PAIN MANAGEMENT PROCEDURES

caring_handsPain-Free Patient Care

Customer service and patient satisfaction are our top priorities. Our entire health care team is dedicated to providing personal attention to address the unique concerns of all of our patients. We practice the highest quality medicine and procedures when treating any condition. Diagnostic studies and medication may be prescribed. Interventional procedures indicated vary from less-invasive steroid injections to more complex procedures, such as percutaneous disc decompression and implantable devices, including spinal cord stimulators and programmable medication pumps.

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New Technology for Chronic Pain Sufferers

Administering ultrasound guided joint injections is a non-invasive, non-ionizing interventional pain management modality thats gaining popularity. The option provides direct visualization of soft tissues while offering real-time needle advancements without the risks of radiation. Doctors can diagnose soft tissue areas impacted by pain as they are administering cortisone injections. This diagnostic ability allows the provider to target the pain with greater precision. Ultrasound guided joint injections offer an easier and more effective way to free patients from pain.

* Treatment plans range from less invasive procedures such as Platelet Rich Plasma Injections to more complex procedures such as Kyphoplasty, MILD procedure, Percutaneous Disc Decompression, Spinal Cord Stimulators, and Programmable Medication Pump Implants. Contact us today to schedule an appointment.

TREATMENTS OFFERED

Epidural Anesthetic Block & Steroid Injection

WHAT IS IT? 

A block that is performed under fluoroscopy to confirm a specific diagnosis and/or decrease pain and inflammation.

HOW IS IT DONE? 

A local skin anesthetic is given. A special needle is then inserted into the epidural space of the Cervical, Thoracic, lumbar or caudal spine. Fluoroscopy is used to guide the needle and prevent complications from the needle. Contrast medium is injected into the space to confirm proper placement and outline the effect of the herniation on the spine and nerve roots, films are taken for review with the patient. An anesthetic and then a steroid (usually a long acting- slow release type of cortisone) are injected into the epidural space.

EXPECTED RESULTS? 

Relief of pain if the medication reaches the inflamed area or source of pain.

HOW LONG DOES IT TAKE? 

Fifteen minutes plus approximately fifteen to forty-five minutes recovery time depending or not as to whether sedation is given.

Epidural Nerve Blocks  Cervical / Thoracic / Lumbar

An epidural steroid injection is performed to help reduce the inflammation and pain associated with nerve root compression. Nerve roots can be compressed by a herniated disc, spinal stenosis, and bone spurs. When the nerve is compressed it becomes inflamed. This can lead to pain, numbness, tingling or weakness along the course of the nerve. This is called radiculopathy. The goal of the epidural steroid injection is to help lessen the inflammation of the nerve root.  The epidural space is located above the outer layer surrounding the spinal cord and nerve roots. An epidural steroid injection goes into the epidural space, directly over the compressed nerve root.

Kyphoplasty

A medical procedure that is similar to vertebroplasty in the use of acrylic cement to stabilize and reduce pain associated with a vertebral compression fracture but that additionally restores vertebral height and lessens spinal deformity by injecting the cement into a cavity created in the fractured bone by the insertion and inflation of a special balloon.

Spinal Cord Stimulator Trial, Implant, and Management

A medical procedure that is similar to vertebroplasty in the use of acrylic cement to stabilize and reduce pain associated with a vertebral compression fracture but that additionally restores vertebral height and lessens spinal deformity by injecting the cement into a cavity created in the fractured bone by the insertion and inflation of a special balloon.

MILD (Minimally Invasive Lumbar Decompression) Procedure

MILD is a safe procedure that can help patients diagnosed with lumbar spinal stenosis (LSS) stand longer and walk farther with less pain. It is a short, outpatient procedure, performed through a very small incision (about the size of a baby aspirin) that requires no general anesthesia, no implants, and no stitches.

Narcotic Pump Trial, Implant, and Management

A spinal infusion pump implant, commonly known as a morphine pump, is a specialized device which delivers concentrated amounts of medication into the spinal fluid space via a small catheter. The intrathecal space is the sac that contains the spinal fluid. The spinal infusion pump is also known as an intrathecal infusion pump.

