Anesthesia and Analgesia-July-August, 1941
Analgesic Block in the Diagnosis and Treatment
of Low-Back Pain.*
Otto Steinbrocker, M.D., F.I.C.A., New York, N. Y.
Assistant .4tletzding Physician,
Pkysician-in-Charge Arth7i:i.T Clinic, Bellevire Hospital, (4th Dizision)
HE USEFULNESS of local and regional anesthesia has
graduatly been extended from its established place in surgery
to diagnosis and treatment in a variety of conditions, To the
complex problem of backache, anesthetic technique is being
adapted with great effectiveness. Without going into a de-
tailed discussion of the well-known difficulties and considerations in the
.
diagnosis and treatment of backache, I will present the analgesic methods
recently evolved for this syndrome.
Diagnostic Procedures
G HE DIFFERENTIATION of deep local pain from referred (or
reflex j pain can be very helpful in the evaluation of symptoms. We
have done this effectively by field block of a tender skin area. Palpation
and pressure are of no diagnostic value when the overlying skin is tender.
The sore patch of skin is surrounded by a circular intracutaneous wheal,
large enough to permit later pressure and palpation within the circle. With
skin tenderness eliminated in that u7ay it is possible to determine whether
there is any real underlying deep sensitivity. Often no further soreness
is elicited and the deep structures are ruled out as a seat of trouble. The
referred nature of the pain points to a source of trouble remote from the
peripheral site of tenderness.
The localization of the sozwcc of low-back pain by h a 1 injections
may provide much more accurate information than the various functional
tests used in backache, particularly f o r lesions of the erector spinae, gluteal,
lunibosacral, sacroilhc and other low-back structures. “Trigger points”
may he palpated where pressure not only elicits tenderness but map even
initiate the troublesome pain.
According to the method of Steindler,l the center of the area of
soreness is palpated and through a wheal over this point a needle is in-
serted. Often the advancing needle will strike the deep trigger point and
Ihe pain of which the patient complains is duplicated in quality and radia-
tion. This relationship is confirmed by injecting 5 cc. of l per cent pro-
caine solution a t the spot. The pain, and even disability, is abolished for
several hours or longer.
Diagn,ostic jaravertebrab lumbar and sacral nerve block frequently
assist in the evaluation of low-hack symptoms which may prove to be due
to neuralgia from degenerative or inflammatory spinal arthritis.
*Presented during the Nineteenth Annual Congress of Anesthetists, the International Anes-
thesia Research Society and the International College of Anesthetists in Joint hieetinq wit11
the Associated Anesthetists of the [J. S. A. and Canada. Mid-Western Association of Anesthetists
and Chicago Society of Anesthetists Clinical Congress of S u r ~ e o n s Week, Congress Hotel,
Chicago, Ill.. October 21-25, 1940. F;om the Arthritis Clinic, Fo&th Medical I)ivision, R e l l e ~ u e
JIospital, Ik. Charles N. Nanimack, Director.
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Anesthesia a n d Analgesia-July-August, 1941
Pvrif ornzis mzmle block has been advocated recently by Haggart2 and
others as an additional step in sciatic truncal injection. It has heen shown
by Freiberg3 that pathology in and about the pyriformis muscle, which
overlies the sciatic, is apt to cause compression of the ne'rve trunk. For
diagnostic purposes the regular technique of sciatic injection described by
Labat and others is used.
A line is drawn from the greater trochanter of the femur to the pos-
terior superior spine of the ilium. This line is bisected with a perpen-
dicular running caudad. For sciatic block the point of entry is 1% inches
along this, line. A point only 1 inch down this perpendicular is the site
of entry for the pyriformis injections ( F i g . 1) (Kreuz).
Figure 1
The needle is directed inward and downward as for the sciatic. When
bone is struck, 5 cc. of 1 per cent procaine is injected. The needle is
withdrawn ;A to inch and another 10 cc. is inserted. If spasm or
pathology in or adjacent to the muscle is the source of sciatic symptoms,
the latter disappear for the duration of the anesthesia or longer.
'e
,
Therapeutic Injections
OR SOME T I M E anesthetic methods have been used in the treat-
ment of low-back conditions. lnjection of the sciatic nerve, the lum-
bar and sacral nerves and epidural block have a long history of usefulness.
A number of recent innovations in these techniques and the addition of
other methods have extended the indications for analgesic injection.
I-ocal analgesia in low-back pain by repeated injection of 1 per cent
procaine solution, aqueous or oily, has proved a surprisingly effective
measure. particularly in traumatic disturbances. The technique corres-
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Anesthesia a n d Analgesia-July-August, 1941
ponds to that used in diagnosis and is simply repeated at intervals of 1 to
7 days. If radiation is not provoked as the needle traverses the soft tis-
sues, a fanwise injection is made a t the point of maximum tenderness in
the depth of the muscle or over the underlying bone. Several equally sore
and separated areas may have to be treated. From 5 to 30 cc. of aqueous
solution may be injected or 1 to 5 cc. of the oil at any site.
Paravertzbral lambar and sacral n e r w bloch are used successfully for
the treatment of neuralgia. Recognition of the nerve distribution of peri-
pheral pain and tenderness permits blocking of the spinal nerve supply.
