Treatments

Treatments

Our goal is to assess and diagnose your pain's cause. Then together form a comprehensive treatment plan to get you pain-free as soon as possible.

Bursa Injections

What is a Bursa?

In many areas of the body, muscles and tendons must slide over and against one another during movement. At each of these places there is a bursa, which is a small sac of lubricating fluid, to help the muscles and tendons move without friction. When the bursa sac becomes inflamed, pain can result each time the tendon has to move over the bone. The pain may eventually be present at rest and may even cause a problem while sleeping.

WHAT TO EXPECT DURING A BURSA INJECTION

  • Using X-ray guidance, or ultrasound the physician will insert a thin needle and inject contrast solution into the bursa thought to be causing your pain. The contrast solution is designed to highlight your anatomy to make sure the nerve thought to be causing your pain is precisely targeted.
  • The physician will then slowly release a combination of anti-inflammatory (steroid) and anesthetic (numbing) medications into the area.
  • You may experience some slight pressure or discomfort during the bursa injections.
  • You may be asked to wait after the procedure so that the clinic staff can monitor your symptoms before you leave.

WHAT TO EXPECT AFTER THE BURSA INJECTION

    • The beneficial effects of the steroids usually require two to three days to take hold, but may take as long as five to seven days.
    • If an initial injection provided a certain amount of relief, a second injection might strengthen the pain relief effect. Also, if your pain subsides, but begins to return weeks or months later, additional injections are possible.
    • If there is no change in your symptoms after a week, your doctor may want to investigate other possible sources for your pain

Celiac Plexus Blocks

A celiac plexus block is an injection of local anesthetic into or around the celiac plexus of nerves that surrounds the aorta, the main artery in the abdomen. Normally these nerves control basic nerve functions. In certain conditions, these nerves can carry pain information from the gut or abdominal organ tissues back to the spinal cord and brain.

A celiac plexus block is performed to block the celiac plexus of nerves that go various organs and parts of the abdomen. This may in turn reduce pain in the abdomen. It is done as a part of the treatment of Chronic Pancreatitis and other types of Chronic Abdominal Pain.

The injection takes from 10 to 30 minutes.

The procedure involves inserting a needle through skin and deeper tissues. So, there is some pain involved. However, we may numb the skin and deeper tissues with a local anesthetic using a very thin needle before inserting the actual block needle. Most of the patients also receive intravenous sedation that makes the procedure easier to tolerate.

This procedure is done under local anesthesia. Most of the patients also receive some sedation, which makes the procedure easy to tolerate. The amount of sedation given generally depends upon the patient tolerance. Some patients may have enough sedation that they have amnesia and may not remember all or parts of the procedure.

The Celiac plexus block is performed with the patient lying on stomach. The patients are monitored with EKG, blood pressure cuff and an oxygen-monitoring device. The celiac plexus block is performed under sterile conditions. The skin on back is cleaned with antiseptic solution and the skin is then numbed with a local anesthetic. Then X-ray is used to guide the needle or needles into the proper position along the outside of the spine. Once in place, a test dose of dye is used to confirm that the injected medication will spread in an appropriate area. If this is okay, the injection takes place gradually over several minutes. The physician will use the X-ray to evaluate the spread of the injected medication. When a sufficient area is covered, the injection will be over. When done, the needle is removed and a Band Aid is applied.

Immediately after the injection, you may feel your abdomen getting warm or feeling a bit different. In addition, you may notice that your abdominal pain may be gone or quite less. You may also notice some temporary weakness or numbness in the abdominal wall or leg, although this is actually not a desired effect of a celiac plexus block.

Cluneal Nerve Blocks & RFTC

FOR YOUR SAFETY, THE PROCEDURE CANNOT BE PERFORMED IF YOU HAVE AN ACTIVE INFECTION, FLU, COLD, FEVER, VERY HIGH BLOOD PRESSURE OR IF YOU ARE ON BLOOD THINNERS. PLEASE MAKE YOUR DOCTOR AWARE OF ANY OF THESE CONDITIONS.

Preparation for the cluneal nerve block procedure involves having a patient lie facedown on a table that is equipped with X-ray machinery. The skin is then sterilized and, if an intravenous anesthetic is necessary (an IV), it is set up along with a monitor that records vital signs (e.g., heart rate, blood pressure, and breathing). Topical anesthesia is applied to the lumbar region before the procedure begins if the patient does not need intravenous anesthesia.

The clinician uses the X-ray to guide the injection needle into the lower back. The X-ray is called a fluoroscope and it provides an image of what is occurring in real-time. Once the needle has been correctly positioned, a dye is administered so that the region it circulates to can be observed. This step ensures that the steroid and anesthetic that are to be injected will be delivered as closely as possible to the affected cluneal nerves. The cluneal nerve roots are the target of the block procedure. The steroid targets the inflamed nerves and the anesthetic relieves the persistent pain.

