Lower Cervical Intramuscular Bupivacaine Injections ...

1 Pain Managementa report by Gary A mellick ,DO,DAAPM andLarry B mellick ,MS,MD,FACEP,FAAPP resident and CEO, American Pain Specialists, and Professor, Department of Emergency Medicine,Medical College of GeorgiaLower Cervical Intramuscular Bupivacaine Injections Another Treatment Option for HeadachesBUSINESS BRIEFING: EMERGENCY MEDICINE REVIEW 200539 The lifetime prevalence of headache is over 90%. Thereported prevalence of migraine headaches is females and among males. Headache is acommon complaint for which patients seek relief in theemergency department (ED) setting. The managementof headaches in US EDs includes an armamentarium ofmedications delivered by the oral, subcutaneous, Intramuscular , or intravenous routes. It has beencharacterized as a broad pharmacopeia ofmedications with opioids commonly administered,especially this article a new anesthetic injection technique ispresented, which appears to be an effective therapeuticoption for the entire spectrum of International HeadacheSociety (IHS) classification headaches.

2 This technicallysimple procedure is rapidly accomplished, and results aretypically robust, occurring in five to 10 minutes. Patientlength of stay in the ED appears to be shortened andother more time-consuming treatment interventions areavoided. Based on the rapid resolution of headache painand other trigeminovascular system-related signs andsymptoms following these Injections , connections to thetrigeminal system appear to be involved. Three patientsillustrative of the therapeutic response to the lowercervical injection with Bupivacaine are One (Migraine Without Aura)This 33-year-old Caucasian female presented to the EDfor pain relief from her usual migraine headache thatbegan two days earlier. She described light sensitivity,nausea and vomiting. Her usual abortive medicationswere attempted without relief. The headache began onthe left but became bilateral and was 10/10 in patient denied any other medical problems.

3 Shewas treated with Injections of of bupivacainebilateral to the spinous process of the seventh patient experienced relief of her headacheto 1/10 in less than five minutes. She also describedcomplete relief of her photophobia and , the patient reported that she did not haveher usual headache postdrome that typically wouldaffect her during the following 24 days later this patient returned to the ED fortreatment of a migraine headache that was initiated bythe smell of strong cologne . Again, photophobia andnausea accompanied the headache. The patient againreceived bilateral Intramuscular Injections of Bupivacaine at the level of C-7 spinous time from the anesthetic Injections to completeheadache relief was exactly six patient hadtwo subsequent visits to the ED for similar migraineheadaches over several months and respondedconsistently to the Cervical injection Two (Infrequent Episodic Tension-type Headache)This 43-year-old black female complained of a constantfrontal, unilateral headache for three days prior toarrival in the ED.

4 Similar headaches would occur everynow and then . The patient described the headache asa tight band about her head. She denied an aura,numbness, phonophobia, photophobia, nausea, orvomiting. Even though she reported feeling congested , there was no clinical evidence of headache was 6/10 in severity. Bilateral lowercervical injection with Bupivacaine resulted incomplete resolution (0/10) of the headache inapproximately five minutes. In follow-up, the patientconfirmed that she remained headache-free afterleaving the ED, and that she was able to returnimmediately to her daily Three (Acute Post-traumaticHeadache)A 22-year-old white male sustained a head injury andorofacial trauma after colliding with a friend whileroller blade skating. A brief loss of consciousnessoccurred. Additionally, there was avulsion andsubsequent reimplantation of the right maxillary centralincisor as well as extrusive luxation of the mandibularcentral incisors.

5 Since the accident the patient hadexperienced on-going severe right maxillary dentalpain with hypersensitivity to cold water and lighttouch. He also experienced significant dental andgingival pain in the luxated but stabilized teeth. Hispain was unresponsive to hydrocodone withacetaminophen or oxycodone with acetaminophen. InGary A mellick , DO, DAAPML arry B mellick , MS, MD, FACEP, FAAPGary A mellick , DO, DAAPM, isPresident and CEO of American PainSpecialists Inc., Grafton, Ohio. He isDirector of the Pain ConsultationClinic, Chalmers P Wylie VeteransClinic, US Department Of VeteransAffairs, Columbus, Ohio. He waspreviously Flight ,US Air Force, 1999 to 2003, Directorof the Human PerformanceLaboratory, US Army Health Clinic,Pentagon, Washington DC, 1985 to1988, Chief of Aviation Medicine,Troop Medical Clinic, 1984 to 1985,and Chief of the Family Practicesection, US Army Academy of HealthSciences, 1981 to B mellick , MS, MD, FAAP, FACEP,is Professor in the Department ofEmergency Medicine, Medical Collegeof Georgia and currently works as aphysician consuItant.

