From the Guidelines
For a patient with a chronic T9 fracture and non-radicular back pain extending from T9 to L3, medial branch blocks would likely be more helpful than epidural injections. Medial branch blocks target the specific facet joints that are often the source of mechanical back pain following vertebral fractures, especially when the pain is non-radicular in nature 1. The procedure involves injecting local anesthetic around the medial branches of the dorsal rami that innervate the painful facet joints, which in this case would include levels from approximately T7-L5 to cover the symptomatic region. If diagnostic blocks provide significant relief, radiofrequency ablation of these same nerves might provide longer-term pain control (6-12 months) 1.
Key Considerations
- The patient's non-radicular back pain suggests that the pain is mechanical in nature, rather than caused by nerve root compression or inflammation.
- Medial branch blocks are recommended to diagnose pain of facet joint origin, followed by radiofrequency denervation when appropriate in the context of multidisciplinary care 1.
- Epidural injections, while useful for radicular pain, are less effective for localized mechanical pain stemming from facet joint arthropathy that commonly develops after vertebral fractures.
- The facet joints often become stressed and painful due to altered biomechanics following a vertebral fracture, making them a primary pain generator in chronic post-fracture back pain without radicular symptoms.
Treatment Approach
- Medial branch blocks can be used to target the specific facet joints that are causing the patient's pain.
- If the blocks provide significant relief, radiofrequency ablation can be used to provide longer-term pain control.
- A multidisciplinary approach to care, including physical therapy and other interventions, may also be beneficial in managing the patient's pain and improving their quality of life 1.
From the Research
Treatment Options for Chronic T9 Fracture and Back Pain
The patient's condition involves a chronic T9 fracture and non-radicular back pain extending from T9 to L3. Considering the available evidence, the following treatment options can be explored:
- Medial Branch Block: Studies have shown that medial branch blocks can be effective in managing chronic thoracic facet joint pain. A randomized, double-blind controlled trial 2 found that therapeutic local anesthetic medial branch blocks with or without steroid can provide significant pain relief and functional improvement in patients with chronic thoracic facet joint pain. Another study 3 reported fair evidence for therapeutic thoracic facet joint nerve blocks, including medial branch blocks.
- Epidural: There is limited evidence to support the use of epidural injections for chronic thoracic facet joint pain. However, epidural injections may be considered for patients with radicular pain or other conditions that are not specifically addressed in the provided evidence.
Comparison of Treatment Options
When comparing medial branch blocks and epidural injections, the available evidence suggests that medial branch blocks may be a more effective treatment option for chronic thoracic facet joint pain. A study 2 found that medial branch blocks provided significant pain relief and functional improvement in 79-83% of patients, whereas there is limited evidence to support the use of epidural injections for this specific condition.
Additional Considerations
It is essential to note that the patient's underlying condition, including the chronic T9 fracture and non-radicular back pain, should be thoroughly evaluated and addressed. Other treatment options, such as physical therapy, lifestyle modification, and medication management, may also be considered as part of a comprehensive treatment plan. In some cases, more advanced interventions, such as vertebroplasty 4, may be necessary to stabilize the fracture and alleviate pain.