Cluneal-Nerve-1A recently reported study described the effect of nerve block procedures that were performed to treat painful cluneal nerve entrapment. The nerve blocks were administered to 25 individuals who presented medial and superior cluneal nerve entrapment symptoms. All of the patients were treated with a single nerve block consisting of a steroid and an anesthetic. At a one-year check-up examination, each patient was asked about their level of pain and they all stated that they experienced pain relief.

As with other forms of treatment, this type of nerve block may result in certain complications although the occurrence is rare. Possible complications that may occur include tingling and numbness in the extremities, bleeding, an infection, and the possible puncturing of a nerve during the needle insertion.

HOW IS A CLUNEAL NERVE BLOCK PERFORMED?

Preparation for the cluneal nerve block procedure involves having a patient lie facedown on a table that is equipped with X-ray machinery. The skin is then sterilized and, if an intravenous anesthetic is necessary (an IV), it is set up along with a monitor that records vital signs (e.g., heart rate, blood pressure, and breathing). Topical anesthesia is applied to the lumbar region before the procedure begins if the patient does not need intravenous anesthesia.

The clinician uses the X-ray to guide the injection needle into the lower back. The X-ray is called a fluoroscope and it provides an image of what is occurring in real-time. Once the needle has been correctly positioned, a dye is administered so that the region it circulates to can be observed. This step ensures that the steroid and anesthetic that are to be injected will be delivered as closely as possible to the affected cluneal nerves. The cluneal nerve roots are the target of the block procedure. The steroid targets the inflamed nerves and the anesthetic relieves the persistent pain.

Cluneal-Nerve-1A recently reported study described the effect of nerve block procedures that were performed to treat painful cluneal nerve entrapment. The nerve blocks were administered to 25 individuals who presented medial and superior cluneal nerve entrapment symptoms. All of the patients were treated with a single nerve block consisting of a steroid and an anesthetic. At a one-year check-up examination, each patient was asked about their level of pain and they all stated that they experienced pain relief.

As with other forms of treatment, this type of nerve block may result in certain complications although the occurrence is rare. Possible complications that may occur include tingling and numbness in the extremities, bleeding, an infection, and the possible puncturing of a nerve during the needle insertion.

Epidural Steroid Injections / Neuroplasty

(Cervical,Thoracic & Lumbar) When patients suffer from nerve impingement that causes them to experience pain in their legs or lower back, sometimes an epidural steroid injection can be an effective treatment that is also minimally invasive. When nerves become compressed, the patient can feel pain. Anti-inflammatory medications such as Cortisone can be placed in exactly the right spot to help interrupt the cycle of irritation. Once this procedure is done, some patients will experience sensations of warmth or numbness due to the anesthetic. Though the effects can take place anywhere from immediately to up to a week, about three days is when most people experience relief. Among those who have not had back surgery before, 70% report having relief. This relief is sometimes permanent, although many patients’ pain returns after weeks or months, and some people get no relief at all.

EPIDURAL NEUROPLASTY

This procedure is otherwise known as epidural lysis of adhesions or the “RACZ” procedure after the physician who first performed the procedure. It has been found that after trauma or surgery of the spine, scar tissue forms around the nerves in the spinal canal. It has also been shown that the presence of scar tissue compounded pain associated with nerve roots by adhering the nerve roots to one position and thus increasing the nerve root to tension or compression. This active insult to nerve roots cause significant intraneural edema, or swelling in the nerve root itself. Pain can also result from the nerve endings found throughout the spinal canal and associated structures. Sometimes after spinal surgery or trauma, scar tissue can build up in the spinal canal, compressing the nerve roots and causing pain. Epidural Neuroplasty, also know as Epidural Neurolysis can help identify epidural adhesion. It is usually an outpatient procedure which is done lightly sedated with x-ray guidance, although some of the variations on the procedure involve inpatient treatment and various medications. Speak with your physician to determine the best fit for your situation.

Facet Injections / Medial Branch Blocks

A medial branch block is an injection of local anesthetic and cortisone placed outside the joint space near the nerve that supplies the joint called the medial branch. You may require multiple injections depending upon how many joints are involved. Facet medial branch blocks are typically ordered for patients who have pain primarily in their back coming from arthritic changes in the facet joints or for mechanical low back pain. A facet block or medial branch block may be therapeutic and/or diagnostic. One of three things may happen.

  • The pain does not go away, which means that the pain is probably not coming from the blocked facet joints. This has diagnostic value
  • The pain goes away and stays away for a few days to a week but the original pain comes back. This would mean the block was also of diagnostic value and the pain is probably coming from the joints.
  • The pain goes away after the block and stays away for a few weeks to a few months. This means that the block was of therapeutic value and the steroid had a long lasting effect on the pain.

If you get good, lasting benefit from the facet injections, the block may be repeated. If you get good, short-term benefit another procedure (radiofrequency lesioning) may be done which may last months to years.

Most patients also receive intravenous sedation, which means the procedure is easy to tolerate, but every person’s response can be different.

WHAT HAPPENS DURING THE ACTUAL PROCEDURE?

