Procedures

Platelet Rich Plasma

What is PRP?

PRP, or platelet rich plasma is a revolutionary new treatment for chronic sports and musculoskeletal injuries.

How does PRP work?

Platelets are specialized type of blood cell. Most people know of them as the part of blood that forms a clot. While that is a primary function of platelets, they are also very involved in injury healing. Platelets are naturally rich in connective tissue growth factors. By concentrating and injecting these growth factors into damaged ligaments, tendons, and joints, they stimulate a natural repair process.

What conditions benefit from PRP?

PRP treatment works best for chronic ligament and tendon sprains/strains that have failed other conservative treatment. These include:

• Rotator cuff injuries (partial tears or tendonopathy)
• Tennis and golfer’s elbow
• Chronic thumb UCL sprain
• Hip and hamstring strains
• Knee sprains
• Patellofemoral syndrome and patellar tendinosis
• Ankle sprains
• Achilles tendinosis
• OCD lesions
• Plantar fasciitis
• Turf toe

Additionally PRP can be very helpful in many cases of wear and tear osteoarthritis, helping to smooth over roughed and arthritic cartilage.

To get the best results from treatment and prevent re-injury, specifically designed rehabilitation and exercise programs are incorporated into your treatment. This helps the newly developing connective tissue to mature into healthy and strong tissues. In addition, nutritional supports will be prescribed to help the healing process.

Prolotherapy

Q: What is Prolotherapy?

A: Prolotherapy (proliferative therapy), also know as sclerotherapy, ligament reconstruction therapy, and fibro-osseous injection therapy, is a recognized orthopedic procedure that stimulates the body’s nature healing processes to strengthen joints weakened by traumatic or over-use injury. Joints when ligaments or tendon attachments are stretched , torn, or fragmented, become hypermobile and painful. Traditional approaches with surgery and anti-inflammatory drugs often fail to stabilized the joint and relieve this pain permanently. Prolotherapy, with its unique ability to directly address the cause of the instability, can repair the weakened sites and produce new fibrous tissues, resulting in permanent stabilization of the joint.

Q: How does Prolotherapy work?

A: With a precise injection of a mild irritant solution directly on the site of the torn or stretched ligament or tendon, prolotherapy creates a mild, controlled injury that stimulates the body’s natural healing mechanisms to lay down new tissue on the weakened area. The mild inflammatory response that is created by the injection encourages growth of new ligament or tendon fibers, resulting in a tightening of the weakened structure. Additional treatments repeat this process, allowing a gradual buildup of tissue to restore the original strength to the area. Injection of varicose veins and other similar abnormalities creates a mild inflammatory response causing them to contract so that they become smaller or even vanish.

Q: What is in the solution that is injected?

A: The prolotherapy injections contain anesthetic agents and natural substances which stimulate the healing response. There are numerous substances, and each treating physician tailors the selection of substance according to the patient’s need.

Q: Is the Prolotherapy treatment painful?

A: Any pain involving an injection will vary according to the structure to be treated, the choice of solution, and the skill of the physician administering the injection. The treatment may result in mild swelling and stiffness. The mild discomfort passes fairly rapidly and can be reduced with pain relievers such as Tylenol. Anti-inflammatory drugs, such as aspirin and ibuprofen, should not be used for pain relief because their action suppresses the desired inflammatory process produced by the injection.

Q: Can Prolotherapy help everyone?

A: Each patient must be evaluated thoroughly with patient history, physical exam, X-ray exam, and full laboratory work up before treatment will be administered. With this information, your physician can evaluate your potential success with this therapy. Success depends on factors which include the history of damage to the patient, the patient’s overall health and ability to heal, and any underlying nutritional deficiencies that would impede the healing process.

Q: What areas of the body can be treated?

A: This form of therapy can be used to treat dislocation of the joints, knee pain, shoulder pain, Temporal Mandibular Joint dysfunction, and Carpal Tunnel Syndrome. The therapy affects only the area treated and does not cause any problem in any other area.

Q: How often do I need these treatments?

A: The treatments should be administered every one, two, or three weeks, as determined by your treating physician.

Q: What’s the rate of success in treatment?

A: The anticipated rate of success depends on a number of variables, including the patient’s history and ability to heal, and the type of solution used.

Q: Is this form of therapy really new?

A: Prolotherapy/sclerotherapy has been used successfully as early as 500 B.C. when Roman soldiers with shoulder joint dislocations were treated with hot branding irons to help fuse the torn ligaments in the shoulder joint. Advances in medicines greatly improved on this process, and led to the modern techniques of strengthening the fibrous tissue rather than producing scarring to fuse tissues.

