RSD Puzzle #105

H. Hooshmand, M. D.

DIPLOMATE AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY

BOARD CERTIFIED IN ELECTROENCEPHOLOGRAPHY

BOARD CERTIFIED IN ELECTROMYOGRAPHY

BOARD CERTIFIED IN AMERICAN BOARD OF ELECTODIAGNOSTIC MEDICINE

INTRACTABLE NEUROLOGY

EPILEPSY, PAIN, MS

An International Referral Center dedicated to Treatment, Education and Research

Lumbar Ganglion Sympathetic Block Versus Caudal Sacral Canal Fluoroscopy Nerve Block

The original pathology of nerve damage results in formation of pain substance and nitric oxide and other destructive chemicals. Chemicals are transmitted through nerve fibers to the spinal cord. These chemicals become backlogged by entering the spine at the cervical spine and thoracic spine regions causing headaches, neck, back, and jaw pain, dizziness and unsteadiness.

The nerve blocks with small doses of Depo-Medrol provide anti-inflammatory medication in the form of Depo- Medrol (which is large molecule of protein with Prednisone attached to the protein). Molecules of protein are so large they can penetrate the walls and get into the system. As a result, they will sit there for at least 3 months by neutralized during the 3 months. These chemicals neutralize the inflammatory effect of the pain substance (substance P).

1. The sympathetic ganglion blocks (stellate and lumbar) are simply diagnostic blocks. It is true that they provide two hours up to 6 days relief of pain, but the only chemical injected is the local anesthetic which wears off very quickly. In this regard, the block has been done just to prove that the pain is sympathetically maintained pain (SMP) but it truly does not have any long lasting therapeutic value. If this type of block is repeated more than a half dozen times, the needle insertion starts causing damage to the sympathetic ganglion cells resulting in eventual death of the majority of the sympathetic ganglion cells. These sympathetic ganglion cells are not just modulating the sympathetic function over the small area of nerve damage, but they also provide sympathetic function to the rest of the extremity. Once they are damaged, then the disease spreads and becomes regional (hence called complex regional pain syndrome).

2. The second form of nerve blocks are ablation, lytic, and neurectomy or sympathectomy type of blocks which are all quite traumatic and destroy perfectly normal nerve fibers. These nerve fibers transmit the abnormal nerve impulse back and forth to the spinal cord from the periphery. Cutting these nerve fibers is going to bypass the painful nerve impulse to the adjacent nerve roots and it is going to result in spread of the CRPS. The chemical nerve blocks are also called lytic blocks because they meltdown every soft tissue in the area that the chemical (phenol, alcohol, etc.) is injected. This meltdown causes extensive scar formation. The relief from this kind of block lasts no more than 1-2 months, but then the pain recurs with vengeance because of the fact that the chemicals do not limit themselves to block the nerves conveying abnormal function, but they block other nerves in the adjacent areas so the pain becomes more severe and spreads because of involvement of the perfectly intact adjacent nerves. Lytic nerve blocks similar to surgical neurectomies and sympathectomies make no sense because of the fact that destroying the nerve fibers is not going to solve the problem and the nervous system simply bypasses the cut off nerve and transmits the abnormal discharge to the spinal cord. All these destructive nerve blocks are harmful. They should not be done on benign complex chronic pain syndromes. The only time they are justified is in cancer patients who have a few months to live and any type of treatment that gives them a few months of pain relief is only humane and should be done. This is in contrast to CRPS patients who are usually young and have 4-5 decades of life expectancy. They can not life and cope with the kind of nerve block damages that generate new sources of pain.

Another form of nerve block is the so-called "release of adhesions". This is done quite frequently by surgeons in patients who have had direct trauma to peripheral nerve or to nerves in the spine. Unfortunately, none of these release of scar formation do any good for the patient because during the release of the scar formation, more damage to the nerves, blood vessels, and adjacent normal tissues is done which causes a new source of pain. Only a few weeks after this so-called release of scar formation and so-called neurolysis, a more extensive and thicker scar is formed which causes severe pain.

One form of this kind of block has become in vogue recently. This is in the form of fluoroscopy and air myelography of the sacral canal and it is also called caudal release of adhesion block. It is peculiar that the majority of these patients have not had any direct injury to the spine or the tail bone, but they undergo the same procedure. The procedure consists of under fluoroscopy and with a fiberglass scope which is inserted into the spinal canal, the doctor looks at the areas that there are some minimal connective tissue looking like scar. Then he tries to cut those and to clean up the specific nerve root that is surrounded with more of these fibers. These fibers are usually quite normal or usually because of inflammation of CRPS. Removal of these fibers just the same as neurolysis mentioned above causes more scar formation and more inflammation with the original disease spreading from the lower extremities up to the tail bone area and the area of neurolysis becomes a new source of pain.

3. The third form of nerve blocks is the injection of local anesthetic with a small dose of anti-inflammatory medication such as Kenalog, Depo Medrol, or Celestone into the spinal canal. This procedure is called epidural nerve block. It is quite safe, and does not cause any serious complications if done in the hands of people who have done this kind of block frequently and who know how to do the block. Also, there is another form of block called paravertebral nerve blocks which is done on the same principle, but they are done in the paravertebral muscles (muscles on each side of the midline of the vertebrae in the back or neck). The same injection is done around the sensory nerves that are transmitting the pain to the spinal cord. They provide excellent relief of pain. Both the epidural and paravertebral nerve blocks last anywhere from 2-3 months and in the meantime, the patient should have proper treatments such as physiotherapy and especially massage so that the patient will not need further blocks in the future.

Except for the third form of blocks, other blocks should be avoided in non-malignant complex chronic back pain, failed neck and failed back, and in CRPS.

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