CT Guided Costovertebral Nerve Ablations

[mmglobal]

Dear Friends,

After more than 10 years of continuous posting in the internet patient communities, I have something new to write about. Sadly, I get to have first hand experience with a extremely rare diagnosis. The full story follows, so get comfortable, get a cup of coffee or whatever.

After my very successful lumbar ADR surgery in 2002 and cervical ADR surgery in 2009, my T-spine decided that I should not feel that good. In September of 2009 my mid-back and chest pain rose to a new level and I have been severely impaired ever since. I'm back up to greater than 60mg per day of oxycodone and hydrocodone, NSAIDs, PPIs, etc...the whole 9 yards as a chronic pain patient. Unless I take much higher doses of pain killers, only able to function well for a few hours a day.

I love my pain management doctor and can't thank him enough for his kindness and support through this process. Unfortunately, he does not have the same tools at his disposal that I do. The treatment plan in the US was large panels of facet injections. I had moderately positive results that should have led to large panels of rhizotomies (nerve ablations). I am averse to destroying tissue without being certain so I did not want to follow through with these ablations. I had them scheduled for January 2010, but now I am really glad I canceled. When I asked, “How is it possible that I have positive facet injections but my facets look so good on MRI?” the reply was shrugged shoulders and, “We don't know. Sometimes it just happens that way”.

Fortunately, last March I was able to come see the BetaKlinik where Dr. Zeegers now performs surgeries in Bonn, Germany. When I asked that same question of Dr. Juergan Reul (the exceptional neuroradiologist who owns the BetaKlinik) his answer was “perhaps the injectant is running from the facet joints into the costovertebral joints, giving you a false positive”. Back in the US I started having panels of diagnostic costovertebral injections (my doctor's first) that yielded the same moderate positive that the facet injections gave. Fortunately I returned to Bonn with a client almost 2 months ago (December 2010) and was able to have CT guided costovertebral joint injections with Dr. Reul and Dr. Axel Jung, who has made this diagnosis and done these injections dozens of times. Not only were these injections extremely positive in removing my mid-back pain, but I also had the benefit of the provocative value of the injections. One of the joints generated 10/10 concordant pain, just like discography “That's it! That's my pain, exactly where I feel my pain”.

Dr. Reul recommended not doing the ablations immediately because the injections were so positive I may get long-term therapeutic value from them. He recommended follow up injections. While I experienced great relief from the injections I was still traveling, wrestling bags on and off train platforms, etc. By the time I got home I wished I had done the ablations.

I set about trying to get CT guided injections per Dr. Reuls recommendations. As I said my pain management doctor is very supportive. He found a place to do them, wrote the prescription, beat up the insurance company, etc. I was getting close to doing them in the US when another opportunity to come here (Bonn) presented itself. After a year and a half of constant disability I decided that long term relief from the injections was very unlikely. I preferred to complete the diagnosis and perform the ablations if indicated.

I arrived with my daughter yesterday and checked into the Kameha Grand. (right next door to the BetaKlinik) We arrived in the clinic at 10:30 this morning and were sitting with Dr. Reul 20 minutes later. After a short discussion I was back on the CT machine for more injections. Instead of doing a panel of injections as we had done before, we were injecting only the one joint that I had perceived as being the most painful. He injected T 8/9 right and left sides. The right side generated pressure but little pain. The injection on the left side was very painful. I was very disappointed that it was not the same 10/10 concordant pain that I had experienced before, but this was still a very positive, provocative injection. Dr. Reul said I should get up and go do whatever I wanted and come back in a half an hour and tell him how I felt. It was clear that the injection was positive, but still not as good as after having the panel of 8 injections last time.