Morphine Pump Implants

Transforaminal Nerve Blocks - Cervical / Thoracic / Lumbar / Sacral

Facet Joint Injections - Cervical / Thoracic / Lumbar

Also known as a zygapophysial joint block, the facet joint block is performed to determine whether a facet joint is a source of pain. Facet joints are located on the back of the spine, where one vertebra slightly overlaps another. These joints guide and restrict the spines movement.

Facet Block

WHAT IS IT?
A block (or local anesthetic injection) that is performed to confirm that a facet joint is the source of pain and decrease pain and inflammation in a facet joint or joints.

Actually this is the only true way to diagnose facet joint syndrome, as an abnormal looking joint on x-ray or ct scan, may be painless, and vice versa a normal looking joint may be the pain generator.

HOW IS IT DONE?
The patient is given the option of light, (or deep in rare cases) iv sedation under monitoring of the ekg, pulse oximeter, etc by a board certified anesthesiologist. A tiny needle (smaller than the size of a paper clip) is then inserted into the area of the facet joint where the nerve reaches it (or directly inside the facet capsule, in some cases) and the physician injects an anesthetic and steroid.

This is done under fluoroscopy. I usually do the first one with a short acting local to quickly diagnose the levels of facet injury involved.

EXPECTED RESULTS?
Decrease in or relief of back pain. More importantly confirmation of the diagnosis, with the allowance of rational treatment.

HOW LONG DOES IT TAKE?
Fifteen to thirty minutes, depending on the number of levels performed.

Note: Injections may be done in conjunction with massage, myo-fascial release, or “light” physical therapy especially ultrasound and stimulation. Chiropractic will universally aggravate facet joint syndrome and must be avoided at all costs.

RISK / BENEFIT RATIO:
Probably the easiest of all interventional procedures (provided done by a board certified physician with experience), with the lowest risk and most benefits.

OTHER THERAPY:
Once, the diagnosis is made by a prognostic block, the block may be repeated with a longer acting local and depot steroid preparation. Some milder cases may be treated, by improving posture, spine bracing during lifting/exercise and anti-arthritic agents such as motrin or the newer (cox-2) inhibitors such as celebrex or vioxx. If the pain recurs, pulsed radiofrequency is the definitive treatment (see inside).

FACET JOINT SYNDROME (Definition):
A constellation of symptoms which result in diffuse pains that do not fit a clear nerve root pattern (e.g. Not sciatica), these pains are worsened with movement of the spine, poor posture, often sleep, sometimes associated with cold burning sensations, usually worsened by cold damp weather and are now known to emanate from the tiny medial branch nerves that supply the facet joint.

Remember the only way to definitively make the diagnosis is by a diagnostic/prognostic facet block.

Radiofrequency Neuroablation - Cervical / Thoracic / Lumbar / Sacroiliac Joint

Discograms - Cervical / Thoracic / Lumbar

Discography confirms or denies the disc(s) as a source of your pain. It is a relatively simple procedure that uses a small needle to inject contrast dye into your disc. MRI and CT scans only demonstrate anatomy and cannot absolutely prove your pain source. In many instances, discs are abnormal on MRI or CT scans but are not a source of pain. Only discography, which is a functional test, can tell if the disc itself is a source of your pain. Discography is usually done only if you think your pain is significant enough for you to consider more advanced treatment options, directed at the disc itself, such as surgery.

Sacroiliac Joint Injections

Sacroiliac joint injections are 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.

Intra-Articular Hip, Knee and Shoulder Injections

An intra-articular injection is typically given when a joint with localized pain (acute or chronic) has not responded to or stops responding to oral pain medication, oral anti-inflammatory medication, or other conservative treatment options. Intra-articular injections have been a treatment option for decades.

Trigger Point Injections

Trigger point injections are an effective treatment modality to inactivate trigger points and provide prompt relief of symptoms from myofascial pain syndrome. [1] Myofascial pain syndrome is a common painful muscle disorder characterized by myofascial trigger points. It is distinguishable from fibromyalgia syndrome, which involves multiple tender points, although these pain syndromes may be concurrent.

Botox Injections

Although botulinum toxin is a lethal, naturally occurring substance, it can be used as an effective and powerful medication.  Researchers discovered in the 1950s that injecting overactive muscles with minute quantities of botulinum toxin type-A would result in decreased muscle activity by blocking the release of acetylcholine from the neuron by preventing the vesicle where the acetylcholine is stored from binding to the membrane where the neurotransmitter can be released. This will effectively weaken the muscle for a period of three to four months.