6 He wasChairman, Department of EmergencyMedicine, Medical College of Georgia,1996 to 2003, Chief of Service andChairman, Department of EmergencyMedicine, Loma Linda UniversityMedical Center, 1993 to 1996, andDirector of Pediatric EmergencyMedicine for both 25/5/05 3:45 pm Page 3940 BUSINESS BRIEFING: EMERGENCY MEDICINE REVIEW 2005 Pain Managementaddition, the patient reported a constant, throbbing,posterior headache rated at 7 10/10 in severity. A C-7paraspinous Intramuscular Bupivacaine injection wasperformed bilaterally. Not only was the patient sheadache relieved, his dental pain was reduced to 1/10in severity. Subsequent to the injection , the patient wasable to bite down, drink tap water, and run cold waterover his previously painful teeth. In follow-up, thepatient reported that his dental pain remaineddiminished and that the headache had not though this procedure appears to suppress anactivated trigeminovascular system through an interfacewith the trigeminocervical complex, it is not clear whythis injection is effective in relieving headache pain aswell as many of the associated signs and relief may be related to the convergence of thetrigeminal nerve with sensory fibers from the uppercervical roots at the trigeminal nucleus clues also suggest that other mechanisms ornervous system structures may be trigeminal nuclear complex has components in themidbrain, pons, and medulla, and even extends downinto the upper Cervical segments of the spinal cord.

7 Thetrigeminal nerve provides sensory innervation to the faceas far back as the angle of the jaw and anterior innervation including C1, C2, and C3 play aprominent role in providing feeling to the head andupper Cervical levels of the neck. The descending spinalnucleus of the trigeminal complex is a pain-conductingnucleus from the ipsilateral face. Somatic sensation (pain,touch, temperature) fibers of cranial nerves VII, IX, andX, which innervate the tympanic membrane, external earcanal, and skin of the outer ear, terminate in the spinaltrigeminal nucleus and tract in the upper Cervical spineas far as C4 to blend with the substantia gelatinosa of thecervical cord. Convergence of these various elements andothers on second-order neurons of the trigeminocervicalcomplex appear to be an important anatomical clue tounderstanding the therapeutic mechanism of the lowercervical Bupivacaine , various lines of evidence identified in recentpublications suggest that brainstem nuclei andperiaqueductal gray (PAG) matter are key in thepathophysiology of migraine.

8 Furthermore, it is wellrecognized that descending modulation from supraspinalsites influences spinal nociceptive input and thatendogenous descending pain modulation can betriggered by aversive environmental stimuli, such as stress,illness, or pain. The potential anatomical substrates forcentral descending inhibition include the thalamus, PAG,rostral ventromedial medulla (RVM), locus coeruleus(LC) as well as other brainstem locations. The PAG is amajor nociception integration site and a key pathway ofcentral pain modulation that contains a high amount ofopioid receptors and peptides. Much of the output fromthe PAG projects to the rostral ventromedial medulla(RVM), which in turn projects largely to the dorsal hornof the spinal cord. Activation of the RVM electrically orchemically produces effects similar to PAG resulting inhibition of nociceptive afferentspinothalamic tract neurons is believed to involvedescending cholinergic and monaminergic systems aswell as activation of intrinsic glycinergic and gamma-amino butyric acid (GABA)ergic dorsal horn RVM is a major relay between the PAG and thespinal cord and has two types of neurons on-cells and off-cells , which are believed to modulate nociceptiveinput from the spinal cord dorsal horn neurons and thetrigeminal nucleus caudalis.

9 Increased activity of the off-cells in the brain stem s modulatory system is capable ofproducing a strong antinociceptive response. Both typesproject to lamina I, II, and V of the dorsal horn and areactivated by stimulation of the the mechanism of pain relief, the apparent softreboot process is robust enough to bring about completeheadache resolution along with relief of all associatedsigns and symptoms within minutes. This rapid andcomplete headache resolution, as well as centrallygenerated associated signs and symptoms, stronglysuggests that the Bupivacaine injection is directly affectingelements of the peripheral and central nervous systemcritical to headache generation and is evidence that other Cervical dorsal rootanesthetic Injections successfully relieve headaches. Thirdoccipital nerve blocks, Injections of lateral atlanto-axialThe management of headaches in US emergency departmentsincludes an armamentarium of medications delivered by the oral,subcutaneous, Intramuscular , or intravenous 25/5/05 3:46 pm Page 40joints (C1-C2 origin of pain), C2 root ganglion blocktherapy and methylprednisolone injection near thegreater and lesser occipital nerves are documented torelieve or reported complications of this procedurehave been muscle soreness at the Lower Cervical injectionsite and vasodepressor-related pre-syncope.

10 Other poten-tial complications include a pneumothorax secondary toa needle inadvertently angled downward toward the apexof a lung or an infection caused by the are a number of potential benefits associatedwith this therapeutic technique. The authors feel thatthe actual costs of Bupivacaine and equipment for theintramuscular injection are small when comparedwith many of the therapeutic interventions currentlyin use in the ED setting. Additionally, the majority ofpatients are free of any medication-related side effectsor neurologic residua associated with their migraineheadaches. This allows patients to resume their dailyactivities without conclusion, the Lower Cervical paraspinous intra-muscular injection with Bupivacaine appears to beanother useful adjunct for the management ofheadache pain in the ED , it seemslikely that a greater understanding of the physiologybehind the pain relief associated with this injectiontechnique will provide a better understanding of thegenesis and pathophysiology of migraine and otherIHS headache classifications.