For the second injection I asked that we only do the left side since my pain has always been left sided and the provocative injections were both left sided. I didn't want the accumulated anesthetic value of many injections. I wanted to do as little as possible. T 7/8 left was also very painful and also provided relief. Lauren and I sat for another half hour. I could feel the band of numbness that I fear from the ablations wrapping around from my back to my chest. I understand there is a 70% chance of getting this numbness from the ablation, and a 30% chance that it is permanent. So coming back in half an hour I have positive injections at T 7/8 left and T 8/9 left. Dr. Reul wanted to do T 9/10 just to be safe. The injection yielded pressure but no concordant pain. Dr. Reul then wanted to go above the successful levels and rule out T 6/7. Like the last injection, T 6/7 yielded pressure but no significant pain.

We were both comfortable that we had duplicated the results of the injections and identified two painful joints that are most likely the culprits. Dr. Reul asked if we should just do the ablation while we are here, and I said yes. Everything up to that point was done without any anesthetic for the needle placement. Since the needles that accommodate the laser are much larger he used a local aesthetic. Just a few minutes and it was done. They asked me to lay down for 30 minutes before we left.

Between 11am and 2:30 I had 3 separate sessions on the CT that included 5 costovertebral joint injections and laser ablations of 2 levels. A few minutes after 3, Lauren and I left the clinic and went to rohmule and had a wonderful lunch. I was still feeling so well after lunch that we had 2 rounds of cappuccinos and a chocolate souffle. We returned to the hotel to rest and make plans for the evening. I feel good enough to go out but decided that discretion is the better part of valor. I will rest tonight and continue sightseeing tomorrow. I had some more numbness which is likely due to the local anesthetic. It is now 9pm, and the numbness is pretty much gone.

From minutes after the second injection until now I feel much better than before. I have no idea how this is going to unfold over the next days, weeks, months, years. Dr. Reul says that with the more accurate needle placement and targeting of energy that the CT guidance and laser provides, these ablations last longer than the typical rhizotomies. He says that I may have to get them redone in 2-3 years but there is a good chance they will be permanent.

Interestingly, none of the spine surgeons I have spoken to about this (and that's a lot) has EVER made this diagnosis. Dr. Reuls's patient following me was a man who'd had these ablations years ago with great success. He's about to leave to climb Kilimanjaro and wanted to have injections just in case.

I'll keep you posted regarding my progress. I have no illusion that these joints are my only pain generators. With any luck they are the main pain generators, and my life will improve substantially.

Thanks for your support. All the best,
Mark

[Keano16]

Very nice story. Its so great to read that BetaKlinik staff is so aware of things that others don't even look at.

Good luck, I hope you are fine - and fingers crossed for longer effect!

[dshobbies]

So much is going through my mind right now and too much of it is anger. Why... should anyone have to travel to receive excellent medical care? Why must the poor suffer while the rich can travel wherever they please? Why does it take countless doctors to tell you stories or honestly say they don't know when the knowledge base it out there for those who wish to avail themselves.

I could go on but... I really hope this does it for you. Suffering sucks, no more need be said. My fingers are crossed.

Dale

[sahuaro]

Ditto to dshobbies' post...
But how wonderful that you were able to pinpoint the diagnosis and get relief.
Wishing you continued success and looking forward to your updates.

[jsewell]

Mark we spoke about a year ago i think after my unpleasant experience here with drRegan

As for you , the best of luck with this treatment. I hope it is all positive from here.
judy

[JeffreyD]

Mark,
Great report. I truly hope you receive long lasting relief.

Dr. Reul is one gifted doc, isn't he? Sincere and caring, as well.

Blessings,
Jeff

[Hooch]

Thanks for posting this Mark, no doubt it will be useful to others suffering thoracic pain.

I suppose it is similar to facet degeneration, in that the degeneration of your thoracic discs has loaded up your costovertebral joints, for whatever reason, more than your facets?

Here's hoping this improves your condition markedly.

[mmglobal]

The people who know me well know that when I'm not posting it's because I'm struggling with the pain. I'm happy to report that for the past few days, it's because the limited capacity I have has been spent on enjoying traveling and sightseeing with my youngest, Lauren.

Here is my catching up on the post-ablation reporting:

Tuesday, late morning spent on diagnostic injections. I had the ablations in the early afternoon (2:30).