Repeated nerve block with procaine solution offers frequent and lasting
effect^.^ Alcohol injection is reserved for unresponsive situations. The
effectiveness of such procedures has been demonstrated recently by Bates
and Judovich5 in the treatment of a large series of patients with first
lumbar neuralgia as the source of backache.
Coccygodynia may be effectively treated by injection of analgesic
solutions into the tender areas, Procaine in aqueous solution is introduced
into the soft tissues at these points over the coccyx in doses of 3 to 10 cc.
Half as muc‘h of the oily solution is used.
Sciatica has been the mbject of more analgesic injection than any
other low-back condition. il variety of methods must be employed, how-
ever, chosen according to the pecularities of the case, to avoid unsatisfac-
tory results. The methods are-local injection of peripheral low-back
lesions (with sciatic radiation), sciatic truncal injection, epidurd injection
and Iumbosacrnl paravertebral ncwe block. For successful therapy it is
irnponrtant to keep in mind the various ways of attack. The method fol-
lowed depends on the nature of the sciatica. The indications f o r each
procedure follow :
Local injection for sci,itica corresponds essentially in location and
technique to what has already been said for local injections of the low-
back. Referred sciatic pain will often respond to such simple measures.
Sciatic trunk (perineural or intraneural) injection with procaine solu-
tion and saline has been carried out for many years. It is effective when
sciatica is due to involvement of the nerve trunk peripherally, below the
sciatic foramen, so-called “low” sciatica. The pyriformis is frequently
involved in these conaitions. Pyriformis block (Fig. 1) should, therefore,
form part of routine sciatic truncal injection.
Caudal injection is used when the above methods fail. If the sciatic
involvement is suspected of arising above the sciatic foramen or at the
nerve roots, so-called “high” sciatica, this procedure should be carried out.
Parawertzbral liinibnr w d sacral nerve black are employed for the
same indications, when the epidural method fails or when the latter tech-
nique cannot be used because of structural anomalies. Complete sciatic
block requires injection of L 4,5 , and S 1, 2. Not infrequently injection
of only S 1 and 2 suffices.
Lumbar sympathetic block is done for postherpetic neuralgia and
phantom pains.
Details of analgesic mdhods, indications and contraindications and
precautions4 are omitted here.
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Anesthesia and Analgesia-July-August, 1941
Results
0 UR R E S U L T S with these analgesic procedures have varied with the
type of case and the technique. Table 1 shows the different thera-
peutic methods used and the outcome. The patients require thorough study
and observation. The appropriate technique must be chosen.
TABLE I
Low Back Pain
Results of Analcesic Injections in Potients 1inresponsii.e to Mrdical
and Physical Tlzerapy
Moderate to Coniplete
Improvement Siignt to No Irnprovrmcnt
Local
(Low-Back) 16 s
Sciatic Nerve
(Perineural) I2 9
Epidural 5 G
Paravertebral
(Lumbar and Sacral) 19 4
(Groups too small for percentages)
Analgesic injections are not to be regarded as a cure-all, nor as the
treatment of choice for every backache. Thorough physical examinatiorl
to rule out visceral disease and to establish at least a tentative diagnosis
is an inflexible rule. When simple, accepted medical, physical and postural
measures fail to provide satisfactory relief, local and regional analgesic
injections have proved an effective adjunct in our hands in the majority
of patients with intractable low back pain.
35 E . ~ S T NINTH ST.
Bibliography
1. Steindler, A . : Interpretation of Sciatic Reaction and Syndrome of Low Back Pain.
1. B. and J . S., 2 2 3 8 , 1940.
1. Haggai-t, G. E.: Sciatic Pain of Unknown Origin. 1. B. a%d 1 S., 20:851, 1938.
.
3. Fretberg, A. H.: Sciatic Pain aild I t s lklief l>>-Operations on Muscle and Fascia.
ArLh. of Slsvg., 34:337, 1937.
4. Steinbrocker, 0.: Local Injections and I
Intractable Pain in Chronic Arthritis and Related Conditions. Ann. Int. W e d . , 12:1917,
1939.
5. Judovich, B. D. and Bates. W.: Low Back l’ain. Indub. Mcd., 8:150, 1939.
Therapy of Pain After Tonsillectomy by Vitamins B, and C. M. Baer.
Oto-Rino-Lariizgologirl Italianu, 10 :65 (January) 1940.
B AER OBSERVED a considerable number of cases of tonsillitis,
during the past year, in which tonsillectomy was performed under
local anesthesia. H e states that inflammation of the tonsils is frequently
associated with vitamin B, and C hypovitaminosis and with actua! or
latent rheumatism. H e believes that local pain during the first twenty-
four hours after tonsillectomy is due ta the wound itself and to exposure
of the nerve ends in the wound, whereas that which is present on the
second day is due to Bi and C hypovitaminosis, either alone or in asso-
ciation with rheumatism. The treatment of early local pain consists of
administration of analgesics. The author was able to demonstrate a
prompt favorable action with vitamins B, and C in fifty patients in his
group who were suffering from local pain late in the postoperative period.
H e used two preparations, precise doses of which are not specified. I n
all cases the treatment caused rapid regression of local pain, improvement
of the general condition and acceleration of the local process of healing.
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