This is an interesting and humble article from 1941 from Dr Livingston, where he exposes the treatment of certain type of low back pain disability after what he called strain of the multifidus muscle related to the involvement of the sacral dorsal nerves (medial cluneal nerves), which he managed with repeated NOVOCAINE INFILTRATIONS with rather good results in 12/17 cases.

Back mice and cluneal nerve entrapments have been treated with repeated anesthetic injections. This article is related to our study since it treats medial cluneal nerve neuropathy (dorsal sacral nerves) by repeated novocaine injections, so we can see a parallelism.

 Novocaine injections were very used in the early years to treat local regional pain.

He also deals with the concept of SECONDARY REFLEX DISTURBANCES that would be produced when the nerves are involved in triggering a more acute pain syndrome by the reflex disturbances in the spinal cord segment.

Livingston concludes:

• Sometimes the back pain can be LOCAL while other times it may be a SYNDROME of widespread muscle spasm, neuritis and pain phenomena due to secondary reflex phenomena.
• If the trigger-point can be located, the NOVOCAINE INJECTION can break the vicious circle of reflexes disturbance.
• One of the locations of these trigger-points for low back pain is located in the “multifidus triangle”, in the lower part of the sacrum (medial cluneal nerves involvement).

He wants to leave the concept that pain accompanying low back disability indicates that the terminal filaments of sensory nerves are being irritated. It doesn’t make any essential difference whether the lesion is a fractured bone, a displaced joint, or an injury to muscle or fascia. If the irritation is SUSTAINED, a SPREADING REFLEX DISTURBANCE may be set up and secondary disturbances, such as muscle spasm, may become new sources of pain. Once the trigger point is removed, its messages successfully interrupted, the whole structure of abnormal physiological activity subsides.

About the author:

He provides just 3 references:

• Steindler, 1938
• Dalton, 1939
• Lewis and Kellgren, 1939

Back Disabilities Due to Strain of the Multifidus Muscle.

Cases Treated by Novocaine Injection

by William Kenneth Livingston

from Portland, Oregon

Published in 1941 in The Western Journal of Surgery, Obstetrics and Gynecology.

Livingston’s introduction

In the introduction, Dr. Livingston starts by saying that the most difficult problem for an “industrial surgeon” is to deal with the disability due to injuries of the lower back.

The etiology often being obscure, prognosis uncertain, and the treatment disappointing.

It also seems that there is NO RELIABLE PARALLELISM between the type of injury and the degree and duration of disability. A simple lifting strain can be very incapacitating.

Sometimes it starts as a mildly annoying pain and it seems to spread over wide areas of the back and the buttock with increasing intensity. Many times the sciatic nerve or other nerves become involved in persistent “neuritis”. As the pain spreads, it becomes difficult to locate the original lesion.

The vogue of the operative techniques

After failure of conservative treatments, then operations “may enjoy a vogue” for a time and then be displaced by other procedures.

• Smith-Peterson operation (to fix the sacroiliac joint)
• Ober operation (which divides fascia lata)
• Epidural injections
• Fusion operation to stabilize the lumbosacral point

And recently on vogue: laminectomy for the removal of a “displaced intervertebral disc” or a “hypertrophied ligamentum flavum”.

Livingston says that he has seen many excellent results from each of these operation techniques, but also many UNFAVORABLE results, so he suspects that sometimes the result may have been incidental, rather than directly ascribable to the operation.

Livingston’s theories

 Livingston: “The fact that the signs and symptoms SEEM TO SPREAD from the original injury to involve nerves and muscles at some distance suggests that REFLEXES have been called into play”.

If the sensory nerve filaments have been involved in the original pain, then with increased intensity and duration, it shows a tendency to spread and to cause a REFLEX SPASM of the neighboring and then more distant muscles, as a kind of ABNORMAL PHYSIOLOGICAL ACTIVITY.

Maybe the ONLY ORGANIC LESION is a very minor injury to muscle or fascia that, in some way, continues to irritate SENSORY NERVE FIBERS.

All this is supported by the fact that by the excision of the tender local area, a manipulation of the back or an epidural injection is followed by a disappearance of the secondary signs and symptoms.

The use of repeated INFILTRATIONS of tender areas for back disabilities

 The use of REPEATED novocaine infiltrations into the local tender areas is not new.

In some clinics, as Steindler 1938 ascribed, the local infiltration is USED to LOCATE the FOCI OF IRRITATION, and then excise the lesion.

In Livingston’s clinic they use the REPEATED INFILTRATION as a therapeutic measure per se.

Livingston’s comments on Daltons’s work

Dalton believes that “the focus” is frequently represented by areas of “fibrositis”, which he visualizes as about the size of an ordinary match head. He searches for these with a needle electrode. The needle has a mild galvanic current, once he localizes it, he keeps the needle steady on that point with galvanic current of very small milliamperage, and then the neuralgic pain is gone. Livingston states that Dalton believes that the novocaine injections produce better results than an electrical current, or simple saline infiltrations, because the anesthetic drug may STOP the “vicious circle” of reflexes maintaining the pain syndrome.

 Livingston’s comments on Kellgren’s work

He studied the reflex effects produced by LOCAL irritation of muscle or fascia. He uses 6% of sodium chloride. This hypertonic solution causes an aching pain for a few seconds without permanent damage.