Sympathetic Blocks - Cervical / Thoracic / Lumbar / Pelvic

A sympathetic nerve block is one that is performed to determine if there is damage to the sympathetic nerve chain. This is a network of nerves extending the length of the spine. These nerves control some of the involuntary functions of the body, such as opening and narrowing blood vessels.

Intercostal and Peripheral Nerve Blocks

Peripheral nerve blocks play an important role in the anesthetic plan for patients undergoing many types of surgical procedures. A peripheral nerve block is accomplished by injecting a local anesthetic near the nerve, or nerves, that control sensation and movement to a specific part of the body. This injection will temporarily numb the area in question, resulting in a number of benefits. An intercostal nerve block is an injection of a steroid or other medication around the intercostal nerves that are located under each rib. The steroid injected reduces the inflammation and/or swelling of tissue around the intercostal nerves, in between the ribs or in the chest wall.

Stellate Ganglion Block

This is a type of sympathetic nerve block performed to determine if there is damage to the sympathetic nerve chain supplying the head, neck, chest, or arms and if it is the source of pain in those areas. Although used mainly as a diagnostic block, the stellate ganglion block may provide pain relief in excess of the duration of the anesthetic.

Ilioinguinal Nerve Blocks

The ilioinguinal nerve originates from the first low back (lumbar) spinal nerve. This nerve wraps above the iliac crest (upper ridge of hip bone) and travels into the groin. It provides sensation to the upper inner thigh, groin, and perineum. The perineum is between the anus and scrotum in men and between the anus and vaginal (and labia) opening in women. Damage to the ilioinguinal nerve can be caused by surgery, trauma, and infection. Pain can be severe and be felt in the groin, testes (men), labia (women), groin, and inner thigh.

 

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.

Costovertebral Joint Block

WHAT IS IT?
A block that is performed under fluoroscopy to identify the costovertebral joint as the pain generator and decease or relieve pain in that area and out toward the lateral rib cage.

HOW IS IT DONE?
The patient is placed in a prone position and given a local skin anesthetic. Under fluoroscopy the specific costovertebral joint(s) is identified. A needle is placed in that area(s) and an anesthetic and steroid are injected.

HOW LONG DOES IT TAKE?
Fifteen to thirty minutes.

EXPECTED RESULTS?
Initially, when a needle is inserted in the costovertebral area(s), there will be a reproduction of pain. Following injection of the medications there may be relief of pain and increased mobility. Duration of relief varies with the individual.

Platelet Rich Plasma Injections

Platelet rich plasma (abbreviated PRP) is a new treatment used for some common orthopedic conditions. PRP is a concentration of platelet cells taken from your blood, and these platelets have growth factors that may help in the healing process of chronic injuries. Growth factors are chemicals that signal the body to initiate a healing response. By injecting PRP into areas of an injury, the hope is to stimulate and optimize your body’s ability to heal the chronic conditions.

Stellate Ganglion Block

WHAT IS IT?
A block that is performed under fluoroscopy to determine if the sympathetic nerve chain in the neck is the source of the patient’s arm pain. This is primarily a diagnostic block but it may provide pain relief in excess of the duration of the anesthetic.

HOW IS IT DONE?
A local skin anesthetic is given near the base of the neck on the affected side. A needle is inserted near the transverse process of the cervical spine (usually at the cervical-6 level) with the guide of fluoroscopy. Sterile tubing is attached to the needle and anesthetic medication is slowly injected through the tubing.

HOW LONG DOES IT TAKE?
It takes less than thirty minutes for the procedure followed by evaluation and recovery for several hours.

EXPECTED RESULTS?
The patient may note increased warmth and redness of the painful arm during and after the injection. The patient can expect hoarseness of their voice, redness of the eye, drooping of the eyelid and pupillary constriction for four to eight hours after the injection. Pain relief may be noted immediately. Duration of relief is variable. The patient must assess their pain relief over the first three to four hours after the injection and report this on a diary card.

Again as in above, one can repeat this block many times in the hopes of shutting the pain generation down. I only rarely do a permanent block at this area, due to the permanent changes of the eye and the voice, i usually will prefer to do a thoracic sympathectomy if necessary (see above).