After signing a consent form and checking your blood pressure the procedure will be done in the fluoroscopy (x-ray) room with you lying on your stomach. For procedures in the neck an intravenous is started. The back is then cleansed with an antiseptic soap. Sterile drapes are placed. Using x-ray guidance, needles are then advanced to the appropriate locations. Once the needles are in the proper location local anesthetic with steroid is injected through the needles and the needles are removed. Your skin will be cleansed and bandages will be applied. (The bandages can be removed on the next morning). Your blood pressure will be checked and you will be discharged to leave with your ride after M.D. authorizes discharge.

Foraminal Stenosis

Osteoarthritis, distinct from many other diseases, is amenable to local intra-articular injections, treatment as well as systemic treatment. Though most efforts so far have concentrated on development of systemic treatments, the agents used bear considerable risk of systemic side effects, such as the cardiovascular events and gastrointestinal adverse effects observed in association with most non-steroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors for treatment of joint pain (Petit-Zeman, 2004; Topol, 2004). The chronic nature of the disease requires development of drugs suitable for chronic systemic treatment with minimal side effects, which is a challenging goal.

Local drug application, i.e., injection of drugs directly into the affected joint, is an option for treatment of osteoarthritis which is already frequently used and has the potential to deliver the desired profile. In summary, progression of knee osteoarthritis results from local factors, which include synovial membrane inflammation, chondrocyte activation, and bone remodeling. Therefore, it appears logical to favor an intra-articular route for treatment of knee (as well as hip) osteoarthritis.

Intrathecal Narcotic or Baclofen Pumps

A Pump is a specialized device, which delivers concentrated amounts of medication(s) into spinal cord area via a small catheter (tubing).

A pump is offered to patients with: Chronic and severe pain, who have not adequately responded to other treatment modalities. Some of the examples are failed back syndrome, cancer pain, RSD. These patients receive infusion of painkillers such as Morphine or Dilaudid. Spastic disorders such as Multiple Sclerosis, Spinal Cord Injury – associated with muscle spasms. These patients receive infusion of an antispasmodic medication called Baclofen.

This device delivers concentrated amounts of medication into spinal cord area allowing the patient to decrease or eliminate the need for oral medications. It delivers medication around the clock, thus eliminating or minimizing breakthrough pain and/or other symptoms.

The procedure is done in two stages. In the first stage, a single injection is made to assess effectiveness and screen for unwanted side effects. If this trial is successful in relieving symptoms, then the permanent device is placed under the skin. The patients have to meet certain other screening criteria before implanting the pump.

The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”). So, there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the needle. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easy to tolerate.

The placement of the tubing is done under local anesthesia with patients mildly sedated. The amount of sedation given generally depends upon the patient tolerance.

For the pump placement, patients are given stronger intravenous sedation and analgesia or general anesthesia if their health permits.

HOW IS THE PROCEDURE PERFORMED?

It is done with the patient lying on the side. Sometimes the tubing is placed with the patient sitting up. The patients are monitored with EKG, blood pressure cuff and blood oxygen-monitoring device. The skin is cleaned with antiseptic solution and then the procedure is carried out. X-ray (fluoroscopy) is used to guide the needle for inserting the tubing. Tubing is inserted in the midline at the lower back. The pump is then placed on the side of the abdomen.

If the procedure is successful, you may feel that your pain may be controlled or quite less. The pump is adjusted electronically to deliver adequate amount of medication.

Kyphoplasty / Vertebroplasty

Kyphoplasty/vertebroplasty are techniques used for treating vertebral compression fractures, small breaks in the thick mass of bone that makes up the front part of the vertebra (called the vertebral body). Vertebral body fractures lead to the collapse or compression of a vertebra, causing the spine to shorten and curve forward. This can result in pain and a kyphotic (hunched-over) deformity. Thinning of bones, or osteoporosis, is the main cause of vertebral compression fractures. Pathologic fractures related to spinal tumors may also be a cause of fractures. During the procedures, the patient will lie on his or her stomach. The doctor will then insert a hollow needle, called a trocar, through the skin and into the vertebra. A type of X-ray, called fluoroscopy, is used to guide the trocar into proper position. Once the trocar is in place, either cement (vertebroplasty) or an inflatable balloon-like device (kyphoplasty) are inserted into the vertebra through the trocar. During a kyphoplasty, as the balloon is inflated, it opens up a space to be filled with bone cement. In addition to stabilizing the vertebra and relieving pain, kyphoplasty/vertebroplasty attempt to restore the height of the vertebra, thereby straightening out the spinal curve.

Kyphoplasty/vertebroplasty are generally reserved for people with painful progressive back pain secondary to osteoporotic or pathologic vertebral compression fractures. Candidates for these procedures often experience significant decreases in mobility and function as a result of the fractures. To be a candidate for a kyphoplasty/vertebroplasty, a patient’s pain must correlate to the vertebral fracture, and must not be due to other problems, such as disk herniation, arthritis, or stenosis. Imaging tests – such as spinal X-rays, bone scans, and computed tomography (CT) or magnetic resonance imaging (MRI) scans – might be ordered to confirm the presence of a vertebral fracture. What type of anesthesia is used during a kyphoplasty/vertebroplasty? Kyphoplasty/vertebroplasty are considered minimally invasive procedures that are most often performed using general anesthesia, depending on the doctor and the needs of the patient. In most cases, this procedure is performed as an overnight stay, although many patients do go home the same afternoon.