For example:

• Solution injected in the erector spinae causes pain that spreads up and down along the spine.
• Solution injected in the intervertebral fascia at the first lumbar level simulates the pain of renal colic in its distribution. The pain is accompanied by muscle spasm, deep and superficial tenderness and even a retraction of the testicle on the affected side.

Livingston’s technique to treat the strain of the multifidus muscle

Livingston says that, personally, he has treated a number of cases of low back pain by the use of REPEATED INJECTIONS of 2% novocaine solution.

If the patient is able to locate the pain, he palpates then the location until he finds the sensitive point that may represent the focus of irritation. He injects from 5 to 10cc. He searches with the needle the tissue that is somehow resistant to the passage of the needle. The injection may reproduce the typical pain; the injection is followed by the IMMEDIATE RELIEF OF PAIN and the increased range of motion in the back.

After the novocaine effect wears off, the patient frequently has an acute exacerbation of pain that may persist for hours or 2 or 3 days. After that, there may be a period of relief.

If the injection is repeated, the cases of exacerbations tend to become less and the periods of relief increasingly long afterwards a variable number of treatments the entity do not recur.

 Linvingston’s cases

Livingston says that 3 months previously he had 3 patients that presented their trigger points in the same area. He got intrigued and collected at the end 17 cases. The original injury was a lifting strain.

The origin of the pain is over the lower part of the sacrum and spreads like a thick sheet over the triangle of multifidus. He had the impression that injections gave relief when injected beneath the sacroespinalis fascia. Livingston thinks that the muscle and some nerve fibers are injured. These posterior branches of the sacral nerves (medial cluneal nerves) are probably involved in the SECONDARY REFLEX PHENOMENA.

 

CASE 1. A 47-year-old man. The man was injured in a work accident. He fell and the left lower back pain caused him to faint. The pain spread to the gluteal region and down to the thigh and to the knee. The pain was of a burning character, worse during stormy weather and aggravated by stooping, straining, sneezing. While sitting, he rested most of his weight on the right buttock. He spent months in the hospital but could not tolerate traction. After he received 8 injections in a 2 months period, he was discharged as cured.

 CASE 2. A 43-year-old man. The patient slipped and fell in a sitting posture. He continued working 3 days but then he was laid off because of increasing pain in the back. The pain spread over the right buttock and leg to the heel. Worse when he got out of bed in the morning. Partially relieved while his leg was in traction for several weeks in a hospital. He also had manipulations and nerve stretching. His back was stiff and restricted in motion. Straight leg rising was 50% on right side. There was one-half inch atrophy of right calf muscle. After receiving 4 injections of novocaine in the multifidus triangle, he was back to work.

 CASE 3. A 37-year-old man. He had a work accident, the wheels of the truck crossed his right buttock and left thigh. He was treated with bed rest, physiotherapy, five weeks of leg traction and manipulations. He wore a TAYLOR back brace with crutch extensions for some five months. The brace gave him relief but he could not leave it off for more than an hour at a time. He was advised a lumbosacral fusion operation. He was unable to bend to the right or do straight leg rising. There was atrophy to the thigh and the calf muscles. He improved by the first 4 novocaine injections. The treatment was still going on.

Of the 17 cases Livingston collected:

-5/17 were classified as failures (2 cases quit treatment after first injection, 2 cases did not show improvement, and one case even went worse).

-4/17 were classified as “improved” (they improved the symptoms but did not return to work.

-8/17 were classified as improved and RETURNED to WORK free from symptoms.

Livingston’s humble considerations about his article

 He states:

“This series of cases is TOO SMALL and the period of observation is TOO SHORT to permit any conclusions to be drawn. I am not certain that the essential lesion involves the multifidus muscle. I am NOT EVEN CERTAIN that the cases I am presenting represent a COMMON type of low back disability since the apparent frequency of the syndrome may be ascribable, in part at least, to the fact that we are looking for it. But in view of the uncertainties attaching to the diagnosis of low back disabilities, and the present active interest in novocaine injection therapy, it has seemed justifiable to report these observations. “ Livingston

 Discussions with other doctors:

 Dr. Edgar L. Gilcreest (San Francisco): He admits he does not have experience with the novocaine injections. He remembers a patient that could have had a syndrome that could be explained by this reflex disturbance, and that was considered neurasthenic and a “damn nuisance”. The patient at the end said she was relieved by manipulation.

 Dr E.W. Rockey (Portland): He says that doctor Livingston selects very well the trigger point where to inject the novocaine. Actually, he himself after a fall had pain that Dr. Livingston treated with novocaine injections.

 Dr. Alson R. Kilgore (San Francisco): He gave an example of a patient that improved in pain over the trochanter area, pointing out that other areas can be treated in the same ways.

 Dr Frederick L. Reichert (San Francisco): He insists that it is very important to have the patient to locate the TRIGGER POINTS. And pressing after injection is important to avoid hemorrhage.

 Dr. Leroy C. Abbot (San Francisco). He says that Doctor Mayer from California used another drug: aciform solution instead of novocaine.

 Finally, Dr Livingston explains his own case of low back pain, which, from a single point of irritation, it spreads to many places because of REFLEX DISTURBANCES and he manages with MANIPULATION that often causes a snap that is audible (he explains this as an example that not always the solution is necessarily an injection).

 Published in October 2018 by Marta Cañis Parera   

 

Reference

K. Livingston. Back Disability due to strain of the multifidus muscle. Cases treated by Novocaine Injection. The Western Journal of Surgery, Obstetrics and Gynecology. Vol 49, 5 May 1941. P 259.