Diagnostic Lumbar Medial Branch Block: Summary and Discharge Instructions

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1 Scheduled Date:! 2012 / /!! Arrival time:!!!! am / pm What is going to be done today and why? Today, you will have a procedure called a diagnostic lumbar medial branch block. The term diagnostic is used because this is a procedure to try to find out the exact diagnosis (the cause and reason) of your low back pain. To understand the term medial branch, we will have to review a little anatomy. Your spine is not one bone, but a series of 29 bones which are all connected to each other. We divide the spine into four regions: the neck (cervical), chest (thoracic), low back (lumbar), and buttocks (sacrum). Each bone in the spine is called a vertebra, and each vertebra is connected to the others, both above and below. There are 3 main connections at each level, a disc and 2 joints called facet joints. You can think of this like a tricycle, with the front wheel being the disc and the 2 back wheels being the facet joints. All of the stresses of moving your spine are born by these 3 critical connections, and so, this is where all the wear and tear tends to end up. Let s discuss the disc first. The discs of the low back are shaped like a large scallop or small, thin hockey puck. The inside of the disc is made of a jelly like substance with the consistency of tooth paste. This is called the nucleus and it has a very strong outside wrapping called the annulus which keeps the inside from getting out. When your spine moves, the discs change shape slightly to allow this, and they divide up the stress so that no single disc has to take all of the punishment. But, for all of this to happen, the annulus (wrapping) has to keep the nucleus on the inside, sometimes under tremendous pressure. The other important connection in the spine is made at the 2 facet joints. The facet joints allow your spine to twist and bend forward and to the side. Like the discs, the facet joints take a lifetime of punishment, and over that time, they can become damaged. Once damaged, the facet joints can be a source of constant pain messages sent to your spinal cord and relayed up to the brain where your experiences of pain and suffering are created. The difficult job for the pain doctor is figuring out where exactly does your pain come from and what is causing it. This is because the areas that patients feel the pain is often the same regardless of the cause. Most patients feel pain in the low back, hips, buttocks, thighs, and legs no matter the cause which is why, up until now, your doctors have been having great difficulty figuring out your problem in order to help you.

2 Next, let s talk a little about nerves and how they work. Nerves are like delicate, complex telephone wires which send messages. When something sets them off like a cut or a bruise, they send their messages to the spinal cord which is like a call center with millions of operators deciding which calls will be let through to the brain. The brain decides what all of these millions of messages mean and then decides what you will feel and what will be done about it. The brain also can send messages down to the spinal cord (call center), and gives it instructions on which calls to let through. Well, what if we could block or shut down particular telephone wires and then see what happened? What if we systematically shut down these telephone connections one by one waiting until we saw the pain improve? Then, we could tell which wires were actually carrying the pain signals AND from where those signals were coming! We d be getting closer to understanding your pain, and we might have a chance of doing something to the nerves to make them send fewer pain messages for months at a time. Diagnostic blocks have to be done very carefully so we are only blocking the wires we want and not others that will just end up confusing us. The X-ray machine guides us to the exact place and makes it less likely we will get confusing information. We cannot actually see the nerves on the X-ray, but we can see the bones and we know precisely where on the bones the nerves will be. Today, we will be blocking nerves called medial branches which send back messages from your facet joints. Each facet joints sends back messages along two wires, and often several facet joints are causing the back pain. This is why we will be blocking 4 medial branches. Many patients ask us if we can see their problem on the X-ray pictures. Usually, all we can tell from the picture is whether your spine looks twisted, has certain vertebrae slipping a little forward, or disc spaces and/or exit tunnels that have become narrow. The interesting and confusing thing to both patients and doctors is that we see people with very bad looking spines that have no pain, and other patients, some of them very young, who have normal looking spines, but suffer terrible pain. This leads us to an important point: chronic pain is terribly complex and poorly understood. It potentially involves many structures including your bones, muscles, tendons, ligaments, joints, and most important of all, your nervous system, the most complex organ in your body. You suffer from a chronic disease primarily involving the nervous system; if it was easy to figure out your problem, it would have already been figured out, but... All of us at KOPI can promise you one thing: we believe you are feeling what you are feeling and we will try our very best to help you.