SYMPTOMS

Patients may feel sore in the area where the trocar was inserted. However, this should resolve within a couple of days. Applying ice to the area can help relieve any soreness.

Kyphoplasty/vertebroplasty usually provide pain relief and improved mobility within 48 hours of the procedures. In some cases, however, patients feel pain relief immediately. The majority of patients are satisfied with the results, with many returning to all their usual activities they were performing before the vertebral fracture occurred.

Lumbar Discography

Lumbar discography is an injection technique used to evaluate patients with back pain who have not responded to extensive conservative (nonsurgical) care regimens. The most common use of discography is for surgical planning prior to a lumbar fusion.

The procedure is done in the Operating Room with fluoroscopic (x-ray) guidance. For lumbar discography (discs in the low back), it is done with you lying on your stomach.

There will be a nurse present during the procedure to monitor you and administer intravenous sedation to help you be comfortable and relaxed. You are watched closely with an EKG monitor, blood pressure cuff and blood oxygen-monitoring device. The skin over the injection site(s) is cleaned with an antiseptic solution and then the injections are carried out. After the injection, you are placed on your back or on your side.

When a normal disc is injected, you will feel a sense of pressure, but not pain. When an abnormal disc is injected, you will feel pain. It is important to try to tell if the pain you are feeling is your usual pain or different. With each disc injected, you will be asked if it is painful, where you feel the pain and whether it is in the same area as your usual pain.

Based on your symptoms and your MRI, we will identify which discs we suspect are causing your pain. These discs will be injected. In addition, we inject a normal disc to serve as a reference point.

Discography takes about 30 to 45 minutes, depending on how many levels are injected.

The injection consists of x-ray dye (x-ray contrast). It is usually mixed with some antibiotics to prevent infection.

Lysis of Adhesions – Racz Catheter

Also called Racz procedure, this procedure is performed to remove excessive scarring in the epidural space. The epidural space is a thin area between the inside of the spine and the protective layer around the spinal cord.

Scar tissue may restrict the natural movement of nerves causing inflammation and pain.

Patients who have had prior neck or back surgery but still have persistent pain may benefit from this procedure. Patients who have herniated disks that are not surgically correctable may also receive pain relief from this procedure.

HOW THE PROCEDURE IS PERFORMED

You will be given conscious sedation through an IV (intravenous needle) inserted in your arm/hand on your admission to the facility where the procedure will be performed. You will be escorted to the surgical suite with the nurse and asked to lay on your stomach for the procedure . The MD and /or nurse will monitor your blood pressure, heart rate and respiratory rate (breathing) during the procedure. The physician will perform the procedure with a special x ray machine called the fluoroscope to accurately visualize the anatomy. Then contrast dye will be injected to see the restrictive location or scarring area in your epidural space which may be causing your pain. Then a special catheter called the Racz catheter (www.epimedint.com) will be guided with x ray to the scarred area. A special medication called hyaluronidase is then injected to breakup the scarring as well as mechanical forces of the Racz catheter to break up the scarring. Finally, a mixture of steroids and local anesthetics will be injected to decreased the inflammation and provide pain relief after the lysis of adhesions.

Typically the sedation provided minimizes pain. Pain may increase in the first 48-72 hours because of the mechanical forces used to break up the scarring.

The most common risks are local pain from the needle and catheter which is a mild to moderate burning sensation lasting 2-7 days. More serious but extremely rare risks are bleeding, infection, nerve injury, paralysis and weakness in the lower extremities.

The beneficial effects are usually appreciated 2-4 weeks following the procedure

Neuroma Injections & RFTC

Foot neuromas are very common findings, especially those that are termed intermetatarsal neuromas (or interdigital neuromas). The painful condition is believed to be caused by sensory nerve irritation, injury or abnormal mechanics of the foot. Yes, there are conservative care modalities as well as surgical treatment measures. However, chemical neurolysis (using a dilute solution of ethyl alcohol) gives us a viable alternative for treating the foot neuroma as it has fewer potential complications and up to an 89 percent success rate.

THE PROCEDURE

  • First things first. When it comes to diagnosing neuromas, be on the lookout for symptoms that may range from numbness, tingling, sharp pain or muscle cramping in the foot or toes.
  • Taking an accurate history and performing a good clinical examination is usually all that is necessary to make the primary diagnosis of neuroma formation. More sophisticated and costly forms of diagnostic techniques, such as ultrasonographic evaluation, are slowly becoming more prevalent in diagnosing neuromas.
  • Taking A Closer Look At The Treatment Options. The standard treatment for these conditions is relatively limited and includes the conservative care options of massage, tape strapping of the foot, functional orthotic foot devices, change in shoe type or style, decreased physical activities, and one or more cortisone injections into the involved area. Complications with the different forms of conservative treatments vary but may include failure to improve the symptoms, difficulty in wearing certain shoes, worsening of the condition, cortisone atrophy or discoloration of the skin.