Selective Nerve Root Block (SNRB)

WHAT IS IT?
A block that is performed to determine if a specific spinal nerve root is the source of pain and reduce inflammation around the nerve root (usually from a herniated disc at this level) thus decreasing or relieving the pain.

HOW IS IT DONE?
The patient is given a local anesthetic – the physician then locates, under fluoroscopy, a specific spinal nerve root. A needle is introduced through the skin into the area adjacent to the nerve root. Dye is injected to confirm proper placement. Medication (anesthetic then steroid) is then injected into the area bathing the nerve root.

EXPECTED RESULTS:

Relief of back and leg pain.

HOW LONG DOES IT TAKE?
Fifteen to twenty minutes, plus recovery time.

Sympathetic Nerve Block

WHAT IS IT?
A block that is performed to determine if there is damage to the sympathetic nerve chain and if it is the source of pain. This is a diagnostic test primarily, but it may provide relief far in excess of the duration of the anesthetic.

HOW IS IT DONE?
A local skin anesthetic is given in the lumbar or thoracic area of the back. A needle is then inserted into the back under fluoroscopy next to the vertebral body at the block may be performed on both sides of the spine if symptoms are on both sides. An anesthetic medication will be injected into the appropriate ganglion area of suspected pain.

EXPECTED RESULTS?
The patient may note redness of the upper or lower extremity and a feeling of warmth.

HOW LONG DOES IT TAKE?
It takes thirty minutes for the procedure followed by evaluation and recovery for several hours.

USUAL COURSE OF TREATMENT
Once the sympathetic chain is identified as the source of pain, medications may be given by mouth to decrease this type of pain. I usually perform repeated injections of the sympathetics to try and shut the pain generation cycle down. If repeat blocks fail, then i perform pulsed or conventional radiofrequency (see below) denervation or sympathectomy of these nerves to permanently shut the pain generation down.

FACET JOINT SYNDROME (Definition): 

Perhaps for me this is the simplest problem to treat, but hardest to explain. Even to doctors!!! The problem is that it was not understood until the late 1980s that the nerves to the Facet Joints could cause severe and diffuse pain. The pain does not follow a nerve root. It is actually referred pain, as the brain has trouble localizing these internal structures.

Consider the case of the man who has a heart attack and presents with pain under his left side of his breast bone, piece of cake. Another man may have a heart attack and present with pain in the left arm, jaw or even stomach or gall bladder area. The problem is that pain is interpreted differentially in different individuals.

It is usually caused by trauma (auto accidents, whiplash, a bad fall) or a degenerated or herniated disc. These all cause the spine to sub-lux (move out of joint) and the joint capsule is ripped.  It is usually worsened by sudden movements or prolonged episodes of poor posture, (e.g. kneeling in the garden, bending over to lift or straining to read a book or a computer terminal). Many patients find the worst time is at night, when all the muscles relax and the joints grind together.  It is typically mistaken for fibromyalgia or myo-fascial syndrome. Both of these are garbage or waste basket terms.

Stem Cell Injections

Spinal Cord Stimulation

Discogram

WHAT IS IT? 

A discogram is a diagnostic injection performed into the disc (structure between the veterbra) to view and assess the internal structure of a disc and determine if it is a source of pain.

HOW IS IT DONE? 

The patient is given intravenous medication as a relaxant and pain reliever. A local anesthetic is injected into the patient’s skin in the area that is being examined. A needle is inserted through a previously placed needle in the skin and into the disc under fluoroscopy. A saline solution and radio-opaque dye are injected into the disc or discs if more than one disc is being examined. A CT scan is usually performed on the painful disc after the dye is injected to obtain images of the dye distribution. This will demonstrate annular tears, scarring, disc bulges and changes in the nucleus of the disc.

EXPECTED RESULTS?
1. Recreation of painful symptoms if the disc/discs is/are abnormal.
2. Confirmation of a diagnosis and/or determination of which disc/discs is/are the source of pain.

HOW LONG DOES IT TAKE?

Thirty minutes plus an additional thirty minutes if a CT is indicated plus recovery time of several hours.

Conventional Facet Neurotomy Conventional Facet Neurotomy (Medial Branch Rhizotomy)

WHAT IS IT?
Facet neurotomy is a procedure, which results in interruption of the nerve supply to a facet joint. This interruption known as denervation, is accomplished by a radio-frequency probe that heats and destroys the 2 small nerve branches to each facet joint. These nerves are called the medial branches.

