The peripheral trigger-point injection could be expected to treat a non-cervical cause of appen-dicular pain. If the peripheral trigger point is a point of referred pain from the cervical spine, one would not expect the trigger-point injection to be beneficial. Selected injections involving the nerve roots and/or facet joints can be both of diagnostic and therapeutic value. The use of such injections is logical in cases where the patient has localized neck pain or referred pain in a nerve root distribution.
The subjective nature of pain, the diversity of the manifestations of cervical spondylosis and the variable natural history have made the objective study of the results of steroid injections difficult and inconclusive. Theoretically, the steroids can act as potent antiinflammatories for a finite period of time at a site of inflammation. The injections are not treating the cause of the inflammation directly and do not act to decompress the neural elements when this mechanism is contributing to the pain. When the steroid has been absorbed and metabolized and is no longer present at the injection site, if the process which produces the pain remains active, the pain should recur. In those instances where the patient has alleviation of the symptoms, it is possible that the underlying cause has become inactive or has been resolved by intrinsic mechanisms. Therefore, steroids probably do not alter the natural history of symptomatic spondylosis, but can temporarily moderate symptoms which are the result of inflammation.
A wide variety of alternative treatments have also been utilized for treatment of symptomatic spondylosis. Often, these treatments are invoked if preliminary conventional methods have failed or if the patient wants to avoid surgery. Acupuncture, deep muscle stimulation, chiropractic manipulation, biofeedback and other such methods remain alternatives. The rationale and results of such techniques are beyond the scope of this chapter. In the authors' experience, some patients appear to obtain some improvement of their pain symptoms from such techniques. It is unclear, however, if this represents the natural history of the disease since, again, as for steroid injections, the techniques involved do not appear to directly alter the underlying pathophysiology of the pain.
In summary, non-operative treatments represent the first line of treatment for patients with pain from cervical spondylosis in the absence of a significant neurological deficit. A variety of non-operative treatment modalities have been used. Objective data regarding the merits of each modality are limited, due to the subjective nature of pain and its associated disability and the various pain generators underlying the symptoms. Immobilization, anti-inflammatories and the judicious use of analgesics are a logical first line of treatment for acute and chronic pain syndromes. Active physical therapy and exercise can be effective in selected cases of chronic axial pain, for reactivation after an acute episode of pain or pro-phylactically to diminish the likelihood of recurrent pain after an acute episode. Steroid injections can help reduce a focus of acute inflammation. The treatment does not directly treat the underlying cause of the pain and the effect is probably temporary. Its use and that of alternative therapies must be studied more closely to determine their usefulness in the treatment of spondylosis.
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