Conditions We Treat
- Chronic back and neck pain
- Facet joint pain
- Acute back and neck pain
- Sciatica/radicular pain
- Whiplash injuries
- Painful neuropathy
- Cancer pain
- Piriformis pain
- Migraine headaches
- Occipital headaches
- Trigeminal nerve pain
- Facial pain
- Persistent pain after surgery
- Complex regional pain syndrome (CRPS)
- Painful joints and extremities
- Vertebral compression fractures
About Pain Treatment
Chronic vs. Acute Back Pain
Chronic back pain is commonly described as deep, aching, dull or burning pain in one area of the back or traveling down the legs. Patients may experience numbness, tingling, burning, or a pins-and-needles type sensation in the legs. Regular daily activities may prove difficult or impossible for the chronic back pain patient. They may find it difficult or unbearable to work, for example, even when the job does not require manual labor. Chronic back pain tends to last a long time and is not relieved by standard types of medical management. It may result from a previous injury long since healed, or it may have an ongoing cause, such as nerve damage or arthritis.
Acute back pain is commonly described as a very sharp pain or a dull ache, usually felt deep in the lower part of the back, and can be more severe in one area, such as the right side, left side, center, or the lower part of the back. Acute pain can be intermittent, but is usually constant, only ranging in severity. Sometimes, acute back pain can be caused by injury or trauma to the back, but just as often has no known cause. Patients with acute back pain, even when it’s severe, will typically improve or completely recover within six to eight weeks.
Approximately half of all back pain patients have acute pain caused by trauma. A contusion, torn muscle, or strained joint resulting from a back injury can cause acute pain. Patients with any of these conditions typically exhibit pain, muscle spasms and decreased functional activities. Treatment is short-term and usually successful. With physical therapy, follow-up treatment and prevention practices, these patients typically return to full functionality in a few weeks. Occasionally, these patients will re-injure themselves and have to return for a short course of treatment. Patients with acute pain occurring more than three times in one year or who experience longer-lasting episodes of back pain that significantly interfere with functional activities (e.g., sleeping, sitting, standing, walking, bending, riding in or driving a car) tend to develop a chronic condition.
Mechanical back pain – a form of acute pain – is aggravated by movement and worsened by coughing. This type of pain is usually alleviated with rest. Mechanical back pain is typical of a herniated disc or stress fracture. For patients with this condition, forward movements of the spine usually cause pain. In addition, one’s posture, coughing, sneezing and movement can all influence pain coming from the spine. When acute back pain is severe and travels down both legs, it could be caused by lumbar disc disease – the most common cause of true sciatica, another form of acute pain.
Diagnosing with Injections
Even if the injections do not alleviate a patient’s pain, they may help diagnose the pain; even for those without definitive MRIs. By using an anesthetic either before or after the steroid injection, we can test for the source of the pain. If the pain stops right after a shot of anesthetic, then its clear the injected area is the source of the pain. It is possible that the patient may have a nerve root irritation even though a MRI does not show a significant bluge. As the space for the nerve root gets tighter and the nerve becomes inflamed, patients can experience ongoing pain without a definitive diagnosis on a MRI. The block may be very helpful in this situation.
Therapeutic vs. Diagnostic Injections
Diagnostic injections allow us to confirm pain originating from a specific nerve through injection of anesthetic into the area surrounding the suspected nerve. This process of correctly identifying the nerve generating the pain signal is perhaps the most important step in the treatment process.
Therapeutic injections are performed to deliver a therapeutic benefit, mainly relief from pain. These injections can provide sufficient pain relief and allow most patients to progress with their rehabilitation program (physical therapy, chiropractic manipulation, etc).
Low back pain is the most prevalent cause of disability in people under age 45, and of the $27 billion spent on all trauma to the musculoskeletal system, $16 billion is spent in the management of low back pain. More than half of that $16 billion is being spent on surgical treatment.
If you have any of the following back pain symptoms, contact a doctor immediately:
- Pain is worse when you cough or sneeze
- Pain or numbness travels down one or both legs
- Pain awakens you from sleep
- You find it difficult to pass urine or have a bowel movement
- Pain is accompanied by loss of control of urination or bowel movements
These important back pain symptoms could signal nerve damage or other serious medical problems. There are many other conditions that could be causing these problems, but an early and accurate diagnosis is vital for successful treatment.
