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How to use paraspinous cervical injections for headaches and orofacial pain

“Who in their right mind would take an inch and a half needle, fill it with some bupivacaine, and stab somebody in the back of the neck to get rid of their headache?”

This quote, by EM:RAP contributor Dr. Al Sacchetti, refers to himself and a technique he has adopted from Dr. Larry Mellick. Dr. Mellick is a professor of emergency medicine at the Medical College of Georgia and the current chairman of the Pediatric Emergency Medicine section of ACEP. During an interview that aired on EM:RAP last August, Dr. Mellick describes an approach to pain management for headaches and painful orofacial conditions that will blow your mind.

To be fair, it’s really not that new. Larry’s twin brother, a neurologist and pain specialist, came up with the technique back in 1996. After six skeptical years, Dr. Mellick finally caved in and tried it on his first patient in 2002. He’s been using it ever since to treat everything from migraines to corneal abrasions. Dr. Mellick spent one day each month for a year performing these injections at an orofacial dental pain clinic where he witnessed miracle-grade pain relief. He has published several articles on the topic including a retrospective review of 417 headache patients, 65% of which experienced complete pain relief, 20% had partial relief, 14% were left unchanged, and in 1% the pain got worse. Overall, a therapeutic response occurred in 85% of patients and the majority occurred within 5-10 minutes.

Practical Tips from Dr. Mellick

1) There is no need to fan; it works the same if you dump it all into one spot.
2) Aim up to avoid the dome of the lung. Dr. Sacchetti added that he looked at a CT scan of the neck to check what dangerous structures we could be poking. It turns out there’s really nothing there except a big muscle belly and the highest value target you’ll hit is a transverse process or a small vessel.
3) Don’t forget to aspirate. Dr. Mellick once had a patient complain of light-headedness during the injection. When he pulled back on the syringe he realized he was injecting directly into an artery.

Many of you are probably thinking what we were thinking when we first heard about this technique: “You must be joking.” We’re sold on nerve blocks, trigger point injections, and local injections for occipital and trigeminal neuralgia; but this seems to be taking the placebo effect a little too far. How could a lower cervical IM injection possibly have any impact on complex headache and orofacial pain pathways? Nobody knows for sure, but the brothers Mellick are convinced the peripheral cervical input is interrupting a central sensitization circuit involving the trigeminal caudate nucleus in the brainstem. Perhaps it’s like adenosine for SVT or cardioversion for atrial flutter.  

Does it work for everyone? No. Does it last forever? No. But ask yourself the same questions about the various drugs that we throw at these people. Before you know it you might have patients backing in the door holding their hair off their neck instead of asking for “the one that starts with a D…”

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References
1. Mellick et al. Treatment of headaches in the ED with lower cervical intramuscular bupivacaine injections; a 1-year retrospective review of 417 patients. Headache. 2006 Oct;46(9):1441-9.

Dr. McCormick is a fourth year emergency medicine resident at Los Angeles County + University of Southern California Medical Center.

Dr. Swadron is an Associate Professor of Clinical Emergency Medicine at the Keck School of Medicine of the University of Southern California. EM:RAP is a monthly educational audio program that can be found at EMRAP.org.
 



 

Comments   

# uh-uh ! alberto pedrinha 2013-06-10 11:02
This is quite interesting.

I'd really love to see a randomized controlled study with techinique as shown vs placebo injection vs subcutaneous bupivacaine ± vs subcutaneous placebo. PLacebo could be hypotonic saline, not saline, well something that hurts a bit.
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# alberto pedrinha 2013-06-13 01:06
By the way, there are 2 faults regarding asepsy that appeared in the video. One by the assistant, who touches the injection area with non sterile hands, and one more questionable of the operator not disinfecting the rubber stopper after removing the anesthetic bottle's metal capsule. We have the same situation with blood cultue bottles and guideines say the plastic /ribber stopper under the capsule should be wiped with iod/alcool solution, if I'm not mistaken.
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# 90% success rateAdan Atriham 2013-07-29 23:28
I started using this injection technique for the lasts 3 months and I've had about 90% success rate treating headaches, from classic migraine to hemicrania continua. I've also tried it in a lady with TMJ sd, but didn't work so well in that case, this pt required rescue medication. However, I will continue using it as first line if pt allow me to "stab" them in the neck and comment more about it later. Thanks Dr Mellick !
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