I felt much better for the rest of the day. I'm surprised that I stayed down for the evening... almost decided to go see Cologne or Bonn, but thought better of it. I must be getting old (or smarter.) About 10pm, the local wore off and, as Dr. Reul suggested may be a possibility. I felt like I’d been kicked by a horse at the injection/ablation site.

Wednesday and Thursday morning were like every other morning on this trip (but just a bit worse.) I woke up with a pain level > 7 looking for my meds. On Wednesday, I decided to lay low again and just went for a brief meeting with Dr. Reul and a PT session with the AMAZING Gabriella. (I’ll write about her in a separate post.)

We had planned to take the train from Bonn to Maastricth to spend some time with Dr. Zeegers on Wednesday afternoon. On my December trip, the injections were very, very successful, but all the travel and wrestling the bags on and off the trains and through the airports really set me back. I didn’t want to make the same mistake, so I rented a car for 1 day. We’d spend Wednesday night in Maastricht and drive to Amsterdam Thursday morning. The international drop-off for the car was expensive, but the ease of travel in the car instead of on the trains made it well worth it.

I was still on the scarf hunt for Zoey. I had bought her a pink fleece scarf with a stuffed giraffe at the Christmas market in Aachen (on the way to Maastricht) during my December trip. When I told Zoey I was returning to Germany, she asked if I could get her a blue scarf with a Zebra. (Believe it or not, I’ve probably stopped in dozens of shops and stands, playing charades with the shopkeepers, but I think we’ll be disappointing her.) Lauren and I stopped there and walked many miles in Aachen. We got lost and accidentally went back to the same place 4 times… uphill both ways!

We had a wonderful evening and morning with Dr. Zeegers and drove to Amsterdam yesterday morning (Thursday). Our B&B here is great. We were greeted with a “welcome to Amsterdam” drink and a long discussion of all the sights and best places to go. They had prepared maps with highlights, circles and arrows (and a paragraph on the back of each picture, for those of you who remember Alice’s Restaurant.) It’s kind of like Berkeley or Height Ashbury here. It seems like a hippie community, but the canals and beautiful old buildings are wonderful to see. I had to “med up” for the sightseeing here, but we went out and saw the Anne Frank house yesterday, then walked for miles and miles again. The presentation at the Anne Frank house is very moving and well done.

After the work I had to do, I could no longer type at all and had to turn off and stash the computer before I could post an update. However, this morning was so much better than all the others on this trip. (now 2 weeks old) I woke up wondering where the pain was. I did not reach for my meds until I’d been up a while. The breakfast here is very pleasant and we are about to go out for the day. There is so much to see here in Amsterdam, we are very excited about having 2 full days here.

I don’t want anyone to think I’ve found the miracle cure here. After being up a while and typing on my computer, the pain is coming back… just at lower levels. I do expect to have a very active day today. I believe that I’ll be able to do it with less meds than yesterday. I’ll try to keep the updates coming as long as the situation is unfolding.

Take care… all the best,

Mark

[ADR seeker]

Originally Posted by mmglobal

Dear Friends,

After more than 10 years of continuous posting in the internet patient communities, I have something new to write about. Sadly, I get to have first hand experience with a extremely rare diagnosis. The full story follows, so get comfortable, get a cup of coffee or whatever.

After my very successful lumbar ADR surgery in 2002 and cervical ADR surgery in 2009, my T-spine decided that I should not feel that good. In September of 2009 my mid-back and chest pain rose to a new level and I have been severely impaired ever since. I'm back up to greater than 60mg per day of oxycodone and hydrocodone, NSAIDs, PPIs, etc...the whole 9 yards as a chronic pain patient. Unless I take much higher doses of pain killers, only able to function well for a few hours a day.

I love my pain management doctor and can't thank him enough for his kindness and support through this process. Unfortunately, he does not have the same tools at his disposal that I do. The treatment plan in the US was large panels of facet injections. I had moderately positive results that should have led to large panels of rhizotomies (nerve ablations). I am averse to destroying tissue without being certain so I did not want to follow through with these ablations. I had them scheduled for January 2010, but now I am really glad I canceled. When I asked, “How is it possible that I have positive facet injections but my facets look so good on MRI?” the reply was shrugged shoulders and, “We don't know. Sometimes it just happens that way”.

