ESI vs Facet Joint Inj & RFA
 

Hi All,
I have a pain mgmt doc I see monthly who is a doll and manages my pain well.
For big flares of pain,
About 5 yrs ago he sent me to another pain doc who did ESI's(epidural steroid injection) that worked well to control pain from a c4/5 herniated disc and helped with some neuropathy...I was very happy. He did this 2 or 3 times.

Well, another bad pain flare last week probably again from disc, an MRI result is pending, so back to the doc that my husband and I call Dr. Needles. However, this time he recommended first Facet Joint Injections, followed by RFA(radio frequency ablation). Now, this is without yet seeing my MRI or examining me as he has in the past, just very briefly talking to me. I asked him why the change in treatment when the previous ESI's worked so well. He got a bit testy and said treatments change and he thought my symptoms were different. I said no, they are the same. He then admitted the ESI now has to be done in the hospital, not in his office and "besides, the ESI is much riskier" than other treatment.

For those of you who have had a facet block and ablation, can you tell me if they helped your pain and what procedure and recovery is like. If anyone else has had ESI and the
facet Inj/ablation...can you offer advice or opinion.

I honestly think this doc is making a decision on what is best for him financially, not what is best for me. He refused to do the ESI he had done in the past.
Thanks, Diandra

Hi Diandra,

Actually, the doc is right. ESI's for the cervical spine are far more risky than facet injections. Facet injections are done in the joint and nowhere near the spinal cord. I was terrified of the one ESI I had for my cervical spine. It went well thank goodness but even my pain doc said they were far more risky. And in truth, the facet injections worked much better! I have never had the medial branch nerve(s) ablated in the cervical spine but have had them done in the lumbar. RF's work very, very well. At least for me. As for having this done in a hospital setting, it is not an "admission" so to say. It is a change in the law from what I understood. I am not sure if this was a new CMS rule or not. But I was told the same thing months and months ago. It is still somewhat confusing to me since my Mom had a lumber ESI in what I term the office setting. However, the group I go to also has a surgical suite so that may be the difference. Anyway, try the facet injections and if they work and ablation is next, you might find much longer relief.

Hi Kathi!
Thanks so much for the advice. I am always a chicken when I get an injection or procedure I have never had before. I am so glad the RF's worked well for you, you have given me just the encouragement I need. I was also very concerned before I had the first the ESI but it was so helpful, I was grateful for the relief. Take care, Diandra

Diandra,

You are welcome! :) Based on your first post my thinking is that your doctor is attempting to target (more specifically) your pain generators. So, that's a good thing! ESI's tend to just flood the area in hopes that it calms everything down. Now, I am just going to say this because facet joints are my problem in the cervical and lumbar..all the time. If they are inflamed, you will know it. The injections may be painful or maybe not. But since you are concerned you can always ask the doc for perhaps 10mg of Valium to get you through the procedure and to help you relax your neck muscles. Or perhaps an IV with Versed. I did that a few times. The nice thing is, these injections are usually pretty quick. And the best thing of all is that I normally had great relief right away from the numbing med! Which told the doc, yes, that was my pain generator. Having said that, you may find an increase in pain for about a week but give the steroid a chance. It takes a little time for it to kick in. And if they work, and the RF is next, rest assured it is actually easier than the injections themselves. I have had 3 in the lumbar over the years and never felt it.

Hi Diandra.

First, I will say: I hope you get some good pain relief from what procedure you and your physician decide to have done for you.

I*, my self, had 2 Epidural Steroid Injections for herniated C6-7 disc with left arm radiculopathy. This procedure was some years ago, and ir was done at an outpaitient surgical center. Thinking back, I am pretty sure it was done under brief general anesthesia.

I must also say, I do not know much about Facet Joint Injection, and have never had it done.

Last, but not least, I must say that the Epidural Steroid Injections did not help- me one bit. I used to say, that I think this procedure is wasteful, and overpriced.

Bur I have heard that this can be very individual. It can help for some, and not for others.
I think you are in your right to assess the situation, find out about the other procedure, and then you and your physician can make a choice.

I also agree with you regarding the doctors wanting to make the choice for the patients in order to suite their (often) financial benefits.
But this may not be the case here. As I said, this other procedure might be right for you.
But if you and the doctor wait for the MRI result, and then sit down to discuss it, then you might be better able to make the right disision.
Also take into concideration that it will give you some extra time to explain to the doctor that what procedure you hadf before, had helped you.

