Case Study: 33-Year-Old Woman with Shoulder and Low Back Pain

Welcome to our Case Study from the Institute for Nerve Medicine in Santa Monica, California.

Our patient is a 33-year-old woman suffering from shoulder pain and low back pain. She has been practicing yoga for over five years and in January 2013 entered into a yoga teacher training program.

As her practice increased in duration, the pain developed in two distinct areas. She currently rates her brachial plexus pain at a 4 on a pain scale of 1 to 10 and her lower back pain at a level of 6 on a pain scale of 1 to 10. She indicates both areas of pain have not increased in intensity but are always present regardless of mild or moderate activity. Her chiropractor has run out of options and has referred her to the Institute for Nerve Medicine with both Thoracic Outlet Syndrome and Lumbar Spondylosis as part of her overall diagnosis.

Previously, she has had Open MRI Guided interventional procedures conducted to the scalene muscles which gave her significant short term relief. However, since then she has had recurrence of pain. Considering the positive response from the Open MRI procedure, we know that the right nerve locations have been identified. To obtain a long term benefit, the patient has the option of having another Open MRI Guided injection (which may have a longer lasting effect) or she may consider a surgical decompression of the brachial plexus with scalene resection.

With regard to her Lumbar Spondylosis, since she did not have any pain relief from a Right L5-S1 lateral disc epidural injection, we know a more refined lumbar spine injection is needed. After discussing her choices with Dr. Aaron G. Filler, MD PhD FRCS, medical director of the Institute, the patient chooses to have Open MRI Guided Interventional procedures staged over the course of 3 days.


Day One

The scalene muscles are targeted for treatment. Once an appropriate image slice of the anterior and middle scalene muscles were mapped, coordinates for the entry points and the targets were determined using the MRI optic eye system and finally, the trajectories were determined.

The area of the entry point was then prepped and the needle was introduced in the area of the anterior scalene muscle. It was necessary with the anterior scalene to use 3 different positions within the muscle tissues for medication distribution. Using additional image slices, a second needle was then advanced to the area of the middle scalene muscle. Similarly, within the middle scalene it was necessary to reposition the needle several times in order to achieve a uniform distribution.

Ultimately there was some patchiness in the distribution, particularly in the middle scalene muscle, suggesting some internal fibrosis in the muscle. The best overall distribution was achieved so the needle was withdrawn, and additional images were obtained post procedure for comparative analysis.


Day Two

The lower back is the focus of this day. Since the previous injection conducted by X-ray was ineffective, we focus on differentiating between spine pain and soft tissue pain.

A series of localizing images were obtained and once an appropriate image slice was identified, providing access to iliac crest and over the transverse process of L5, the trajectory, entry points, and targets were determined. The area for the entry point was then prepped and a needle was introduced and advanced gradually into the area of the L5-S1 foramen. Once a good location was achieved, an injection was carried out. The needle was then advanced further into the lateral margin of the disc space just inferior to the foramen where an additional injection was completed.


Day Three

Based on the lumbar MRI imaging, we believe that the lower back pain may also be a combination of the piriformis muscle and the obturator internus muscle.

Using the previous day’s real time optic imaging additional image slices are taken of the hip area. The entry points and targets are determined using the optic eye system and trajectories are evaluated for each of the entry points.

The area was prepped and a needle was first advanced into the area of the piriformis muscle on the left side; an injection was carried out. It was necessary to reposition the needle several times. The muscles seemed to be multi-compartmented and demonstrated patchy distribution, suggesting internal fibrosis within the muscle.

The needle was then withdrawn and through a separate approach was introduced into the area of the obturator internus muscle. The muscle was quite sensitive, particularly over the tendon. Nonetheless, the injection was carried out both on the surface of the muscle and in the body of the muscle.


The Recovery Period

The patient is now four weeks from her staged Open MRI Guided Interventional treatment. She has had many significant improvements. She notes improvement in the lower back pain, saying that it is about 75% better, and she notes the pain is no longer constant.

With regard to the anterior and middle scalene symptoms, she notes that like before, she experienced significant pain relief initially following the procedure but with increased activity she finds that there is no real significant improvement in pain. Since the patient does not want to undergo brachial plexus surgery at this time, hopefully some of these residual shoulder symptoms will resolve with anti-inflammatories.

Dr. Filler estimates that soft tissue injuries generally take between 3 and 6 months to heal and recommends that she limits her yoga practice and refrains from shoulder stands and arm balance poses while undergoing a Medrol dose pack to treat the inflammation.


The need to treat multiple pain locations has become a routine part of this practice and many spine patients have multiple areas of pain that are aggravated by exercise.

Treating varying pain symptoms in different locations can be challenging, especially when the patient continues to be active. By focusing on each location individually and then developing an overall treatment plan, we have learned that many pain locations can be resolved with good success.

Most importantly, repetitive and chronic pain will reduce if it is effectively treated and then allowed adequate time to heal. Sometimes, it is hard for patients to give the body time to heal, but it is a necessary part of our successful outcomes.

To learn more about our treatment methods for pain conditions email us at or call our office today at 310-314-6410 to schedule a consultation.