Fortunately, last March I was able to come see the BetaKlinik where Dr. Zeegers now performs surgeries in Bonn, Germany. When I asked that same question of Dr. Juergan Reul (the exceptional neuroradiologist who owns the BetaKlinik) his answer was “perhaps the injectant is running from the facet joints into the costovertebral joints, giving you a false positive”. Back in the US I started having panels of diagnostic costovertebral injections (my doctor's first) that yielded the same moderate positive that the facet injections gave. Fortunately I returned to Bonn with a client almost 2 months ago (December 2010) and was able to have CT guided costovertebral joint injections with Dr. Reul and Dr. Axel Jung, who has made this diagnosis and done these injections dozens of times. Not only were these injections extremely positive in removing my mid-back pain, but I also had the benefit of the provocative value of the injections. One of the joints generated 10/10 concordant pain, just like discography “That's it! That's my pain, exactly where I feel my pain”.

Dr. Reul recommended not doing the ablations immediately because the injections were so positive I may get long-term therapeutic value from them. He recommended follow up injections. While I experienced great relief from the injections I was still traveling, wrestling bags on and off train platforms, etc. By the time I got home I wished I had done the ablations.

I set about trying to get CT guided injections per Dr. Reuls recommendations. As I said my pain management doctor is very supportive. He found a place to do them, wrote the prescription, beat up the insurance company, etc. I was getting close to doing them in the US when another opportunity to come here (Bonn) presented itself. After a year and a half of constant disability I decided that long term relief from the injections was very unlikely. I preferred to complete the diagnosis and perform the ablations if indicated.

I arrived with my daughter yesterday and checked into the Kameha Grand. (right next door to the BetaKlinik) We arrived in the clinic at 10:30 this morning and were sitting with Dr. Reul 20 minutes later. After a short discussion I was back on the CT machine for more injections. Instead of doing a panel of injections as we had done before, we were injecting only the one joint that I had perceived as being the most painful. He injected T 8/9 right and left sides. The right side generated pressure but little pain. The injection on the left side was very painful. I was very disappointed that it was not the same 10/10 concordant pain that I had experienced before, but this was still a very positive, provocative injection. Dr. Reul said I should get up and go do whatever I wanted and come back in a half an hour and tell him how I felt. It was clear that the injection was positive, but still not as good as after having the panel of 8 injections last time.

For the second injection I asked that we only do the left side since my pain has always been left sided and the provocative injections were both left sided. I didn't want the accumulated anesthetic value of many injections. I wanted to do as little as possible. T 7/8 left was also very painful and also provided relief. Lauren and I sat for another half hour. I could feel the band of numbness that I fear from the ablations wrapping around from my back to my chest. I understand there is a 70% chance of getting this numbness from the ablation, and a 30% chance that it is permanent. So coming back in half an hour I have positive injections at T 7/8 left and T 8/9 left. Dr. Reul wanted to do T 9/10 just to be safe. The injection yielded pressure but no concordant pain. Dr. Reul then wanted to go above the successful levels and rule out T 6/7. Like the last injection, T 6/7 yielded pressure but no significant pain.

We were both comfortable that we had duplicated the results of the injections and identified two painful joints that are most likely the culprits. Dr. Reul asked if we should just do the ablation while we are here, and I said yes. Everything up to that point was done without any anesthetic for the needle placement. Since the needles that accommodate the laser are much larger he used a local aesthetic. Just a few minutes and it was done. They asked me to lay down for 30 minutes before we left.

Between 11am and 2:30 I had 3 separate sessions on the CT that included 5 costovertebral joint injections and laser ablations of 2 levels. A few minutes after 3, Lauren and I left the clinic and went to rohmule and had a wonderful lunch. I was still feeling so well after lunch that we had 2 rounds of cappuccinos and a chocolate souffle. We returned to the hotel to rest and make plans for the evening. I feel good enough to go out but decided that discretion is the better part of valor. I will rest tonight and continue sightseeing tomorrow. I had some more numbness which is likely due to the local anesthetic. It is now 9pm, and the numbness is pretty much gone.