There is another point to remember that I think is important: It is always good to know that when one has a invasive risky procedure, it is done in a safe hospital invironment.

Good luck with your procedure.

Synnove

Have any of you ever considered going to a chiropractor for pain relief without drugs?

My recent MRI had revealed that I have several disc herniations and spinal cord impingement with C6 and C7 being the worse.

And that for years my C1 (Atlas) and C2 (Axis) never stays in place. Getting worse as years have gone by.

I have gone to a chiropractor since 1999 for my lumbar L4, L5 and S1 issues.

I now have had a Thoracic MRI and Cervical MRI and they showed T4 is herniated and again C1, C2, C3, C4, C6 and C7 are really messed up. To say the least.

My current chiropractor had suggested that I try cervical decompression. Where they decompress the cervical spine with slow mechanical movements. It is painless and actually I go to sleep for the 5 to 7 minutes that I am having it done, lol. It has helped me tremendously. My migraines are eased and I can sleep better than I have in a long while.

Mind you that I have been dx with RRMS too.

I have recently been talking with my old chiropractor from where I used to live and she has been a Godsend to say the least.

She suggested that I would benefit from seeing a Upper Cervical Chiropractor (they xray you standing upright) They are able to see problems of the cervical spine differently as opposed to lying down the conventional way.

I recently was able to buy a great read on this very subject. "The Downside of Upright Posture" by Michael Flannagan, D.C. ($24.95)

It is so informative and is an easy read. I can't put it down. It was talking to me to a T!!! Best money I ever spent.

Mind you, I have had no success with neuro's and my reg PCP on why my face was going numb and how I lost partial vision in my right eye. They still think it is from the MS as the optic neuritis keeps recurring.

While I have lesions on my spine (reason for RRMS dx) ... I wonder how much my neck has played a role in this and could it actually be from not enough blood supply going to my brain.

I never believed in chiropractic until about 1999 when a good friend from work had found relief from his painful back.

I exercise as much as I can and I stretch ALOT. Recently I have changed my diet. Gluten free, a little at a time, to see if I see any changes in how I feel.

Can't hurt ... and wouldn't it be LOVELY ... if just this simple change can take some or all of our pain away .. without the use of drugs? Drugs are toxic to the rest of the body. Mmmm something to ponder on.

Praying for pain free days ahead
God Bless
Str*

yup....tried 6 or 7 over the yrs along with DO's and acupuncture, massage, phys therapy. no luck way before I went the drug route. I recently had been very deconditioned and my high blood pressure was problem. I did not want to add more drugs i tried swimming slowly and aqua therapy and hanging upside down from gym equipment....apparently I did more harm than good. honestly, cranial sacral therapy and these various injections are the only things that have helped my cerv disc issues. diandr

Pain relief without medication is always the primary goal of pain mangement.

Studies have shown that physical therapy is as effective as surgery in the long term for some conditions.

study: surgery vs. physical therapy

Myofascial Trigger Point Therapy (MTPT) is very effective for soft tissue and some musculoskeletal issues.

TENS, Biofeedback, Mindfullness Meditation, diet (avoiding triggers and feeding the body with nutrients), supplements (Do you consider supplements to be medications?), distraction, acupressure/acupuncture, lifestyle changes, and other techniques can all be effective for some. Medications generally are—and should be—the last resort before surgical intervention.

I accomplished cervical decompression (as much as possible) with gentle traction.

Chiropractic can be a polarizing topic around here. Ask IllPn (there are others as well, but I'd have to search for posts/threads) about chiropractors for cervical issues.

Lumbar... maybe, if you buy into that stuff.
I'd be extremely wary, particularly with the kinds of spinal issues of members here.
emphasis mine

I don't expect to change any minds of chiropractic converts/followers, but for any on the fence or wondering, I advocate diligent research and coming to one's own conclusions rather than anecdotal evidence.

Doc

Hi Doc,
You said, "I accomplished cervical decompression (as much as possible) with gentle traction."

How did you do it, with a physical therapist or your own home traction device, etc?
Thanks, Diandra

Both. It began with PT, at which time it was suggested I might get a home unit. After asking a lot of questions of PTs, my doctors (my ortho uses one) and reading online, I chose an over-the-door unit and made some slight modifications so it would work better for me.

