I think we all love nursemaid's elbow so much because it's one of those magical “Alakazam, you're cured!” moments. It's not often in emergency medicine that we get these, which is why I'd like to add another one to your arsenal: the paraspinal cervical injection.
I recently started a shift with a patient writhing in pain. “Seventy-five-year-old visiting from Denmark with trigeminal neuralgia,” my colleague told me. “He said they usually give him Demerol. I've been trying IV Dilaudid. He stopped screaming about 15 minutes ago, so I think it might be starting to work.”
I went back to reassess my signed-out patient, and he was still clutching the left side of his face. I introduced myself, told him I'd like to try a paraspinal cervical injection, and he said, “Sure, I'll try anything.” (I find this to be a fairly good indicator of legitimate pain because I had explained that I wanted like to put a 2 cm needle into the back of his neck. Twice.) Three minutes later, the patient asked the nurse, “What did that guy do? My pain's gone.” I provided him with a paper describing the technique at his request so his own physicians could do the same thing back home, and he left about 10 minutes later.
And, by the way, this is par for the course with this technique. In my experience, these patients are pain-free and ready to be discharged within five to 10 minutes. Do I have your attention now?
I first heard about this technique from an attending in residency, but thought it was crazy (sorry, Gino!). I first performed it after watching Larry Mellick, MD, do it on his YouTube channel and seeing some amazing testimonials from patients.
The procedure is fairly straightforward, but I recommend watching Dr. Mellick's videos first. (Read his EMN blog and watch a video on this topic at http://bit.ly/1uH8hYs. Visit his YouTube channel at http://bit.ly/MellickYouTube.)
- Palpate the C7 spinous process. This is also known as vertebra prominens because it's easily palpable under the skin. You can have the patient flex and extend his neck to help find it, if needed.
- Draw up 3 mL of 0.5% bupivacaine in a syringe, and attach it to a long 25/27G needle.
- After a standard sterile prep (and if you have it, skin vapocoolant spray), insert the needle about 2 cm deep and 2 cm lateral to the C7 spinous process. Inject 1.5 mL after aspirating to make sure you're not in a vessel. Aim parallel to the floor to avoid the lung apices.
- Repeat on the other side.
No technique is perfect, but Dr. Mellick reports an 85 percent success rate. The procedure apparently works on any craniofacial pain. I've used it for refractory migraines, trigeminal neuralgia, and dental pain. Dr. Mellick likes using it on corneal abrasions and glaucoma, too. It also reportedly works for tension headache, chronic daily headache, and post-herpetic neuralgia. But, fair warning: It works on any craniofacial pain. I've had it completely resolve the headache of LP-confirmed viral meningitis as well. You cannot use it diagnostically to rule out a life-threatening pathology, though.
There are many neurologic pathways and theories to consider, but the idea is that craniofacial pain has a central and spinal component to it through sympathetic innervation and interacts with the trigeminal nerve. You can turn off the pain if you can disrupt this loop by blocking one of the lower sinuvertebral nerves when you inject IM.
Dr. Mellick, a professor of emergency medicine at Georgia Regents University in Augusta, and his twin brother, Gary Mellick, MD, a neurologist and pain specialist, came up with the paraspinal cervical injection. The latter Mellick tried it on a hunch with one of his pain patients, and had great success.
Dr. Mellick told me that he has had a few patients with vagal responses after the injection. A colleague's patient with a severe vasovagal response had a brief cardiac arrest after injection, but he did not think it was intra-arterial. He, of course, always recommends double- or triple-checking that you're not in a vessel first. (Obviously, this is a scary outcome, but other medicines that we give all the time have similar risks.)
Dr. Mellick has published several studies on this in the neurology and emergency medicine literature. The best one is “Treatment of Headaches in the ED with Lower Cervical Intramuscular Bupivacaine Injections: A 1-Year Retrospective Review of 417 Patients.” (Headache 2006;46:1441.) The paper reports an 85 percent success rate (65% complete relief, 20% partial relief) with only minor, transient side effects.
I use this technique more frequently in refractory migraine patients and facial pain patients than anyone else. I still stick with good ol' Reglan/Toradol/IV fluids combo for the headache/migraine patient with few or no visits to the ED. We all know, however, that those refractory migraine folks or severe facial pain patients are, in my mind, the perfect candidates for this procedure.
I admit that I was scared to perform this procedure my first few times, and that my colleagues look at me like I'm certifiably crazy. But it is absolutely practice-changing in the right patient.
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