grading rubric for five paragraph essay

Mar 21, There is often overlap between the discussion and conclusion, and in some to avoid when writing the discussion section of your dissertation.

Similarly, the prevalence of facet joint pain in patients with CPSS was significantly higher after double level fusions compared to single level surgery[ 10 ]. The anterior approach is most common[ 1 - 7 ]. An alternative to an interbody fusion with or without anterior instrumentation is the implantation of a disc prosthesis.

Donal Harney

There is no range of motion in the index level after fusion, which has to be compensated by an increase in motion at the adjacent segments[ 20 ]. Therefore, the incidence of disc degeneration in adjacent levels is increased[ 21 - 23 ], and changes in the load on the facet joints occur[ 21 ]. Especially during extension the force in the adjacent joints increases significantly, for which reason the joint capsules are stretched whereby pain can be provoked[ 24 , 25 ]. In contrast, after arthroplasty with implantation of a disc prosthesis, the range of motion in the index segment increases most prosthesis use a ball-socket joint.

The continuing movement in the index segment protects the adjacent segments from overload; however, the forces on the facet joints increase in the index level, especially if the center of rotation of the prosthesis is not in the ideal position[ 10 , 26 ]. Many of these etiologies are interrelated and arise from biomechanical derangement at the facet joints[ 8 ], potentiated by inflammation[ 3 ].

Furthermore, degenerative alterations of the spine can often not be changed by surgery. Particularly, the degeneration of adjacent levels can remain a painful condition as the underlying degenerative disease progresses[ 10 ]. Another reason for CFSS is poor decision making or an inadequate indication for surgery[ 1 ]. Generally, two fundamentally different therapeutic approaches in interventional pain therapy for the cervical spine exist: Treatment of facet joint pain MBBs and RF neurotomy and epidural injections transforaminal and interlaminar.

The rationale of cervical medial branch thermal RF neurotomy is to achieve pain relief by coagulating the medial branch, which conducts the pain, and, thereby, interrupting the nociceptive pathways[ 10 , 27 ]. The only prerequisite is that the pain is mediated by a cervical medial branch. Therefore, the indication for RF neurotomy is analgesic response to comparative or controlled diagnostic MBBs[ 12 , 27 ]. MBBs are a diagnostic procedure to test whether the pain is mediated by one or more of the medial branches[ 28 ].

The nerve is anesthetized with a small volume of local anesthetic under fluoroscopic control. Sometimes, MBBs are used in a therapeutic intention; steroids are added to the local anesthetic to treat inflammatory processes[ 10 - 12 , 29 - 31 ].


Cervical epidural injections are used to treat radicular pain from a herniated disc or a spinal canal stenosis, but also to treat chronic neck pain of discogenic origin[ 3 , 10 , 32 ]. Either transforaminal or interlaminar approaches are used. The recent literature about cervical interventions in patients with CPSS provides some evidence, but is limited to single studies with a small number of patients Table 1.

Different forms of RF for spinal pain exist and can be confused with medial branch thermal RF neurotomy. Some techniques are not anatomically valid and do not produce effective thermal lesions, others use different techniques like pulsed-RF[ 15 ]. A recent review about cervical thermal RF lesions[ 15 ] has taken these differences into account; comprising only the indication and technique as described in the guidelines of the International Spine Intervention Society[ 27 , 28 ]. Earlier studies validated the technique and became the basis for the guidelines[ 33 - 35 ]. Thermal medial branch neurotomy is only done if the facet joint pain is diagnosed definitively by comparative MBBs.

Dr Tom Bendinger - Claremont Private Hospital

The face validity, construct validity and predictive validity has been demonstrated[ 36 - 38 ] for comparative MBBs. Engel et al[ 15 ] included six observational studies[ 14 , 33 - 35 , 39 , 40 ] and two explanatory studies[ 41 , 42 ]. This effectiveness is dependent on the type of RF procedure and cannot be generalized for different techniques[ 15 ]. Only one study Table 1 exists evaluating the effectiveness of thermal RF neurotomy in patients with CPSS[ 10 ]; overall, 32 patients were treated. It has to be taken into account that patients might have different pain sources at the same time after surgery.

Although MBBs are actually a diagnostic tool, facet joint nerve blocks are sometimes used in a therapeutic intention[ 10 - 12 , 29 - 31 ], because some studies show encouraging results[ 29 , 30 ].

Want to book an appointment?

A recent study[ 31 ] reveals Level II evidence for the long-term effectiveness of facet joint nerve blocks in managing cervical facet joint pain. The evidence for cervical epidural injections is a subject of debate and depends on, whether an interlaminar or a transforaminal approach was chosen. For the interlaminar approach, a recent review[ 43 ] including eight randomized controlled studies[ 3 , 44 - 50 ] was performed. The evidence for the management of a cervical disc herniation, discogenic pain, or spinal canal stenosis is Level II evidence from at least one relevant high quality randomized controlled trial or multiple relevant moderate or low quality randomized trials [ 43 ].


For the transforaminal approach, the review of Engel et al[ 51 ] found six primary papers[ 52 - 57 ] presenting the effectiveness of transforaminal injections. The evidence was found to be of low quality[ 51 ]. The outcome in the different studies shows moderate effectiveness. However, the number of reports of severe complications spinal cord infarction, cerebral ischemia, quadriplegia, seizures increases[ 51 ]. Therefore, cervical transforaminal injections are not strongly recommended. When comparing the interlaminar and the transforminal approach, better evidence and less reports of severe complications make the interlaminar approach superior[ 43 , 51 ].

The main advantage of the transforminal approach is the selection of a single nerve root which. Therefore, the result after transforaminal injection can be helpful for the decision, which level is eligible for surgery. Patients with CPSS are sporadically included in studies about the effectiveness of epidural injections[ 35 , 47 , 48 , 58 ].

Only one trial Table 1 evaluated the effect of interlaminar epidural injections explicitly in patients after surgery[ 3 ]. The average duration of pain relief was 12 to 15 wk after two initial injections. Persistent pain after cervical spine surgery is a frequent problem.

  • chapter and author info?
  • Dr Tom Bendinger (m)!
  • essays about heroes my dad.

Both, facet joint interventions and epidural injections are used. Some evidence exists for these procedures. Patients with CPSS are sporadically included in evaluations about the effectiveness of cervical injections. In addition, regarding thermal RF neurotomy, therapeutic MBBs, and interlaminar epidural injections only single studies exist that specifically follow-up CPPS patients. Further studies focusing on CPPS patients are necessary. Advanced Search. This Article. Academic Rules and Norms of This Article.

Citation of this article.

Klessinger S. Interventional pain therapy in cervical post-surgery syndrome. Corresponding Author of This Article. Publishing Process of This Article. Research Domain of This Article. Article-Type of This Article. Open-Access Policy of This Article.

This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. Number of Hits and Downloads for This Article. Total Article Views All Articles published online. Times Cited of This Article. Journal Information of This Article. Published by Baishideng Publishing Group Inc. All rights reserved. World J Anesthesiol. Author contributions : Klessinger S solely contributed to this paper; He wrote the complete manuscript. Open-Access : This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers.

Correspondence to : Dr.