Selective Nerve Root Blocks
A SNRB is primarily used to diagnose the specific source of nerve root pain, and secondarily, for therapeutic relief of low back pain and/or leg pain.
When a nerve root becomes compressed and inflamed, it can produce back and/or leg pain. A MRI may not clearly show which nerve is causing the pain. A SNRB injection is performed to assist in isolating the source of pain. In addition to its diagnostic function, this type of injection can also be used as a treatment for a far lateral disc herniation (a disc that ruptures outside the spinal canal).
In a SNRB, the nerve is approached at the level where it exits the foramen (the hole between the vertebrates). 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 precisely where it is needed. If the patient’s pain diminishes completely after the injection, it can be inferred that the 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.
Sympathetic Nerve Blocks
Chronic pain conditions often involve malfunctions of the sympathetic nerves. These nerves regulate blood flow, sweating, and glandular function. Blocks of these sympathetic nerves can provide important diagnostic information, and can also lead to a reduction of the pain. Following are four examples of sympathetic nerve blocks.
- The sympathetic nerves of the stellate ganglion lie just in front of the spine in the lower neck. Blocking these nerves can help with pain stemming from the face, arms and hands.
- The lumbar sympathetic nerves in front of the spine of the lower back can be blocked to help with pain originating from the legs and feet.
- Pelvic pain often involves the sympathetic nerves in front of the sacrum. These nerves can be blocked with injections just above or below the sacrum.
- The celiac plexus (the solar plexus) is a bundle of sympathetic and sensory nerves that transmit much of the sensation from the abdominal organs. Celiac plexus blocks can help control a variety of chronic abdominal pains.
Epidural Steroid Injection
An Epidural Steroid Injection (ESI) is a safe, non-surgical treatment that is commonly used to decrease pain and inflammation. This procedure involves injection of anesthetic pain medicine and steroid, similar to cortisone, into the epidural space where irritated spinal nerves are located. ESI is a minimally invasive therapy which may relieve pain in the neck, back, arms, and legs due to a variety of spine conditions.
Conditions treated by Epidural Steroid Injections:
ESI may be done for diagnostic purposes to identify a structure within the epidural space as a pain generator. ESI is also used to effectively treat the following conditions:
– Radiculopathy (pain affecting the arms, legs, or trunk due to spinal nerve compression)
– Recurrent pain after surgery
– Torn or herniated discs
– Spinal stenosis (narrowed spinal canal)
– Spondylolithesis (slippage of the vertebral column)
– Pain related to Shingles.
During the procedure:
This procedure is conducted with the patient positioned on his or her stomach. The skin on the back is disinfected and then sterile drapes are placed. IV sedation may be used in addition to local anesthetic for comfort. Although several techniques exist to perform this injection, CPS physicians use fluoroscopy (low-dose X-ray guidance) as well as contrast dye for maximum accuracy during all ESIs. Only non-particulate steroids are used for these injections. ESIs may be performed in the cervical, thoracic, or lumbar spine. Most patients tolerate this procedure well with minimal, if any, discomfort.
ESI follow up:
Pain relief may occur within 1 hour of the injection if local anesthetic is used with the steroid. This may wear off within a few hours and discomfort may recur prior to onset of the steroid in 2-5 days. You may notice heaviness or numbness in your legs after the injection, which typically improves within minutes to hours. Discomfort at the injection site is usually mild and may be treated with an ice pack if necessary. The number of injections needed will depend on your response to each treatment. If sustainable pain relief occurs after one injection, it is unlikely that further treatment will be required. Although up to three injections may be performed several weeks apart, every patient is different. If zero pain relief occurs after the first ESI, your doctor may recommend a different treatment for your pain.
Possible side effects and complications:
ESIs have been considered a safe and effective treatment for decades. Minor side effects from the injected medications may occur, and include difficulty sleeping for several days, itching, flushing, and possibly nausea. Patients with Diabetes should monitor their blood sugar closely for the first few days after the injection. Serious complications are rare, and these will be discussed with you prior to the injection.