Doc

I did the same Dr. Smith; through PT and my Neurosurgeon at the time. It felt great hanging off the door and while in it. :) But the minute I came out of it, it just seemed like my facet joints just slammed back down for lack of a better description. And I did this for 3 years!! It wasn't until I found a great SPINAL PM doc, that found that true problem(s). Facet joint injections were the ticket for pain relief at that point. It was wonderful to be completely pain free for a few weeks. But my C3/C4 was so far gone, I had to have a fusion. C5/C6 two years later. My point being, it is always best to have conservative therapy first but if too far gone, more has to be done. As for as Chiro goes, I will only relay what my PM had to say. He said, "Some people swear by it. But as for you and as bad as your cervical spine is, STAY AWAY from them UNLESS they are just going to work on the muscles and relieve spasms!" Just remember, the cervical spine is a far cry from the lumbar and far, far more serious.

Hi Kathi,
It sounds like you did the conservative route as long as you could, which is the smart thing to do and then had the surgery. Did the surgery help you? Are you glad you did it?

I did have the Facet injections yesterday. The doc gave me 15 mg of Valium to take 30 min before and I was pretty loopy before I got on the table....after so much pain it felt good to be that relaxed. I do think the shots helped...He injected into 3 sets of facets joints and said I may be sore for a couple days.

In two weeks I have the ablation. Since you have had the ablation, even though it was lumbar, Could you explain your experience in a bit more detail if you recall it. The lit the doc gave me says:

"Since nerves cannot be seen on x-ray,the needles are positioned using bony landmarks that indicate where the nerves usually are. fluoroscopy x-ray is used to identify those bony landmarks. a local anesthetic like a lidocaine is injected to minimize the discomfort after confirmation of the needle tip position, a special needle tip is inserted. when the needle is in good position, as confirmed by x-ray electrical stimulation is done before any ablation. this stimulation may produce a tingling or pressure sensation Or may be like hitting your funny bone. you may also feel your muscles jump. you need to be awake during this procedure so you can report what you're feeling. the tissue surrounding the needle tip Are then heated when electric current is passed using the radiofrequency machine for, a few seconds this numbs the nerves semi-permanently."

The facet joint injections, were not painful, not much more than a flu shot. However this sounds much more painful if they are running electrical stimulation into a nerve to test for correct position and then a heated electric current zaps the nerve. Did you experience much pain?

Would love to hear your thoughts or anyone who has had the ablation. Thanks, Diandra

p.s. wanted to recommend the "Dragon" dictation app. I use it on my Ipad. I talk my "post" into the app and then copy and paste into this thread....it saves me SO much typing.

Hi Diandra, yes, I went the conservative route for 3 years; everything and anything, you name it. Plus handfuls of meds (non-narcotic) which I NEVER want to go through again. I was so sick to stomach all of the time, dizzy, in a fog and on and on. I forgot to say that this all began in 2000 so it has been several years and I haven't had any injections for cervical spine for awhile. At least two years now. But I have for the lumbar.

Anyway, I am giggling at you. :) I shouldn't say that. What I mean is I am understanding of your fear of the RF. I could NOT wrap my brain around it! I thought just as you did. If they are going to destroy the medial branch nerves, I WILL feel it!! WRONG! I didn't feel a thing! What your doctor told you is correct. So, I will just add what my own doc said. He said that the medial branch nerves sole purpose in life is to transmit pain. That's it...that is all they do! So, they aren't like motor nerves. Again, I was scared and told him I just could not fathom this procedure. He simply said to trust him and I wouldn't feel anything. And I didn't. I believe he gave me a cocktail (IV) of Versed, Fentanly and Toradol. And the only thing I remember saying is "How about those Colts?!" :) That and a feeling of a thump in my leg periodically. And yes, I was awake! I know I said more things I just hope I didn't spill any beans ha!ha! So, I have had this done at least 3 times over the years and each time it gave me about a year or longer in relief. Seriously, it was easier than the facet injections. But my facets were always inflamed anyway.

I am glad the injections weren't too painful for you and you are having some relief. Give it some time...at least two weeks. I remember calling in once and swearing up and down that they didn't work. I was wrong. I just had not given it enough time. And yes, you might have an increase in pain for a bit but it should subside. And the Valium. Isn't it great for an injection procedure?! Sometimes my doc will give me a few but it really depends on the type of injection. Most of the time I just don't take anything.

So, keep us posted as to how you are doing. It's a great thing to get relief.

