Facet Pain in Thoracic Compression Fractures

Pain Medicine

Volume 11, Issue 11, pages 1674–1677, November 2010

1. Raj Mitra MD, 
2. Huy Do MD, 
3. Todd Alamin MD, 
4. Ivan Cheng MD

Article first published online: 1 OCT 2010

Abstract

Objective.  To determine if thoracic facet joints may be a significant secondary pain generator in patients with compression fractures. Traditionally, pain from vertebral compression fractures has been attributed to vertebral body itself. Compression fractures have been shown to increase thoracic kyphosis and thereby increase the thoracic flexion moment; these changes eventually increase the shear stress on the posterior elements.

Design.  We present a small case series of patients with thoracic compression fractures managed with intra-articular facet injections.

Setting.  Tertiary care academic medical center.

Participants.  Two patients with thoracic compression fractures.

Interventions.  The subjects received fluoroscopically guided thoracic facet steroid injections for pain management.

Main Outcome.  Change in verbal analog pain score.

Results.  Patients with thoracic compression fractures received significant long-lasting relief after receiving fluoroscopically guided intra-articular injections.

Conclusion.  Facet joints may be abnormally stressed due to the increasing thoracic flexion moment in anterior compression fractures, which may serve as a secondary pain generator; intra-articular facet blocks may be an alternative to vertebroplasty.

Occipital Nerve Blocks: When and What to Inject?

Headache: The Journal of Head and Face Pain

Volume 49 Issue 10, Pages 1521 - 1533 Published Online: 6 Aug 2009 Copyright © 2009 American Headache Society

Joshua Tobin, MD; Stephen Flitman, MD

From 21st Century Neurology – Neurology, Phoenix, AZ, USA.

Correspondence to J. Tobin, 21st Century Neurology – Neurology, 2601 North Third Street Suite 125, Phoenix, AZ 85004, USA.

Conflict of Interest: None

ABSTRACT

Introduction.—Occipital nerve block (ONB) is a promising treatment for headaches. Its indications, selection criteria, and best techniques are not clear, however.

Objective.—To summarize in narrative format what is known about ONBs and what needs to be learned.

Methods.—MD Consult and Google Scholar were searched using the terms occipital, suboccipital, block, and injection to identify relevant articles that were reviewed. This process was repeated for all additional pertinent articles identified from these articles, and so on, until no additional articles were identified.

Results.—A total of 21 articles were identified.

Conclusions.—Occipital nerve block is an effective treatment for cervicogenic headache, cluster headache, and occipital neuralgia. While a double blinded randomized placebo controlled clinical trial is lacking, multiple open label studies reported favorable results for migraine. Two other possible uses of ONB worthy of further study are use as a rescue treatment and as an adjunctive treatment for medication overuse headache. ONB may be effective for tension headache, but only under very specific circumstances. ONB is either ineffective or only effective under as yet unstudied circumstances for hemicrania continua and chronic paroxysmal hemicrania. Some practitioners use occipital nerve (ON) tenderness to palpation (TTP) or reproduction of headache pain with ON pressure (RHPONP) as selection criteria for identifying appropriate patients. While only a clinical trial can produce a definitive answer, current evidence suggests that these selection criteria are not necessary for cervicogenic headache or cluster headache. Occipital neuralgia by definition involves TTP of the ONs. Whether RHPONP or ON TTP predicts success in migraine is unclear, and may relate to whether steroids are used. A single blinded randomized controlled trial evaluating local anesthetic with steroids vs local anesthetic alone for transformed migraine reported slightly worse results with steroids, but there are several alternate explanations for this finding other than steroids being counterproductive. The technique of repetitive ONBs deserves further study.