Occipital Nerve Blocks

An occipital nerve block is an injection of a steroid or other medication around the greater and lesser occipital nerves that are located on the back of the head just above the neck area.

The steroid injected reduces the inflammation and swelling of tissue around the occipital nerves. This may in turn reduce pain, and other symptoms caused by inflammation or irritation of the nerves and surrounding structures. Typically, headaches over the back of the head, including certain types of tension headaches and migraine headaches, may respond to occipital nerve blocks.

SYMPTOMS

The injection consists of a local anesthetic and a steroid medication. and only takes a few minutes.

The procedure involves inserting a needle through skin and deeper tissues. So, there is some pain involved. However, the skin and deeper tissues are numbed with a local anesthetic using a very thin needle during the performance of the block.

This procedure is done with a small thin needle, usually without any sedation. There is local anesthetic within the injection.

The procedure is performed with the patient seated or lying down. The skin and hair of the back of the head are cleaned with antiseptic solution and then the injection is carried out.

Immediately after the injection, you may feel that your pain may be gone or quite less. This is due to the local anesthetic injected. This will last only for a few hours. Your pain may return and you may have a sore head for a day or two. This is due to the mechanical process of needle insertion as well as initial irritation from the steroid itself. You should start noticing a more lasting pain relief starting the third day or so.

After the occipital nerve block, you will rest for a while in the office. Most patients can drive themselves home. We advise the patient to take it easy for several hours after the procedure. You may want to apply ice to the injected area. You can perform any activity you can tolerate.

Posterior Rami Blocks & RFTC

The posterior ramus of spinal nerve (or posterior primary division) refers to the posterior division of a spinal nerve. The ramus is also known by a number of other names, “posterior (or dorsal) rami (or branches or divisions) of the spinal nerves”. The posterior ramus is one of two major branches of a spinal nerve that emerge after the nerve emerges from the intervertebral foramen. The posterior ramus carries information that supplies muscles and sensation to the human back.

Shortly after a spinal nerve exits the intervertebral foramen, it branches into the posterior ramus, anterior ramus, and rami communicantes. Each of these carries both sensory and motor information. After it is formed, the posterior ramus (plural: rami) of each spinal nerve is travels backward, except for the first cervical, the fourth and fifth sacral, and the coccygeal. Posterior rami divide into medial and lateral branches which supply muscles and skin of the back. The medial branch (Latin: rami medialis) also supplies articular branches to the zygopophyseal joints and the periosteum of the vertebral arch. In the neck and upper back, the medial branch continues through the deep and superficial back muscles to supply overlying skin; in the lower back, the lateral branch does this. Nomina Anatomica lists dorsal primary rami as “rami dorsales” for each group of spinal nerves:

  • Cervical (nervorum cervicalium)
  • Thoracic (nervorum thoracicorum)
  • Lumbar (nervorum lumbalium)
  • Sacral (nervorum sacralium)
  • coccygeal (nervi coccygei)

SYMPTOMS

Because each spinal nerve carries both sensory and motor information, spinal nerves are referred to as “mixed nerves.” Posterior rami carry visceral motor, somatic motor, and sensory information to and from the skin and deep muscles of the back. The posterior rami remain distinct from each other, and each innervates a narrow strip of skin and muscle along the back, more or less at the level from which the ramus leaves the spinal nerve.

Radio Frequency (RF) Nerve Ablation (also known as RF Rhizotomy) is a therapeutic procedure designed to decrease or eliminate pain symptoms within spinal facets by temporarily deactivating minor nerves around the spine. The pain generating nerves for many patients are often small, unimportant fibers which can cause severe pain. These nerves can be temporarily shut down using radiofrequency energy to heat the surrounding tissue and deactivate the pain generating nerve fibers. The procedure is performed by accessing the affected nerve under x-ray guidance. Once properly positioned, a special probe is advanced allowing the delivery of radiofrequency energy to the targeted area. An electric current is then used to cauterize the sensory nerves that innervate the facet joint(s). Before patients can be scheduled for an RF rhizotomy procedure, they generally must undergo a series of facet injections to verify the exact source of their symptoms. These tests may require several visits. If a patient’s pain can be taken away or significantly relieved with a local anesthetic block for a short term, then blocking the nerves with Radiofrequency denervation will usually give long term or even permanent relief. If successful, the pain relief following an RF procedure can last considerably longer than relief following local anesthetic and steroid blocks (Results can last from months to years.) This process can be used on any area of the spine, cervical, thoracic, or lumbar. Due to the trauma to the nerve, you may experience an increase in symptoms for 5-7 days after the procedure. Pain relief benefits should be apparent within 2-4 weeks.

Hip & Leg Pain

Radiofrequency thermocoagulation (RTFC) is a treatment utilizing radiowaves and heat to destroy tissue, in our case a nerve, for pain relief. Radiofrequency has also been used for treating fast heartbeats and tumors with great success.

Radiofrequency thermocoagulation of the spinal facet joints provides significant pain relief in well selected patients with facet joint syndrome.