Oh almost forgot. No, I do not regret the surgery for two reasons. I had cervicogenic headaches every day 24/7 for 3 years. And that pain was off the charts! I can still get them periodically but normally can kick them out with ice, heat and my regulars meds. Secondly, and most importantly, the C3/C4 level is very critical due to the phrenic nerve. My Neurosurgeon had stated that any fall, any accident, etc. would either cause me to stop breathing or I would be paralyzed for life. So, the C3/C4 was in very, very bad shape. The C5/C6 was going then but I managed to hold off for two more years. In any case, no I don't regret either one. Last summer I was told that the C4/C5 is getting bad so I am keeping an eye on that level so to speak. I really don't want to go through this again due to the spasms that can be horrendous. But if I have to, I will.

I think most everyone is in violent agreement on that point. :rolleyes: ;)

Doc

"Anyway, I am giggling at you. I shouldn't say that. What I mean is I am understanding of your fear of the RF. I could NOT wrap my brain around it! I thought just as you did. If they are going to destroy the medial branch nerves, I WILL feel it!! WRONG! I didn't feel a thing! What your doctor told you is correct. So, I will just add what my own doc said. He said that the medial branch nerves sole purpose in life is to transmit pain."

Thanks for the information on your experiences Kathi....it helps me so much because, truly, I just don't get it. When my doctors handout says things like "semi-permanent" results.....really!!!!! What the heLL does SEMI permanent mean....who writes this stuff?!?!

I am waffling with the decision with the ablation vs ESI because even though the pain has softened, it is only lower, like someone turned the dial from 10 to 5...enough to get me out of bed and more functional but not ready to resume swimming and physical therapy. My doc explained that if not ALL the pain was gone, he did not get all the facet joints that were affected. You do encourage me by saying your relief was a yr or longer, that is terrific.

Your advice to give it two weeks was also very helpful because I thought it would only be a few days that would indicate my best result.

You certainly have gone through quite an ordeal and having to now deal with a fragile c3 c4 that if damaged could cause paralysis or stopping breathing is so stressful. I hope you never have to deal with that issue worsening. Do you ever wear a cervical collar or anything to protect yourself? Or perhaps do PT or exercises to strengthen your neck and upper back?

Again, thanks for sharing. Bless you, Diandra

Dianda,

I am pretty sure what semi-permanent means is that while the nerves are ablated they do grow back. That is why RF's are repeated. Which is what is good about them. As I said, I would have about a year or so of relief and over time could pretty much tell when I needed another one. But it takes a long time for them to grow back which is why I would have long periods of relief. :)

I am glad your pain has dialed back. And your doc is correct about the various levels. That was what was happening to me originally. My first PM just wasn't getting to the correct pain generator. They were forever giving me injections but missing the C3/C4 or at least not getting it right. Of course at that time I had Interns doing it which was being overseen by my PM. In any case, my entire cervical spine had issues. So, yes, it can take a few times before they find the right one. Anyway, my second spine doc, who is the best in town btw, found it right off the bat! And I had two or three Selective Nerve Root injections done as well.

Oh, my C3/C4 is fused now. Also, the C5/C6. It is the level in the middle that they are watching. But I haven't really had any symptoms yet. And yes, I wore a soft collar after my surgeries. Sometimes I will put one back on if I start to get a headache. And oh yes to the PT!! Too numerous to count! They tell you, keep your neck muscles soft and pliable, yet strong. It IS difficult to do and the docs will admit as much. I found though, over time, that what worked best for me was massage therapy and aqua therapy. There is a hospital here that works strictly with spinal disorders patients in the water. And they knew what they were doing! Believe me, not all PT is helpful. I found that out the hard way and a couple of times they made things worse. And I am not "downing" PT. It is just that I had a couple of youngsters, fresh out of college that thought they knew more than the patient did. Since that time, the Spine Group I go to has their own therapists thank goodness!

In all honesty what helps is simply being in the water and doing the exercises I was taught to do a long time ago. Through the winter months I just go easy. Over time I have learned what I can and cannot do. And it hasn't been too bad; just the lumbar acts up every now and then.

I wouldn't be too overly concerned about the RF. I know, it is difficult to wrap your mind around it. But talk it over with your doc and he can set you at ease. I did that very thing at least two or three times before I had it done. Hang in there Diandra!

Hello Diandra;
I have limited knowledge on blocks because I had only one two years ago & it didn't work 4 me. I hope things work out smooth for you with this waterfall of information in here. I can give you though, a link that may help you better understand what is actually happening to your body and why. experience is the best teacher they say. A block is what it says, a block, stopping or trying to stop/prevent something malfunctioning in our bodies. Enough of me ranting, here is the link it has 7 pages of info on your initial post. Best of luck with the treatments and may your pain level decrease immensely.
http://www.medscape.com/viewarticle/718292_!