HOW IS IT DONE?
With the patient in a prone position and under local anesthesia and fluoroscopic guidance, a radio-frequency needle is advanced to the base of the transverse processes. The needle is placed along the course of the medial branch. The needle is heated to 70 to 80° c for 90 seconds. At least 2 branches for each joint are treated in this same manner.

HOW LONG DOES IT TAKE?
The neurotomy takes 30 to 45 minutes, depending on the number of levels to be done. The patient is then recovered in the observation area for 30 minutes to 1 hour.

POTENTIAL RISK?
Increased localized back pain and/or leg pain can be expected from several days to several weeks and rarely several months. Destabilization of the facet joint is a risk and post injection training to strengthen the extensor muscles can prevent this possibility.

EXPECTED RESULTS?
Following the neurotomy, there is a 70% chance of pain relief, if the symptoms are only from the facet joints. This typically lasts for 9 months to 1 1/2 years. The nerve eventually grows back and the procedure can be repeated. While the patient is experiencing pain relief, vigorous physical therapy is necessary to try and strengthen the involved facet joint(s). Many patients have a combination of facet and discogenic pain, and require separate treatments.

Pulsed Radiofrequency Facet Neurotomy

WHAT IS IT?

This is similar to the conventional facet neurotomy; except that pulsed radiofrequency waves are delivered at a lower temperature (just three to five degrees over body temperature). It is thought that by avoiding the burning, that less damage to the nerve is done, and that there are fewer tendencies for the nerve to want to regenerate. In addition, the pulse radiofrequency creates an electro-magnetic field that may reprogram the dna in the nerve to stop pain transmission. This technique was recently FDA approved.

HOW LONG DOES IT TAKE?
The neurotomy takes 30 to 45 minutes, depending on the number of levels to be done. The patient is then recovered in the observation area for 30 minutes to 1 hour.

POTENTIAL RISK?
Increased localized back pain and/or neck pain can be expected from several days to two weeks and rarely beyond this. There is less nerve damage potential than the conventional neurotomy and thus in my opinion it is the procedure of choice. It may be in the dna or other structures of the nerve are scrambled, as opposed to the whole nerve being burned with conventional radiofrequency.

IV Vitamin Therapy

Nutritional Consultations

Epidurolysis / Epiduroscopy

Additional procedures available at Integrated Pain Management Specialists, include:

  • Knee Injections
  • Nucleoplasty
  • Discography
  • Electrical Stimulation Therapy
  • Nerve Conductions Study

DEFINITIONS & GLOSSARY

Dura

The dura is a hard covering of the spinal cord which prevents fluid from leaking out,  protecting the spinal cord and nerve roots.

Facet Joints

Joints located on the back of the spine on each side where one vertebra slightly overlaps the adjacent vertebrae. They guide and allow the complicated movements of the spine. They are like the facets of a diamond, which is smooth and have almost no friction.

Facet Joint Syndrome

A constellation of symptoms which result in diffuse pains that do not fit a clear nerve root pattern (e.g. not sciatica), these pains are worsened with movement of the spine, poor posture, often sleep, sometimes associated with cold burning sensations, usually worsened by cold damp weather and are now known to emanate from the tiny medial branch nerves that supply the facet joint.

Remember the only way to definitively make the diagnosis is by a diagnostic/prognostic facet block.

Facet Neurotomy

A procedure that results in interruption of the nerve supply to a facet joint.

Fluoroscopy

X-ray like imaging (which uses much less radiation) of a part of the body that is displayed on a screen or monitor in the block suite – this facilitates and assures proper placement of the needle and medication. There is also an intensifier, which magnifies the image, and improves the accuracy of the treatment. Furthermore, a hard copy can be made for insurance, medical legal and purposes of comparison.

Epidural

An epidural is the space outside the dura or covering of the spinal cord and inside the spinal canal. This space runs the length of the spine.

Inflammation

Tissue reaction to irritation

Pain Block

A pain block is an anesthetic injection near or in a certain area that is thought to cause or generate pain.

Sympathetic Nerves

A network of nerves extending the length of the spine that control some of the involuntary functions of the body such as opening and narrowing blood vessels. They are involved in RSD or chronic regional pain syndrome.