The Occurrence of Dropped Head Syndrome After a Cervical Medial Branch Nerve Block in a Patient With Cervicothoracic Kyphotic Deformity: A Case Report.

Complications from medial branch blocks (MBBs) are rare when following proper procedural protocol. Dropped head syndrome (DHS) is characterized by profound muscle weakness in the cervical spine, resulting in a failure to maintain a level horizontal gaze and, in the worst cases, a chin-on-chest deformity. In this case report, we described DHS developing after cervical MBBs using short-acting anesthetic agents and subsequent management. A 69-year-old woman with a previous C6-C7 anterior cervical discectomy and fusion (ACDF) underwent bilateral posterior cervical MBBs targeting the C4-C5 and C5-C6 levels. Immediately following the injection, she reported a sudden inability to lift her head and was subsequently diagnosed with DHS. This condition continued with minimal improvement for over six months. After weighing the risks, the patient elected to avoid surgery, and she was provided a soft cervical collar and prescribed physical therapy. DHS is a debilitating condition more commonly associated with neurodegenerative conditions and inflammatory myopathy, which has received limited attention due to its rarity as a complication of cervical radiofrequency neurotomy. Surgery for this condition, when considered, typically involves long-segment posterior cervical instrumented fusion. Undergoing such a surgery is a complicated discussion that should consider patient clinical factors and preferences. The clinical impact of loss of strength in paraspinal musculature in this patient population is clearly deserving of further study.

Lidocaine-Associated CNS Toxicity at Therapeutic Dosage: A Case Report and Literature Review.

Lidocaine is a commonly used anesthetic. High doses or intravenous administration of lidocaine, as well as other local anesthetics, may result in systemic effects involving the cardiovascular and neurologic systems. Typically, effects are dependent on the serum concentrations of the offending agent. This is a case where a patient presented with symptoms of systemic lidocaine toxicity despite therapeutic dosage and an undetectable serum lidocaine concentration. A 47-year-old Caucasian male received a lumbar medial branch injection of lidocaine and presented with symptoms of perioral numbness, seizure-like activity, and confusion. The patient had a workup, including a CT head without acute findings and an undetectable serum lidocaine level. Due to symptoms consistent with systemic local anesthetic toxicity, intravenous lipid emulsion (ILE) was administered with resolution and without recurrence of symptoms. There should be a low threshold of suspicion for local anesthetic systemic toxicity when patients have neurologic or cardiovascular symptoms following exposure. Toxicity may be present despite therapeutic dosages and low serum concentrations. ILE may be beneficial and should be considered.

Chronic Low Back Pain: The Therapeutic Benefits of Diagnostic Medial Branch Nerve Blocks.

BACKGROUND: Chronic low back pain (CLBP) is an extremely prevalent disease, whose etiology is often multifactorial. Facet joint arthropathy is one of the most common causes of CLBP. Facet joints are innervated by the medial branches of the primary and adjacent level dorsal rami and are, therefore, key potential targets for the symptomatic management of CLBP. A lumbar medial branch nerve block (MBB) procedure is often used to assist in the diagnosis of facet mediated CLBP. For unclear reasons, some patients experience protracted relief of CLBP after diagnostic MBBs alone. OBJECTIVE: To describe the phenomenon of protracted relief of CLBP after diagnostic MBBs and search for predictors of this response. STUDY DESIGN: A retrospective chart review of patients who underwent MBB procedures by a single practitioner, over a 2 year period, was conducted. SETTING: All patients were seen at the Montefiore Multidisciplinary Pain Program, Bronx, NY. METHODS: Data from follow up visits was used to categorize patient's response to MBBs as having no relief (NR), transient relief (TR) or protracted relief (PR). Patient demographics and characteristics were collected, and a multivariate analysis investigating associations with PR was conducted. RESULTS: 146 patients met inclusion criteria. 41 patients (28%) had NR, 54 (37%) had TR, and 51 (35%) had PR. CLBP symptom duration of < 6 months (P = 0.013) and unilateral back pain symptoms (P = 0.0253) were significantly associated with PR after MBB. LIMITATION: This is a retrospective study with a relatively small sample size conducted on patients belonging to a single practitioner. Outcomes were based largely on subjective patient satisfaction scores. CONCLUSIONS: In select patients, MBB may produce protracted relief of CLBP symptoms. The authors present distinct hypotheses which may help explain the therapeutic effects of diagnostic MBB procedures.

Ultrasound-Guided Procedures in the Cervical Spine.

Cervical pain is a common symptom among the general population. When conservative strategies fail to provide pain relief, cervical spine injections may be considered. Compared with cervical surgery, cervical injections have low major complications and, with the right indication, have demonstrated good results. Traditionally, these types of procedures have been performed under fluoroscopy; however, in recent years, ultrasound has become a more common imaging modality to guide spinal injections. Although ultrasound presents an excellent quality image for soft tissue and allows ​the observation of vascular tissues, nerves, and the contour of bone surfaces, the cervical region has a complicated neurovascular network and a comprehensive understanding of the cervical sonoanatomy should remain as the basis before one can plan cervical ultrasound-guided intervention. This paper aims to show the advantages of ultrasound in facilitating the performance of cervical spine procedures, including facet joint injections, medial branch blocks, and selective nerve root blocks; analyze the sonoanatomy and landmarks of commonly intervened cervical structures; and illustrate how these procedures can be performed safely and precisely under ultrasound guidance.