Spinal Cord Stimulation
Description of the Spinal Cord Stimulator (SCS) device:
Spinal cord stimulation is a safe, minimally-invasive treatment for certain types of chronic pain. A spinal cord stimulator is an implanted device used to generate low level electric fields over the spinal cord and spinal nerves by way of electrical impulses. These impulses provide a pleasant sensation which interrupts the nerve conduction of pain. This procedure is performed by placing small leads in the epidural space behind the spinal cord. For most patients, 2 leads will be necessary. Each system is programmable with a remote control, so patients may adjust the type, frequency, and intensity of sensation provided.
SCS is most often used for patients with chronic neuropathic pain that has not responded adequately to more conservative treatment. Neuropathic pain relates to discomfort from damaged and malfunctioning nerve tissue. Common examples include patients with post-laminectomy (after spine surgery) pain, radiculopathy, peripheral neuropathy including neuropathy from Diabetes or chemotherapy, and Complex Regional Pain Syndrome. Ideally during treatment with SCS, patients will notice improved pain control, decreased need for pain medication, and improvement in the functions of daily living.
SCS treatment is performed in 2 steps with a trial followed by a permanent implant. First, patients with have a trial with a temporary system which will be removed after about 7 days. This gives patients the opportunity to experience SCS treatment prior to undergoing a permanent implant. Trial lead placement is performed under sterile conditions with IV anesthesia along with monitors for blood pressure, heart rate, and oxygen. This procedure is conducted with x-ray guidance with the patient lying on his or her stomach. For most patients, two needles will be used to access the epidural space, through which leads are threaded. For pain involving the low back, legs, or feet, the leads are placed in the midline or the low back. Pain affecting the arms or upper body necessitates lead placement at higher levels over the spine. Once the leads overlie the proper position, each is connected to an external device. When SCS signals are felt t to cover the painful areas, the needles are removed and each lead is secured to the skin using a small stitch and an adhesive bandage.
Patients can go then home the same day and try different programs of device stimulation over the next week using a remote control programmer. Placement of SCS trial leads is an outpatient procedure, and each patient will need a ride home the same day. Patients may experience some soreness at the side of needle placement, which usually resolves after a day or two. Although patients can complete most usual daily activities during the trial period, it is best to avoid bending or twisting of the spine as much as possible.
If the SCS trial provides increased comfort, decreases the need for medications, or helps a patient become more functional, he or she will be a candidate for permanent device placement. Permanent SCS devices are usually implanted several weeks after the trial period. Most permanent SCS batteries are rechargeable and may need to be replaced after several years. Your physician will provide further information about placing permanent systems during your appointment.
Risks associated with SCS treatment are minimal, but may include bruising or soreness, and less commonly headache, bleeding, infection, weakness or numbness. Generally, metal detectors and airport security do not pose issues for people treated with SCS. Regardless, all patients will be provided with identification indicating that a metal device has been implanted.
Radiofrequency ablation (RFA) involves the application of heat energy to nerve branches in order to interrupt pain signal conduction. Heat is created from a generator and is delivered over nerve surfaces with precise needle placement. This procedure is used to provide semi-permanent pain relief when injections or nerve blocks do not provide sustainable benefit. Pain may be eliminated for several months up to greater than 1 year.
Conditions treated with RFA:
Several chronic conditions may respond to RFA including spinal arthritis (spondylosis), post-traumatic pain such as whiplash, pain after spine surgery, and even some types of headaches. Most patients will require 1-2 diagnostic nerve blocks to predict the highest likelihood that the pain will improve after RFA.
Description of the RFA procedure:
Patients who have experienced pain relief after facet injections or medial branch blocks may be candidates for RFA. The procedure is conducted with the patient positioned on his or her stomach. The skin overlying the affected area will then be disinfected and draped with sterile towels. IV sedation may be used to for comfort during the procedure. After local anesthetic is placed, your doctor will insert a needle over the targeted nerves. After testing the needle placement with a small electric current, local anesthetic is injected to numb the targeted area. These needles are then heated such that the nerves will be prevented from conducting pain signals. Fluoroscopy, a type of x-ray, is always used to ensure the safe and proper position of the needle.