RFTC is an outpatient procedure performed under local anesthesia. Intravenous sedation is used to help the patient relax. During the procedure, radiofrequency waves are transmitted through the tip of a specialized needle placed into the facet joint under x-ray guidance. The heat generated from the needle coagulates the nerve and renders it non-effective for transmitting pain impulses, thus providing pain relief.

After the procedure, the patient will be taken to the recovery room for a brief period of monitoring, and for instructions before discharge.

RFTC is a safe, non-surgical treatment. There are a few possible complications related to RFTC but the risk is low. Your doctor will gladly explain the procedure and the risks to you in detail and answer any question that you may have.

You may experience an increase in pain and/or muscle spam for the first several days following the procedure. Additional pain medications or muscle relaxants may be necessary to help you stay comfortable.

You may notice some swelling and bruising at the needle sites. Using a cold pack will ease the discomfort.

You will be given an instruction sheet on what to do and whom to call should you have any question or concern.

Your doctor will arrange a follow-up appointment or phone consult within three to four weeks after the procedure to see how you are doing.

The degree of pain relief varies from person to person. The maximum decrease in pain may take up to three or more weeks to occur. You can eventually expect 50 percent or greater pain relief. Pain relief can last from six to12 months, or longer. The nerves do repair themselves and your pain may return. The procedure can be repeated if the pain returns some later time.

It is important that you start a program of conditioning, strengthening, and range of motion exercises after radiofrequency ablation. Ideally, increased muscle strength around the arthritic joints will make pain relief more prolonged after radiofrequency ablation. With rehabilitation, when the nerves do regenerate, you will not likely experience the same intensity of pain as before the procedure.

You may be prescribed a formal physical therapy program after undergoing the RFTC procedure.

Sacroiliac Joint Injections

A sacroiliac (SI) joint injection, also called a sacroiliac joint block, is primarily used either to diagnose or treat low back pain and/or sciatica symptoms associated with sacroiliac joint dysfunction. The sacroiliac joints lie next to the spine and connect the sacrum with the hip on both sides. There are two sacroiliac joints, one on the right and one on the left. Joint inflammation and/or dysfunction in this area can cause pain. Read more about Sacroiliac Joint Dysfunction.

The purpose of a sacroiliac joint injection is two-fold: to diagnose the source of a patient’s pain, and to provide therapeutic pain relief. At times, these are separated and a patient will undergo a purely diagnostic or therapeutic injection, although often the two are combined into one injection.

CHARACTERISTICS OF PHANTOM PAIN

The Sacroiliac Joint injection procedure is usually performed in an operating room or a dedicated procedure room. The entire procedure usually takes only minutes, and the patient goes home the same day. The following outlines the typical injection procedure:

  • After informed consent has been obtained, the patient lies face down on his or her stomach on the radiography table. A pillow might be placed under the hips for patient comfort.
  • The patient’s vitals (e.g. pulse rate and blood pressure) are monitored throughout the procedure.
  • Depending on the physician and the patient’s preference, an intravenous line may be inserted to deliver medication to help the patient relax.
  • To maintain sterility, the skin overlying the sacroiliac joint injection is cleansed using an iodine based solution (e.g. Povidine-Iodine) or an alcohol-based antiseptic (e.g. chlorhexidine 0.5% in 70% alcohol). Sterile gloves are used throughout the entire injection procedure.
  • For the patient’s comfort, the needle insertion site is often numbed using local anesthetic. Once the needle enters the sacroiliac joint under fluoroscopy guidance, contrast – ‘dye’ that shows up under X-ray – is injected to verify needle placement within the sacroiliac joint and to verify spread of solution within the joint.
  • Once the needle has been guided into the joint successfully, diagnostic and/or therapeutic medications are injected into the joint.

 

Two types of medications are typically injected:

  • A local anesthetic (usually lidocaine or bupivacaine) is typically injected into the joint with the goal of determining immediate pain relief to confirm the sacroiliac joint as the source of the patient’s pain. This solution is used for a diagnostic sacroiliac joint injection.
  • An anti-inflammatory medication (usually a corticosteroid) may help reduce inflammation within the joint, which in turn could help alleviate the pain over a longer period of time (typically for several months, up to a year). This solution is injected for a therapeutic sacroiliac joint injec

Selective Nerve Root Block

n an SNRB, the nerve is approached at the level where it exits the foramen (the hole between the vertebral bodies). The injection is done both with a steroid (an anti-inflammatory medication) and lidocaine (a numbing agent). Fluoroscopy (live X-ray) is used to ensure the medication is delivered to the correct location. If the patient’s pain goes away after the injection, it can be inferred that the back pain generator is the specific nerve root that has just been injected. Following the injection, the steroid also helps reduce inflammation around the nerve root.

