Atlantoaxial

By Mavis Blake

You drive to the clinic alone that day. As usual. You are not required to have a driver if you opt for no sedation for the procedure. During the divorce, your attorney suggested keeping medical issues out of matters: the stigma. The pills. Now, even ten years later, this never-ending conveyer belt of doctor’s appointments is still a rat under your hat. Sunglasses struggle to buffer the light but fail as the sunshine clenches the side of your head in a vice grip.

Patient has intractable headaches and has failed multiple pharmacological managements (nonsteroidal anti-inflammatory drugs, muscle relaxants, antiseizures, tricyclic antidepressants, opioids, etc.). Chiropractic treatment, physical therapy and acupuncture provided no relief.

How many times have you had some type of steroid injected into various parts of your body: shoulder, back, neck, spine, head, jaw? The trigger point injections are easy, no more painful than sharp pinches, but it can be upwards of a dozen shots at one time. The occipital nerve blocks feel more like being stung by a steel wasp in the back of your skull. The epidural steroid injections are more nerve-wracking than painful. A thin plastic tube is thread through a disc in your spine in attempt to dull the burning inflammation with a blast of cortisone. Your best guess would be that you have underwent at least a few dozen of such procedures. It’s like playing Whack-a-Mole with pain.

The lateral atlantoaxial steroid injection will be performed using the classic intra-articular posterior approach under fluoroscopic guidance.

You arrive at the clinic, which looks more like a mini mall than a hospital. Inside you report to the woman at the front desk. This is Delilah, you typically discuss books her, but today she is busy unloading patients. She hands you a clip board with the paperwork to review: name, address, employer, insurance, primary physician. The pulsating in the back of your head heaves and moans. You take a seat on a waiting room chair. The life-size cutout advertisement for a pain pump stares down at you. It could be worse, you think. A nurse calls your name and escorts you to the pre-procedure room to take your vitals. All normal.

“When is the last time you ate or drank?” she asks.

“Coffee and toast, about two hours ago.”

“Oh no,” she says, “you can’t eat prior to sedation.”

You tell her you won’t be sedated for the procedure. She collects her chart and leaves you alone in the room. The sedation offered for this procedure is a mixture of fentanyl and an anti-anxiety drug. No one could drive after that cocktail.

After you remove your clothes and slip your arms into the open-backed hospital gown, you sit. Arms wrapped around your folded legs, holding them to your chest as you perch on the medical-grade recliner. The stiff, unwelcoming vinyl upholstery makes you shiver. You chill easily in this artic air-conditioning. A metal tree donning plastic tubes and bags filled with clear fluid looms to your side. A hand grabs the edge of the suspended curtain divider and it glides open. Dr. Faltos enters the room. He is younger, early thirties is your guess; articulate and confident. He begins by introducing himself and explaining the procedure you are about to undergo.

“Starting at the base of your skull, the joint between C1 and C2 is the atlantoaxial joint. Because anatomic variations of C2 and the course of the vertebral artery, which supplies blood to the upper spinal cord, brainstem, cerebellum, and posterior part of brain are common, the intraarticular injection is only performed as a last resort, after all other measures fail to relieve an occipital headache.

“I use the utmost care and take extreme precautions: live fluoroscopy, digital subtraction, blunt needle to prevent nicking the artery. Only preservative-free lidocaine and nonparticulate steroid will be used. However, it is my obligation to inform you that despite all precautions, there is a risk. Penetration into the spinal canal and damage to the nerve roots or spinal cord is a possibility, leading to paralysis, stroke or death.

“The practice of AA injections has been abandoned by most specialists,” Dr. Faltos finishes. However, he proceeds to tell you that he is highly skilled—he has performed many, he assures. Although he is a new doctor to you, this clinic is not. Your usual doctor, Dr. Neurothin does not attempt AA injections. You have what feels like a hot axe blade wedged into the back-right side of your skull. It throbs behind your right eye. It’s been merciless for over five weeks now. The headaches coupled with the full body aches, ravage you. Broken, shattered. Aside from Botox for migraines, which insurance has denied coverage on (twice), you have exhausted all other options. But the thought does enter your mind that perhaps you should hold off, maybe you could pay out-of-pocket to get some Botox into your brain before you dive into this procedure. Except your healthcare expenses thus far this year have devoured your savings. And insurance pre-approved today’s procedure.

You tell him you aren’t sure if this is the best day for this, “Bad body pain day, like an all-over migraine.”

This isn’t a lie.

“We can give you a shot of Toradol before you leave.” He says. Toradol is a nonsteroidal anti-inflammatory and it feels like fire when it’s administered straight into the muscle. The burning lasts for hours. It’s like the old joke where the guy tells the doctor his arm hurts, so the doctor kicks him in the knee and asks what hurts now—Toradol is the knee.

But you are tired, already here, and desperately in need of removing of the sweltering axe from your sore aching head. You agree to be another notch in Dr. Faltos’ belt.

Dr. Faltos wants to confirm that you are proceeding without sedation.

You nod.

“The nurse will come shortly to escort you to the surgical room.” The curtain drifts behind him as he exits.