3 What should I do after my diagnostic injection? Since this injection is a test block, it is important that you tell us exactly what happens after it. We will give you a pain diary to fill out, but it is important to remember that pain is NOT just a number. The best way for us to get a sense of your pain is by you telling us how you feel when you DO things. We block the nerves with freezing drugs like the ones a dentist uses, and often the nerves will be shut off only for 4-6 hours. This is when you should be testing out the block. Do whatever activities reliably trigger your pain. If you cannot comfortably walk a block to get a coffee, do that. If you cannot unload the dishwasher without having to lay down to bed, do that. If you never can sweep or vacuum a single room, try that out as well. The more information about how you felt after the test block the better. Be very specific. Tell us what used to happen when you did these things, and how it was different this time. If certain parts of your body felt much better, but other areas continued to hurt, tell us that. And, if it didn t help at all, tell us that as well. Remember, regardless of whether the test block helps or not, it will give us more information about what your problem might be. Then, write the information down so we can discuss it later, and do it right away while you still can really remember exactly how you felt. If you want, you can write your notes on the back of your pain diary. Then, send an the next day and tell us what happened. The address is drsmithfeedback@gmail.com. We will also give you a follow-up appointment in 6 weeks time, and when you come, please bring your notes and we will discuss what happened. Remember, you can expect soreness from the needles; we only want to know what happened to the pain that you ve been having all along before you came to see us at KOPI. What problems might occur after my treatment? What problems might occur after my treatment? The most common problem is soreness at the needle sites. When we do a procedure like this, we have to insert a needle through skin, fat, and muscle, and we may brush against bone. All of this can cause inflammation, and inflammation leads to bruising, swelling, and pain. The best way to stop inflammation early after a procedure is to use ice. When a part of the body is made cold, it shuts down the blood vessels and makes it much harder for the inflammatory cells to get to the site of the injury. If the cells can t get there, then they can t make and release bad inflammatory chemicals, and that means less soreness and pain!

4 So, we recommend that you ice the place where the needles were inserted for 15 minutes every hour until you go to sleep. Bags of frozen peas work best, use one while several others are kept cold in the fridge and rotate them. Taking tylenol and ibuprofen for several days (Advil or Motrin) will also help and they are best taken together since they also block inflammation at different steps along the inflammatory assembly line. You also should continue all of your other medications as usual. If your test block works dramatically, it is likely that several hours later all of your regular pain will come back. If you are at KOPI, then you ve been dealing with constant pain for many years and this might be the first time in a long time that you ve felt good. But, that also means that when the pain comes back it will be the first time it all comes back at once, so we want to make sure you know this may very well happen. If you know it might happen, you will be better prepared to handle it mentally. We will see you to follow-up on your test block results after 6 weeks. We will give you this appointment before we discharge you after your procedure. Make sure to come to your appointment because this is when we will discuss the results with you and the treatments that may follow. Our goal is to find a procedure that, in combination with medications, physiotherapy, massage therapy, and psychological support, will get you back to feeling and living better. As always, the doctors and staff at KOPI appreciate that you have trusted us with your body and we will do everything possible to make your procedure as smooth and anxiety free as possible. We want to help! Thank you, Dr. Greg Murphy Dr. David Smith Dr. John Cain Dr. Joe Quigg Dr. George Kolbe and the rest of the KOPI Pain Team

5 This is a picture of the lumbar spine as seen from the left side. Your belly would be to the left of the picture and your back, to the right. The lumbar medial branch nerves are colored in red. They carry sensation information from the lumbar facet joints. The fact joint at the top is labeled zj.

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