Success rates vary depending on the primary diagnosis and whether or not the injections are being used primarily for diagnosis. While there is no definitive research to dictate the frequency of SNRBs, it is generally considered reasonable to limit SNRBs to three times per year. Technically, SNRB injections are more difficult to perform than epidural steroid injections and should be performed by experienced physicians. Since the injection is outside the spine, there is no risk of a wet tap (cerebrospinal fluid leak). However, since the injection is right next to the nerve root, sometimes an SNRB will temporarily worsen the patient’s leg pain.

Sphenopalatine / Glossopharyngeal / Trigeminal Nerve Blocks

A Sphenopalatine Ganglion block is a minimally invasive procedure used to treat head and facial pain. While the procedure itself is short and performed in your doctor’s office, it requires a great deal of technical proficiency and very few physicians are trained on how to do it. A sphenopalatine ganglion block is an established treatment method of a wide variety of pain syndromes:

  • Trigeminal Neuralgia
  • Sphenopalatine neuralgia
  • Migraine headaches
  • Cluster headaches
  • Atypical facial pain
  • Cancer pain of the head and neck
  • Tongue and mouth pain
  • Temporomandibular joint (TMJ) pain2
  • Sluder’s neuralgia
  • Paroxysmal hemicrania

Other possible therapeutic uses reported in literature include:

  • Herpes Zoster
  • Postherpetic neuralgia
  • Vasomotor rhinitis
  • Complex regional pain syndrome (CRPS)
  • Reflex Sympathetic Dystrophy (RSD)
  • Post-traumatic headache

BENEFITS

The Sphenopalatine ganglion block is a safe, effective and established procedure for treating refractory head and face pain. Any patient suffering from facial pain, chronic headaches, trigeminal neuralgia and the like will attest to how debilitating their pain can be. Classically, these types of pain are treated with a series of medications, cycling from one to another based on trial and error. Most medications are ineffectual and those that are effective either have intolerable side effects or are the fourth or fifth medication tried. This life changing procedure can offer immediate relief and potentially allow pain sufferers to avoid the nuisance of daily medications.

Spinal Cord Stimulator / Peripheral Nerve Stimulator

Approved by the FDA in 1989, spinal cord stimulation (SCS) has become a standard treatment for patients with chronic pain in their back and or limbs who have not found pain relief from other treatments. While the treatment does not work for everyone, most patients who qualify for neurostimulation therapy report a 50 to 70% reduction in overall pain, as well as an increased ability to participate in normal family and work activities.

Many patients find that they can decrease or stop taking painkillers or other pain medications after undergoing spinal cord stimulation. Given these benefits, there has been ongoing investment and advances in spinal cord stimulation technology, and many individuals suffering from chronic pain find that neurostimulation positively impacts the quality of their lives.

In general, neurostimulation works by applying an electrical current to the source of chronic pain. This creates a pleasant sensation that blocks the brain’s ability to sense the previously perceived pain. There are two related forms of electrical stimulation commonly used to treat chronic pain:

  • Spinal cord stimulation (SCS). In spinal cord stimulation, soft, thin wires with electrical leads on their tips are placed through a needle in the back near to the spinal column. The leads are placed through a needle inserted in the back (no incision is required). A small incision is then made and a tiny, programmable generator is placed in the upper buttock or abdomen (under the skin) which emits electrical currents to the spinal column.
  • Peripheral Nerve Field Stimulation (PNFS). Very similar to spinal cord stimulation, peripheral nerve field stimulation involves placing the leads just under the skin in an area near to the nerves involved in pain.

In both approaches, the generator can be programmed in a way similar to using a remote control to adjust the television. The area or intensity of electrical stimulation can be changed, and the system can be turned on and off or adjusted as necessary to provide optimal pain relief. Although programming is initially done at the physician’s office, patients can learn how to control the stimulation on their own and adjust it to their pain levels.

Stellate Ganglion Blocks

A Stellate Ganglion Block is an injection of local anesthetic in the “sympathetic nerve tissue”, the nerves which are a part of Sympathetic Nervous System. The nerves are located on the either side of the voice box, in the neck.

The injection blocks the Sympathetic Nerves. This may in turn reduce pain, swelling, color, and sweating changes in the upper extremity and may improve mobility. It is done as a part of the treatment of Reflex Sympathetic Dystrophy (RSD), Sympathetic Maintained Pain, Complex Regional Pain Syndrome, and Herpes Zoster (shingles) involving upper extremity or head and face.

The injection only takes a few minutes and consists of a local anesthetic (like lidocaine or bupivacaine) and cortisone.

The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”). So, there is some discomfort involved. However, we may numb the skin and deeper tissues with a local anesthetic using a very thin needle before inserting the actual block needle. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easy to tolerate.

This procedure is done under local anesthesia. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easy to tolerate. The amount of sedation given generally depends upon the patient tolerance.

The injuction is performed with the patient laying flat. The chin is slightly raised. The patients are monitored with EKG, blood pressure cuff and blood oxygen-monitoring device. The skin in the front of the neck, next to the “voice box” is cleaned with antiseptic solution and then the injection is carried out.

Immediately after the injection, you may feel your upper extremity getting warm. In addition, you may notice that your pain may be gone lessen. You may also notice “a lump in the throat” as well as hoarse voice, droopy and red eye, and some nasal congestion on the side of the injection. You may also develop a headache.