After the procedure:
You will be monitored for approximately 30 minutes after the procedure. Most people tolerate RFA well, though you may feel some irritation or soreness at the site of the procedure. This discomfort usually resolves within several days and may benefit from application of ice packs. You should be able to return to work the day after the procedure.
Sacroiliac Joint Injection
Sacroiliac (SI) joint description:
The SI joint is a large, C-shaped joint between the sacrum and ilium of the pelvis, which is a common source of low back pain. The sacrum supports the lumbar spine and is bordered on either side by the ilium, the largest bone of the pelvis. SI joints are capable of movement, and are covered in several layers of ligaments. SI joint pain may be unilateral (one side) or bilateral (both right and left). Discomfort from the SI joint may feel aching, stiff, or sharp, and can affect the low back, buttocks, and groin. Occasionally, pain from the SI joint radiate past the level of the knee. Pain is often worse with activities and may be better with rest. SI joint pain may result from multiple causes such as injury, arthritis, certain genetic conditions, or even pregnancy. Inflammation of the SI joints may also occur due to abnormal motion in the joint or muscle imbalances.
During an SI joint injection:
An injection can be used to diagnose and treat SI joint pain. If the injection lessens your pain and helps you move your hips or back more easily, then your doctor will know that this joint is a likely source of pain. The procedure is conducted with the patient positioned on his or her stomach. The skin overlying the targeted SI joint will then be disinfected and draped with sterile towels. IV sedation may be used in some cases to help with relaxation. After anesthetic is placed, your doctor will insert a thin needle directly into the SI joint. Fluoroscopy, a type of x-ray, is always used to ensure the safe and proper position of the needle. A dye will also be injected to make sure the medicine is directed into the correct structure, providing an appropriate outline of the joint known as an arthrogram. Once the needle is in the correct location, a local anesthetic and a steroid will be injected. For only diagnostic information in some cases, local anesthetic will be used to block the sacral lateral branch nerves which carry pain signals from the SI joint.
SI joint injections are a safe, effective way to diagnose and treat back pain. As with all invasive medical procedures, there are potential risks, however complications are rare. Some patients may experience a brief and mild reaction to the steroid itself, including flushing, a feeling of warmth, agitation, or sweating. Your doctor will more thoroughly discuss risks and benefits prior to your injection.
Stellate Ganglion Block
The stellate ganglion is part of a neural network in the sympathetic nervous system, located near the front of the neck. Occasionally, the sympathetic nervous system can cause pain after injury or infection. Separate from nerves branching from the spinal cord, the stellate ganglion provides innervation to the upper extremities, head, neck, and part of the cardiovascular system for pain and circulation, but not movement. Injecting medication over the stellate ganglion may block its signaling, and may be used to treat complex regional pain syndrome/reflex sympathetic dystrophy, pain from shingles, phantom limb pain, or other neuropathic states of the face, chest, or arms. It also may improve pain from severe angina and improve circulation.
This block is performed with the patient positioned on his or her back, often with IV sedation for comfort. During a stellate ganglion block, the skin overlying the target nerves will be anesthetized after which a thin needle will be directed to the site of injection. A small amount of contrast is used to demonstrate accurate needle positioning, and then an anesthetic medication mixture will be administered. Most patients tolerate this procedure very well with minimal, if any discomfort.
After a stellate ganglion block, patients may experience temporary eyelid droop, red eyes, tearing, stuffy nose, hoarse voice, difficulty swallowing or warm arm. These symptoms typically last a few hours. Pain relief after a stellate ganglion block may be immediate or delayed. Patients are asked to keep a pain journal over the next 1-2 weeks to determine response to the procedure. Some patients may experience pain relief for weeks to months after one injection, however others may require a series of stellate ganglion blocks for prolonged relief.
Stellate ganglion blocks are a safe option to treat many types of pain conditions. This injection may cause several temporary side effects as noted above. Serious complications are very uncommon, but may include low blood pressure and reaction to the medication. Your physician will more thoroughly discuss the risks with you prior to the procedure.