The nurse is Sarah. She is bold and unwavering; you imagine her in rock-and-roll aesthetic when she isn’t wearing scrubs. She probably likes bands like Aerosmith, maybe Def Leopard. You remember the first time you met her. That was when the clinic changed ownership and all former nurses were replaced. Sarah was one of the new nurses. She made you cry; you didn’t want to sign her “bullshit contract and where’s Dr. Neurothin?” That was the January of 2016, when the rules changed. No more popping in once or twice a year with a severe flare up. Now it’s contracts, monthly appointments, drug tests and pill counts. Patient or probationer? You are back to sprinkle a dash of shame on top of that stigma sundae. Precisely why you go to all your appointments alone.

“Hey, it’s the prodigal patient,” Sarah says. “How long has it been—over a year?”

“Almost two,” you say.

“I didn’t think it was possible. No one ever leaves us.”

“Thought I’d swing in for a tune-up. I’m not sticking around for long,” you say.

You follow her lead into the ambulatory surgery room. Showtime. Like the set of a movie, the surgery room is filled with the spotlights shining in various directions and monitors suspended from the ceiling, cords and computers beeping and buzzing out of sync. The surgical table is center stage. There are two additional nurses in the room. A nurse hands you a hair net to pull back your mane. Sarah supports your elbow as you crawl on hands and knees up onto the table, then situate yourself onto your stomach with a pillow propped under your chest. Your neck strains as you plant your face into the u-shaped headrest above your shoulders. Sarah and another nurse each grab one of your wrists and begin to wrap one end of a strap around it. They wrap and pull the strap until your arms are pulled taught to your sides. It digs into to your wrists, but it needs to be taught. The strap serves two purposes: holding your shoulders down to assist in opening spaces in the spine and keeping your hands out of the way of the doctor. Dr. Faltas enters as the nurses finish hoisting the strap ends to fasten at the flats of your feet.

The pulse monitor is clipped onto your forefinger confined near your upper thigh. The team chirps a chorus of your stats for the medical record. Numbers are murmured as the snout of an x-ray machine touches the side of your neck, cold and hard metal to flesh. The hair net subtly sways as a paper cloth is draped over the back of your head. Where there is an opening in the paper cloth, at the back of your neck, you feel a scribble and then a coolness wash over your neck, as an astringent waft prickles your nose. Your eyes are closed. Darkness. Face-down and tied up tightly, you think to yourself the worst part about chronic pain is how it leaves you like this sometimes, trapped in your own suffering and unable to see outside yourself at what others are going through. You don’t want to be this person.

Patient is placed in the prone position, with standard monitors in place and a pillow under her chest to allow for slight neck flexion. The fluoroscopy C arm is brought to the head of the table in an anteroposterior direction. Under fluoroscopic guidance, the C arm is rotated until the lateral atlantoaxial joint is better visualized with its biconcave appearance. Using a marking pen, the needle insertion site is marked on the skin overlying the lateral part of the atlantoaxial joint. The skin is prepped and draped in the usual sterile fashion, and a skin wheal is raised with local anesthetic at the insertion site.

A needle, seemingly as thick as a pencil, glides into the skin near the top of your neck, roughly an inch under the base of your skull. You hear a tap inside your head as the needle crashes into your spine. Not two seconds later, deep inside the utmost top of your neck, behind your throat, you feel a pop, like a champagne cork. The machine monitoring your heart rate speeds its rhythm. Everyone in the room reassures you how well you are doing. You are a pilot in flight, no turning back now.

Then a 24G 3.5-inch blunt needle (to minimize vascular entry) is advanced in the anterior and medial direction toward the posterolateral aspect of the inferior margin of the inferior articular process of the atlas. This will avoid contact with the C2 nerve root and dorsal ganglion, which crosses the posterior aspect of the middle of the joint.

After touching the bone to safely establish the correct depth, the needle is withdrawn slightly, directed toward the posterolateral aspect of the lateral atlantoaxial joint, and advanced for only few millimeters. Usually a distinctive pop is felt, signaling the entrance into the joint cavity.

Let’s rewind to when you declined sedation for this procedure. Fentanyl, the Mack truck of opiates, is in the sedation cocktail. Not Nubain or some other Shirley Temple pain killer. That should have been your cue that this procedure was not going to be a ride at Disney Land.

The moment you feel the needle contact the deepest, bottom edge of the sweltering axe lodged inside your brain, that spot lower and deeper than the back of your eyeball, there’s an electrical surge, like clamping a live jumper cable to the sorest spot inside your head—the occipital nerve. The pain courses up and shoots through the top of your head like a bullet, but remember, DONT MOVE! There is a blunt needle sidling the main artery that feeds your brain stem.

Careful attention should be paid to avoid the vertebral artery that lies lateral to the lateral atlantoaxial joint as it courses through the C1 and C2 foramina. After careful negative aspiration for blood or cerebrospinal fluid, a contrast agent is injected to verify intra-articular placement of the tip of the needle. After careful negative aspiration, 1.0 mL of a mixture of bupivacaine 0.5% and 10 mg of triamcinolone is injected. This may trigger the patient's usual occipital headache.

“Sarah,” you say, in a whisper, so as not to move a muscle.

“I’m right here,” she says.

“Please touch me,” you say.

She wraps her hand over your toes and rubs your ankle. She reassures you that everything’s going to be fine. For a second, you believe her.