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Wednesday, December 18, 2013

All I want for Christmas is...

...a pulsed radiofrequency nerve ablation! And Christmas has come early, my friends. Tomorrow is the big day :)

In my last post, I explained that I was scheduled to receive another diagnostic bilateral medial branch nerve block, this time at C2/C3/C4. That procedure, which I had last Thursday, was more successful than the prior week's block at C2/C3. I recorded up to 70-80% pain reduction in my 3 hour post-injection pain log, which was a lot more encouraging than the 40-50% from the first time around. When we saw Dr. Schurgin for a follow-up on Monday morning, he gave me the green light for the pulsed radiofrequency I had tentatively scheduled for this Thursday, contingent on the approval of Dr. Cohen, the TMJ specialist I would be seeing on Tuesday.

At Dr. Cohen's office (Southwest Pain Management), I had a consultation with Dr. Patel, DMD, who specializes in orofacial pain. Orofacial pain can include temporomandibular disorders, neurovascular pain, neuropathic pain, headaches, etc. As previously described, I wasn't totally aligned with the thought process of the first "TMJ specialist" I had seen, who proposed a treatment plan that would include building up my back teeth in order to change my bite and ultimately, position of my jaw. Despite my annoying jaw "popping", Dr. Patel's examination and review of imaging didn't reveal any significant pathology with my jaw joints or muscles, though. She even recommended I discontinue use of the mouth piece that I'd been wearing to bed, explaining that long-term use could potentially cause a bite change, which could lead to further problems. The fact that she didn't think my jaw issues are a SOURCE of my upper cervical and head pain was a huge POSITIVE in my book, and also confirmed what my PTs have been speculating - that the dysfunction at C2 is likely causing the dysfunction of my TMD joint above. Checking this box off also meant that we can go on ahead with tomorrow's procedure. (High five!)

I included this is a previous post but a little review, if you will...

"Radiofrequency neurolysis is a procedure in which sensory afferent nerve fibers are selectively destroyed with heat produced by radio waves delivered through an electrode. Treatment objectives are to eliminate pain, reduce the likelihood of recurrence and prolong the time to recurrence by selectively destroying pain fibers without inducing excessive sensory loss, motor dysfunction, or other complications. Radiofrequency (RF) neurolysis carries the potential risk of neuritis (nerve inflammation). Histological studies have revealed indiscriminate destruction of both small and large fibers following RF treatment.

Pulsed radiofrequency is thought to be a less destructive alternative to standard RF in that it applies RF energy with a pulsed time cycle that delivers short bursts of RF current instead of a continuous RF flow. By pulsing the electrical current, the needle remains relatively cool (up to 42 degrees celsius compared to temperatures of 60-69 degrees celsius with continuous RF) so that the tissue cools slightly between each burst, reducing the risk of destroying nearby tissue and preventing any long-term damage to the nerve. The reasoning behind this is transmission of impulses across small unmyelinated fibers is disrupted while larger fibers remain protected by the myelin sheath."

Certainly there are still potential risks of the pulsed variation (though neuritis is less likely). With tomorrow's procedure, Dr. Schurgin will be blocking the nerve that supplies my multifidus, shown in red on the image to the right. Impairing my multifidus just reinforces the importance of continued rehab for me, so it's all good. The bottom line, benefit exceeds risk.

I am a little nervous for tomorrow, but really just about the result, rather than procedure itself. I just so badly want it to help and am not sure what the next step is, from a pain perspective, if it doesn't work. So I'm trying to stay positive, but also manage my expectations...or as Craig calls it, staying "cautiously optimistic".

Like I've already explained, the goal of pulsed radiofrequency is to help with the pain. It doesn't correct the biomechanical issues going on in my neck, so tomorrow's result won't change my commitment to rehab, which currently consists of manual therapy with Veronika, ARP-wave therapy and DNS with Jeff, Pilates-based PT with Anna, and a recent addition - some deep tissue massage with a therapist named Todd. It's been a while since I've had much massage, so Veronika and I both thought it would be worth a try. Luckily, she communicated with him beforehand and told him exactly what she needed him to work on (which has been a HUGE relief for me to not have to try explaining everything). I saw Todd three times last week and will have two more sessions with him this week before Craig and I head to Tennessee on Saturday. It's basically impossible to pin point any one variable that's helping the most, because it's really the synergy of all, but I have had a few days here and there of "less than normal" pain in the past week or so. Saturday was the best - I got down to a 3/10 and it felt f-ing awesome, let me tell you. For the first time in a long time, I was focused on something other than my headache in my yoga class and finished off the day with a long mountain bike ride with Mark, Mark, and Craig. My pain has worked its way back up between then and now but it was still incredibly encouraging to know that my body is physically capable of less pain.

I'll plan to post again tomorrow or Friday. Fingers crossed!

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