional enhancement. A positive outcome in terms of functional improvement should involve measurable progress in physical activity goals, including a return to baseline or work activities.
Pain assessment should occur before the procedure, immediately afterward, and at specified intervals post-procedure, using accepted pain scales. If the initial therapeutic injection doesn’t bring sustained pain relief, substantiated by at least a 50% documented reduction in pain on accepted scales and improved function lasting 4-to-6 weeks, repeating steroid injections is not recommended. It’s important to note that a positive response to a therapeutic injection doesn’t necessarily dictate the need for radiofrequency ablation.
Regarding the time it takes for the effects to manifest, it’s up to 30 minutes for the local anesthetic and up to 72 hours for the corticosteroid. The frequency of injections is capped at three for each applicable joint within a 12-month period, not exceeding three joint levels (four medial branch nerves) per session, depending on the patient’s documented response in terms of improved functional gain and pain reduction. The maximum allowable sessions are three per year. It’s worth mentioning that the time frames mentioned for different injections may vary based on specific clinical considerations for each patient.
Intradiscal Steroid Therapy
Not recommended.
Occipital Nerve Block
Occipital nerve blocks serve a dual purpose, acting both as a diagnostic tool and a therapeutic measure in addressing occipital neuralgia, with a focus on the greater occipital nerve.
It is recommended to consider a peripheral block of the greater occipital nerve as the initial treatment for occipital neuralgia. The frequency and duration are flexible, with one to three injections allowed, contingent on a positive response. If there’s documented progressive improvement in symptoms and function, up to three injections may be administered.
Potential complications include bleeding, infection, and neural injury. Post-procedural ataxia, a lack of muscle coordination, is common and typically lasts about 30 minutes after the procedure. Due to the proximity of the occipital artery to the occipital nerve, there’s a risk of inadvertent intravascular injection, which could lead to systemic toxicity and/or seizures.
The time it takes for the effects to manifest is approximately 30 minutes for the local anesthetic and 48 to 72 hours for the corticosteroid.
Trigger Point Injections and Dry Needling Treatment
Myofascial trigger points are specific, sensitive areas in taut muscle fibers, forming painful nodules that can cause localized pain and pain referred to other areas.
The treatment for trigger points involves dry needling or injecting a local anesthetic directly into these nodules. It’s crucial to note that trigger point injection is distinct from acupuncture, and details regarding acupuncture should be referred to the relevant Medical Treatment Guideline.
Importantly, there is no evidence supporting the idea that injecting medications enhances the effectiveness of trigger point injections. The therapeutic response may, in part, be attributed to needling alone.
As with any treatment, setting realistic expectations for treatment outcomes is essential.
It is considered reasonable to consider trigger point injections as secondary or tertiary options for non-acute pain that persists despite conservative measures (such as NSAIDs, progressive aerobic exercises, and other exercises) within a six-week timeframe. However, it’s not recommended to use trigger point injections for treating acute neck pain.
Indications for trigger point injections include primarily facilitating functional progress. They can be used to alleviate myofascial pain and support active therapy and stretching in affected areas. However, it’s not advisable to use therapeutic injections without engaging in an active therapy program or within the context of maintaining employment.
Patients should undergo reassessment two weeks after each injection, focusing on improvement in function, temporary and sustained pain relief (at least a 50% reduction on the Visual Analog Scale), and/or a reduction in the use of prescribed analgesic medication. Medical management should be continued or adjusted based on ongoing patient assessment and response.
Functional improvement should ideally last for three months. A positive outcome in terms of functional improvement should involve measurable progress in physical activity goals, leading to a return to baseline function or work duties.
Lastly, the use of ultrasound or other imaging studies for trigger point injections is not recommended.
Regarding the frequency of injections:
– It is advised not to exceed four injections per session, and no more than four sessions within a 12-month period.
– In the case of a partial demonstrated improvement after the initial set of injections, considering a second set is deemed reasonable.
– It is recommended to allow a minimum of three to four weeks between these injection sessions.
– If there are no subjective and objective improvements at that juncture, further injections are not advised.
– Repeated injections should be tied to documented subjective and objective improvements.
– If the outcomes are unsatisfactory after the first set of injections, considering a second set is deemed reasonable. However, if there are no subjective and objective improvements at that stage, further injections are not recommended.
Indications for discontinuation include:
– Resolution of the condition
– Intolerance to the injections
– Completion of two sets of injections without materially affecting the condition.
Prolotherapy (Sclerotherapy), Platelet Rich Plasma (PRP), and Epiduroscopy with Epidural Lysis of Adhesions are not recommended procedures. Specifically, Epiduroscopy and Epidural Lysis of Adhesions are discouraged in the cervical spine due to the associated risks of dural puncture, hematoma, and spinal cord injury.
