Is Bilateral spinal accessory nerve branch block injection medically indicated for a patient with a diagnosis of chronic pain or limited mobility in the shoulder or neck region?

Bilateral Spinal Accessory Nerve Branch Block Injection is NOT Medically Indicated

This procedure is not medically indicated for chronic pain or limited mobility in the shoulder or neck region, as there is no evidence supporting spinal accessory nerve blocks for these conditions, and current guidelines recommend against peripheral nerve blocks for chronic pain management outside of comprehensive pain programs. 1

Critical Evidence Against This Procedure

Lack of Evidence for Spinal Accessory Nerve Blocks

• No guideline or research evidence supports spinal accessory nerve blocks for shoulder or neck pain. The spinal accessory nerve (cranial nerve XI) primarily innervates the trapezius and sternocleidomastoid muscles and is not a recognized target for chronic pain management in clinical guidelines. 2, 1

• The American Society of Anesthesiologists explicitly states that peripheral nerve blocks have insufficient evidence for chronic pain treatment and should only be used as part of an active component of a comprehensive pain management program, not as standalone interventions. 1

Guidelines Recommend Against Similar Interventions

• The 2025 BMJ guideline on interventional procedures for chronic spine pain issued strong recommendations AGAINST intramuscular injections of local anesthetic with or without steroids for chronic axial spine pain. 2

• Trigger point injections for chronic pain lack evidence for long-term benefit, with the American Society of Anesthesiologists recommending against their use for chronic low back pain without radiculopathy. 1

• The American Society of Anesthesiologists notes that peripheral somatic nerve blocks should not be used for long-term treatment of chronic pain, as they may provide only short-term relief without evidence for sustained benefit. 1

What Should Be Done Instead

Conservative Management Requirements

• At least 6 weeks of conservative treatment must be attempted before considering any interventional procedures for chronic musculoskeletal pain. 3, 4

• Conservative approaches should include physical therapy, exercise programs, and appropriate pharmacologic management before escalating to invasive procedures. 2

Proper Diagnostic Workup

• Comprehensive evaluation is required to identify the actual pain generator before any interventional procedure. This includes detailed history, physical examination, and appropriate imaging studies. 3

• For neck and shoulder pain, consider alternative diagnoses such as:

  • Cervical facet arthropathy (requires double-injection diagnostic blocks with ≥80% pain relief threshold for confirmation) 3, 4
  • Cervical radiculopathy (may benefit from selective nerve root blocks or epidural injections if conservative management fails) 5, 6
  • Myofascial pain syndrome (requires comprehensive pain management program, not isolated injections) 1

Evidence-Based Alternatives

• If facet-mediated pain is suspected, diagnostic medial branch blocks using the double-injection technique with ≥80% pain relief threshold should be performed, followed by radiofrequency ablation if positive. 3, 4

• For confirmed radicular symptoms, selective nerve root injections under fluoroscopic guidance have diagnostic and therapeutic value, with positive predictive values of 87-100% for surgical planning. 7, 6

• Comprehensive pain management programs that include physical therapy, behavioral interventions, and multimodal pharmacologic approaches are the appropriate first-line treatment for chronic neck and shoulder pain. 1

Common Pitfalls to Avoid

• Do not proceed with interventional procedures based solely on patient symptoms without adequate conservative management and proper diagnostic confirmation. 3, 4

• Avoid performing nerve blocks that lack evidence-based support, even if they seem anatomically logical, as this exposes patients to procedural risks without proven benefit. 2, 1

• Do not confuse diagnostic utility with therapeutic benefit - even procedures with diagnostic value may not provide long-term therapeutic relief. 3, 4

• Bilateral procedures carry increased risks including higher doses of local anesthetic with potential for systemic toxicity, and should only be performed when absolutely necessary with strong evidence of benefit. 8, 9