From minutes after the second injection until now I feel much better than before. I have no idea how this is going to unfold over the next days, weeks, months, years. Dr. Reul says that with the more accurate needle placement and targeting of energy that the CT guidance and laser provides, these ablations last longer than the typical rhizotomies. He says that I may have to get them redone in 2-3 years but there is a good chance they will be permanent.

Interestingly, none of the spine surgeons I have spoken to about this (and that's a lot) has EVER made this diagnosis. Dr. Reuls's patient following me was a man who'd had these ablations years ago with great success. He's about to leave to climb Kilimanjaro and wanted to have injections just in case.

I'll keep you posted regarding my progress. I have no illusion that these joints are my only pain generators. With any luck they are the main pain generators, and my life will improve substantially.

Thanks for your support. All the best,
Mark

Here is what I suspect.

The ADRs you have over rotate and I think you need the MRI done standing up.

Also, see an atlas orthogonal chiropractor. The MDs sound like they don't have a clue.

MDs also like to deny the effect subluxations in the spine can have on pain and they deny that spinal orthoganality effect the function of the spine.

YouTube - Upper Cervical - Montel Williams

This may fix you!

[naki]

Originally Posted by mmglobal

Dear Friends,

After more than 10 years of continuous posting in the internet patient communities, I have something new to write about. Sadly, I get to have first hand experience with a extremely rare diagnosis. The full story follows, so get comfortable, get a cup of coffee or whatever.

After my very successful lumbar ADR surgery in 2002 and cervical ADR surgery in 2009, my T-spine decided that I should not feel that good. In September of 2009 my mid-back and chest pain rose to a new level and I have been severely impaired ever since. I'm back up to greater than 60mg per day of oxycodone and hydrocodone, NSAIDs, PPIs, etc...the whole 9 yards as a chronic pain patient. Unless I take much higher doses of pain killers, only able to function well for a few hours a day.

I love my pain management doctor and can't thank him enough for his kindness and support through this process. Unfortunately, he does not have the same tools at his disposal that I do. The treatment plan in the US was large panels of facet injections. I had moderately positive results that should have led to large panels of rhizotomies (nerve ablations). I am averse to destroying tissue without being certain so I did not want to follow through with these ablations. I had them scheduled for January 2010, but now I am really glad I canceled. When I asked, “How is it possible that I have positive facet injections but my facets look so good on MRI?” the reply was shrugged shoulders and, “We don't know. Sometimes it just happens that way”.

Fortunately, last March I was able to come see the BetaKlinik where Dr. Zeegers now performs surgeries in Bonn, Germany. When I asked that same question of Dr. Juergan Reul (the exceptional neuroradiologist who owns the BetaKlinik) his answer was “perhaps the injectant is running from the facet joints into the costovertebral joints, giving you a false positive”. Back in the US I started having panels of diagnostic costovertebral injections (my doctor's first) that yielded the same moderate positive that the facet injections gave. Fortunately I returned to Bonn with a client almost 2 months ago (December 2010) and was able to have CT guided costovertebral joint injections with Dr. Reul and Dr. Axel Jung, who has made this diagnosis and done these injections dozens of times. Not only were these injections extremely positive in removing my mid-back pain, but I also had the benefit of the provocative value of the injections. One of the joints generated 10/10 concordant pain, just like discography “That's it! That's my pain, exactly where I feel my pain”.

Dr. Reul recommended not doing the ablations immediately because the injections were so positive I may get long-term therapeutic value from them. He recommended follow up injections. While I experienced great relief from the injections I was still traveling, wrestling bags on and off train platforms, etc. By the time I got home I wished I had done the ablations.