After the procedure, you should get a ride home. We advise the patients to take it easy for a day or so after the procedure. Perform the activities as tolerated by you. Some of the patients may go for immediate physical therapy.

Sympathetic Nerve Blocks & RFTC

A Sympathetic Nerve Block is an injection of local anesthetic and cortisone in the “sympathetic nerve tissue”, the nerves which are a part of Sympathetic Nervous System. The nerves are located on the either side of spine, in the back.

The injection blocks the Sympathetic Nerves. This may in turn reduce pain, swelling, color, and sweating changes in the lower extremity and may improve mobility. It is done as a part of the treatment of Reflex Sympathetic Dystrophy (RSD), Sympathetic Maintained Pain, and Complex Regional Pain Syndrome.

The injection consists of a local anesthetic (like lidocaine or bupivacaine) and cortisone, and only takes a few minutes.

The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”). So, there is some discomfort involved. However, we may numb the skin and deeper tissues with a local anesthetic using a very thin needle before inserting the actual block needle. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easy to tolerate.

This procedure is done under local anesthesia. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easy to tolerate. The amount of sedation given generally depends upon the patient tolerance.

The injection is performed with the patient lying on their stomach. The patients are monitored with a blood pressure cuff and blood oxygen-monitoring device. The skin on back is cleaned with antiseptic solution and then the injection is carried out. Fluoroscopy (X-rays) is used to guide the needle(s) in the proper position.

Immediately after the injection, you may feel your lower extremity getting warm. In addition, you may notice that your pain may be gone or quite less. You may also notice some weakness and/or numbness in the leg, which is temporary.

Ganglion Impar Blocks

A ganglion of impar block is safe and easy procedure used to treat visceral, pelvic, genital, perineal and anal pain. This injection is considered to be a type of sympathetic block that can be used in the treatment of sympathetically-mediated pain, pain secondary to malignancy, neuropathic pain and post-surgical pain. Patients who will benefit from this blockade will frequently present with vague and poorly localized pain in the “seat” region, which is burning in character and frequently accompanied by sensations of urgency with urination and/or defecation.

Ever since Plancarte et al. (1990) introduced and described their approach to performing the impar ganglion block via the horizontal approach through the anococcygeal ligament, researchers to date continue to introduce modified techniques that attempt to maximize the ease of performing this block, while maintaining patient safety and increasing the chance of maximal pain alleviation for their patients. A successful ganglion impar block is marked by profound pain relief. Local anesthetic is usually administered for diagnostic ganglion impar blocks or for patients with noncancer-related pain. For patients who have a documented response to the administration of local anesthetic onto the ganglion impar, a therapeutic block is preformed with administration of the neurolytic agent like phenol. Radioablation of the ganglion impar is also another treatment modality for longer-lasting pain relief. The procedure usually takes less than 15 minutes. Sometimes your physician will recommend intravenous sedation to make the procedure more comfortable. Your physician will monitor your pain and vital signs (pulse, blood pressure, temperature) after the procedure.

SYMPTOMS

  • Pain that is usually related to activity and will flare up at times but then return to a low-grade pain level, or the pain will go away entirely
  • The amount of chronic pain referred to as the patient’s baseline level of pain is variable between individuals and can range from almost no pain/just a nagging level of irritation, to severe and disabling pain
  • Severe episodes of back or neck pain that will generally last from a few days to a few months before returning to the individual’s baseline level of chronic pain
  • Chronic pain that is completely disabling from degenerative disc disease does happen in some cases, but is relatively rare
  • Activities that involve bending, lifting, and twisting will usually make the patient’s pain worse
  • Certain positions will usually make the pain worse.
  • Walking, and even running, may actually feel better than prolonged sitting or standing
  • Patients will generally feel better if they can change positions frequently
  • Patients with lumbar DDD will generally feel better lying in a reclining position (such as with legs propped up in a recliner), or lying down with a pillow under the knees, since these positions relieve stress on the lumbar disc space

Trigger Point Injections

Trigger point injections (TPI) may be an option for treating pain in some patients. TPI is a procedure used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax. Many times, such knots can be felt under the skin.
Trigger points may irritate the nerves around them and cause referred pain, or pain that is felt in another part of the body.

In the TPI procedure, a health care professional inserts a small needle into the patient’s trigger point. The injection contains a local anesthetic or saline, and may include a corticosteroid. With the injection, the trigger point is made inactive and the pain is alleviated. Usually, a brief course of treatment will result in sustained relief. Injections are given in a doctor’s office and usually take just a few minutes. Several sites may be injected in one visit. If a patient has an allergy to a certain drug, a dry-needle technique (involving no medications) can be used.

TPI is used to treat many muscle groups, especially those in the arms, legs, lower back, and neck. In addition, TPI can be used to treat fibromyalgia and tension headaches. The technique is also used to alleviate myofascial pain syndrome (chronic pain involving tissue that surrounds muscle) that does not respond to other treatments. However, the effectiveness of TPI for treating myofascial pain is still under study.