Medial Branch Blocks
Medial branch nerves are small nerve structures that transmit pain signals from the facet joints in the spine. Facet joints, also known as zygopophysial joints, connect each vertebral level to the ones above and below. These joints may become painful due to a variety of acute and chronic conditions. Medial branch nerves may be blocked for the purpose of determining if neck or back pain is coming from the facet joints. While injections directly into the facet joint may be therapeutic and diagnostic, medial branch blocks are purely diagnostic.
Medial branch blocks (MBBs) are performed in a specialized procedure room under fluoroscopy (x-ray) with the patient positioned on his or her stomach. The area being treated will be sterilely cleansed and draped, and IV sedation may be provided for comfort and relaxation. The target areas of the nerves is identified under x-ray, and the overlying skin is then anesthetized with local anesthetic. Next, a thin needle is precisely advanced towards the target nerve, and contrast dye is given to confirm that the needle is accurately placed. Next, a very small volume of highly concentrated anesthetic is then administered over the nerve branch only.
Typically, benefit from MBBs occurs immediately after the procedure. If the facet joints are a primary generator of your pain, you will experience improved pain relief and possibly greater range of motion. Because benefit from MBBs is usually short-lived, it is often followed by treatment with radiofrequency ablation at a later time for more permanent results. If no pain relief occurs after MBBs, your doctor may recommend a different treatment approach.
MBBs are a safe, effective way to diagnose and treat spine pain and some types of headaches. As with all invasive medical procedures, there are potential risks, however complications are extremely rare. There may be mild, brief soft tissue irritation for 1-2 days after the procedure. Your doctor will more thoroughly discuss risks and benefits prior to your injection.
Facet Joint Injection
Description of Facet Joints:
Facet joints connect each level of the spinal vertebrae to each other from the neck (cervical spine) to the low back (lumbosacral spine). Facet joints are found on both the right and left of the spine, at each level’s top and bottom surface. These structures not only connect the vertebrae, but may also guide the spine during movement. They are a known source of pain in the spine, and in some cases may contribute to headaches.
Symptoms of facet-mediated pain:
Facet joint pain is the result of joint dysfunction due to injury such as whiplash, arthritis, or other degenerative changes. The symptoms may feel dull or sharp and is most commonly worsened with rotation and extension of the spine. Sometimes, feeling like your neck or back is “popping” or “cracking” may be associated. Depending on which facet joints are affected, the resulting pain may occur in an area from the head as far down as the legs. Several other conditions may share similar symptoms, such as sacroiliac joint pain, painful intervertebral discs, or soft tissue pain.
During a facet joint injection:
During this procedure, an anesthetic and a steroid are injected into the facet joints. The injection can be used to diagnose and treat pain. If the injection lessens your pain and helps you move your neck or back more easily, then your doctor will know which facet joint is causing the pain. The procedure is usually conducted with the patient positioned on his or her stomach. The skin overlying the targeted facet joints will then be disinfected and draped with sterile towels. IV sedation may be used in some cases to help with relaxation. After local anesthetic is placed, your doctor will insert a thin needle towards the facet joint. Fluoroscopy, a type of low-dose x-ray, is always used to ensure the safe and proper position of the needle. A dye will also be injected to make sure the medicine targets the correct structure. Once the needle is in the correct location, a mixture of anesthetic and steroid will be administered.
After the procedure:
You will be monitored for approximately 30 minutes after the procedure. It is normal to feel better immediately after the procedure. This is the effect of the anesthetic, which may wear off several hours after the procedure. Steroids can take two to three days to begin working, during which time your pain may not feel considerably better. You also may feel some irritation or soreness at the site of the injection, which may be caused by the needle or by the steroid itself. This irritation usually resolves within 1-2 days. You should be able to return to work the day after the procedure.
Facet joint injections are a safe, effective way to diagnose and treat spine pain and some types of headaches. As with all invasive medical procedures, there are potential risks, however complications are rare. Infrequently, patients may experience a brief reaction to the steroid itself, including flushing, a feeling of warmth, agitation, or sweating. There may be mild, brief soft tissue irritation for 1-2 days after the procedure. Your doctor will more thoroughly discuss risks and benefits prior to your injection.