I set about trying to get CT guided injections per Dr. Reuls recommendations. As I said my pain management doctor is very supportive. He found a place to do them, wrote the prescription, beat up the insurance company, etc. I was getting close to doing them in the US when another opportunity to come here (Bonn) presented itself. After a year and a half of constant disability I decided that long term relief from the injections was very unlikely. I preferred to complete the diagnosis and perform the ablations if indicated.

I arrived with my daughter yesterday and checked into the Kameha Grand. (right next door to the BetaKlinik) We arrived in the clinic at 10:30 this morning and were sitting with Dr. Reul 20 minutes later. After a short discussion I was back on the CT machine for more injections. Instead of doing a panel of injections as we had done before, we were injecting only the one joint that I had perceived as being the most painful. He injected T 8/9 right and left sides. The right side generated pressure but little pain. The injection on the left side was very painful. I was very disappointed that it was not the same 10/10 concordant pain that I had experienced before, but this was still a very positive, provocative injection. Dr. Reul said I should get up and go do whatever I wanted and come back in a half an hour and tell him how I felt. It was clear that the injection was positive, but still not as good as after having the panel of 8 injections last time.

For the second injection I asked that we only do the left side since my pain has always been left sided and the provocative injections were both left sided. I didn't want the accumulated anesthetic value of many injections. I wanted to do as little as possible. T 7/8 left was also very painful and also provided relief. Lauren and I sat for another half hour. I could feel the band of numbness that I fear from the ablations wrapping around from my back to my chest. I understand there is a 70% chance of getting this numbness from the ablation, and a 30% chance that it is permanent. So coming back in half an hour I have positive injections at T 7/8 left and T 8/9 left. Dr. Reul wanted to do T 9/10 just to be safe. The injection yielded pressure but no concordant pain. Dr. Reul then wanted to go above the successful levels and rule out T 6/7. Like the last injection, T 6/7 yielded pressure but no significant pain.

We were both comfortable that we had duplicated the results of the injections and identified two painful joints that are most likely the culprits. Dr. Reul asked if we should just do the ablation while we are here, and I said yes. Everything up to that point was done without any anesthetic for the needle placement. Since the needles that accommodate the laser are much larger he used a local aesthetic. Just a few minutes and it was done. They asked me to lay down for 30 minutes before we left.

Between 11am and 2:30 I had 3 separate sessions on the CT that included 5 costovertebral joint injections and laser ablations of 2 levels. A few minutes after 3, Lauren and I left the clinic and went to rohmule and had a wonderful lunch. I was still feeling so well after lunch that we had 2 rounds of cappuccinos and a chocolate souffle. We returned to the hotel to rest and make plans for the evening. I feel good enough to go out but decided that discretion is the better part of valor. I will rest tonight and continue sightseeing tomorrow. I had some more numbness which is likely due to the local anesthetic. It is now 9pm, and the numbness is pretty much gone.

From minutes after the second injection until now I feel much better than before. I have no idea how this is going to unfold over the next days, weeks, months, years. Dr. Reul says that with the more accurate needle placement and targeting of energy that the CT guidance and laser provides, these ablations last longer than the typical rhizotomies. He says that I may have to get them redone in 2-3 years but there is a good chance they will be permanent.

Interestingly, none of the spine surgeons I have spoken to about this (and that's a lot) has EVER made this diagnosis. Dr. Reuls's patient following me was a man who'd had these ablations years ago with great success. He's about to leave to climb Kilimanjaro and wanted to have injections just in case.

I'll keep you posted regarding my progress. I have no illusion that these joints are my only pain generators. With any luck they are the main pain generators, and my life will improve substantially.

Thanks for your support. All the best,
Mark

After very good reviews, in 2010 I flew to Beta Klinik where I had my ADR done by Dr. Jung, but I have to report that I am still in pain and sometimes, it is even worse! I have thought about pain injections, but after reading your post, I am very skeptical. I also have the option of going under the knife again, this time, a fusion! Something that I had gladly taken out of the options when I went for ADR. Fusion? injection? talk of confusion! But one definite thing ofcourse is I am stuck with the depleted line of credit and still stuck with back pain!!!!Watch out, ADR is not for everybody!!!Not even the best doctors will tell you so!