so Britney's a patient who suffers from chronic neck pain and headaches the pain is going down both arms um mainly the left got your right right okay mainly the right side uh she's had in the past a combination of bracho plexus blocks occipital nerve blocks trigger points uh accessory blocks par vertebral nerve blocks and it's given her over 70% relief she's way better than she was a month ago when I when I believe I first met her and now she wants just a repeat the same therapy to keep at it and prevent the pain from getting worse again since she's had these injections she's been able to function better at work etc correct and do more your activities of daily living are easier yeah okay yep very good so it we start the pain goes down the right arm to her pinky yeah and then it'll go to each finger does it go to the thumb um no okay so it's basically radiating more towards C7 so we're going to first find the super clavicular brachial plexus by the subclavian artery and we're going to trace it back up to her neck to the inter scaling brachial flexus right here decrease depth decrease depth decrease gain and just a little flick of the wrist how I move my ultrasound you see the nerves appear differently they appear as a stop sign one on top of I see a street light one on top of the other or the Snowman sign and increased depth I could trace them back to the Fram and as you see they're disappearing and C6 is entering at the frame in here you could see the anterior tubal Chast nags of C6 anterior to the nerve let's make sure there's no blood vessels in the vicinity color mode okay it looks like we're free and clear the vertebral arteries anterior here and well away from where we want to go be mode capture image anything shoot down your hand just let me know okay yeah negative aspiration we got up closer to the nerve that was close to the medial branch because that travels posteriorly you may feel something down the arm now there right yeah a little bit at the 12:00 position of the nerve to avoid touching it still good yeah all right we're right around the Nerf going down your arm no okay it doesn't have to but capture image you see the needle is 12:00 of the nerve and it's also between C7 and C6 C6 is above C7 is below scanning downwards I see the articular pillar where I could do a par vertebral block as well as get into the facet capsule right here this will get the the Facet Joint as well as the medial branch external to the Joint which is a little hard to see but it's over there doing good yep okay you have paint higher or lower than this point um a little bit lower okay right here yeah okay and here we could see the articular pillar again of a pinch you little trigger point here on the way in have trigger points as well that's right here is a articular pillar facet capsule as well as theal Branch once again hard to see but it's there now we're going to do her occipitals scanning the spine can you just look down please at C2 the first spinus process is bifid and we just scan laterally we see the oblas capitus inferior muscle decreased depth and the semi- spinalis muscle and between them lies the occipital nerve and it may appear as one branch or more than one this is the greater occipital nerve before it joins the artery little pinch right capture image a little closer to it and just getting in that plane will dissect the medication will just Hydro dissect over towards the nerve above the needle right here now centered are we doing good y okay here is the sternal mastoid muscle posterior to the is the region of The Superficial cervical plexus and analgesia the flexus will get the transverse cervical nerves little pinch as well as the Lesser occipital nerve and gives some relief to her for her headache and neck pain as well capture image Bing a small amount over there and sometimes you can see the accessory nerve as well which should be leaving the sternal mastoid heading towards the trapezius and it's quite superficial about 8 cm superior to the clavicle and I I would judge it's in this plane right here little [Music] pinch right there capture image there we go just a small amount of local there I think I have uh one more thing left to do are you okay yep have you had enough or you want me to continue I'm going to do this the super scapular nerve walks so I'm scanning over the trapezi and Super spinous Muscle looking down at the spine of the scapular focusing in decreased depth at the transverse scapular liament where the super scapular nerve lies and I'm going to deposit a little bit of local anesthetic just to give her some relief of the pain that radiates towards the back of her shoulders a low pinch yep sorry TCH it I know it won't do that it's going to go a little bit more shallow because it was close to the artery and we're Perforating the ligament now and there we go nice spread over the nerve needle mode there we go right there I'm injecting onto the super scapular nerve you can relax are you feeling lie headed or dizzy or anything no I'm not I'd like to say something many of my procedures I do sitting up which is what many practitioners will not do out of fear for vagel I've almost never had a vagel in this position with these particular injections where the vagal reaction has occurred the Syncopy or the near Syncopy has been mainly with cervical facet injections and I'm I'm guessing part of that is because in the facet you could have communication with the epidural space and the patient could feel faint or dizzy it could still happen with what I'm doing and I advise caution I'm not telling everyone to sit patients up because there is a risk of vagal I've been doing this for 17 years and I I have a sense of who to do this with and who not to do this with I know her she's had a good history of receiving injections without feeling faint as well as the fact that she's on a table where I'm prepared to lie her down if she becomes lightheaded or dizzy or has any signs of Brady cardio or hypotension