Spinal Cord Stimulation

About Spinal Cord Stimulation

Spinal cord stimulation (also known as neurostimulation therapy) is delivered with a small spinal cord stimulator (similar to a pacemaker) implanted under the skin. It delivers mild electrical impulses to your spine, causing a tingling sensation in the area of your chronic pain.

How Spinal Cord Stimulation Works

Spinal cord stimulation provides pain relief by modifying the pain messages before they reach the brain. The neurostimulator sends out mild electrical impulses that reach the brain faster than the pain signal can arrive. In other words, it outsmarts your back and leg pain. Instead of feeling pain, you feel a tingling sensation.

You can adjust the strength and location of stimulation using a handheld programmer. For example, you can regulate different levels of stimulation at different times of the day or for various activities – such as walking, sleeping, or sitting.

Components of the Neurostimulation System

A complete spinal cord stimulation or neurostimulation system includes several components:

• Neurostimulator – The device, similar to a pacemaker, that sends mild electrical impulses and is usually surgically implanted under the skin in your abdomen or upper buttock
• Leads (pronounced “leeds”) – Thin, insulated medical wires that deliver neurostimulation to the epidural space near the spine
• Physician’s Programmer – A computer at your doctor’s office that lets your doctor adjust the neurostimulation system and set stimulation levels
• Handheld Programmer – A device similar to a remote control that you can use at home to optimize pain relief based on how your pain is changing throughout the day or during various activities

The neurostimulation system does not make any noise. The spinal cord stimulator may be felt as a small bump under your skin, but does not normally show through your clothes.

Benefits of Medtronic Spinal Cord Stimulation

Many people experience improvements in their pain symptoms and quality of life after receiving spinal cord stimulation. Benefits may include:

• Significant and sustained reduction in chronic pain
• Improved ability to function and participate in activities of daily living
• Less oral pain medications
• Proven safe and effective when used as directed
• Reversible – the therapy can be turned off or surgically removed
• t is trialed first to see if you like it before the device is surgically implanted. Unlike traditional spine surgery, if you do NOT like the stimulation or find relief during the trial, the device is NOT surgically placed in your body.

In addition, this treatment:

• Can be adjusted to provide different levels of stimulation for various activities and times of day
• Lets you try the therapy for a short period of time before you receive a permanent implant.

Risks of Spinal Cord Stimulation

Complications are possible and may include infection, pain at the site at the injection or surgical site, and bleeding into the epidural space. Once the neurostimulation system is implanted, device complications may occur and include corrective surgery, jolting, lead breaking, and movement of the lead within the epidural space which may require reprogramming or surgical replacement of the leads. These events may result in uncomfortable stimulation or loss of therapy.

Advantages Over Other Therapies

Both spinal cord stimulation and drug delivery therapy offer several advantages over other chronic pain therapies:

• Unlike other chronic pain treatments or surgeries, you can experience spinal cord stimulation and see if it relieves your pain before committing to the long-term therapy
• A screening test serves as a temporary evaluation period. Like an epidural, a special needle will be used. Instead of injecting medication into the epidural space, temporary medical wires called leads will be placed
• t does not have to be a permanent procedure. The neurostimulator can be surgically removed if you decide to pursue a different treatment
• Unlike oral medications that circulate throughout your entire body, spinal cord stimulation targets the precise area where you are feeling pain
• Spinal cord stimulation may provide relief when other treatments – like medications or injections – have not

Screening Test for Spinal Cord Stimulation

If you have been in pain for more than 6 months and your current treatment has not provided adequate relief or you’re experiencing intolerable side effects don’t lose hope. Spinal cord stimulation may be an option for you. One of the benefits of spinal cord stimulation is that you can test it to see if it will help manage your chronic pain before making a long-term commitment.

During the screening test, you can:

• Assess how well the spinal cord stimulator relieves your pain during different activities
• Feel the tingling sensation generated by the neurostimulator to mask your pain
• Decide if you want to go on to have the long-term therapy

What Happens During the Spinal Cord Stimulation Screening Test?

You can try a temporary system to see if spinal cord stimulation will work for you. During the 3- to 7-day screening test, you will find out how neurostimulation feels, how much it reduces your pain, and how well it helps you achieve your pain management goals.

The temporary system consists of these components:

• The external neurostimulator, which you wear on your waist band, generates the mild electrical impulses
• The screening cable connects to thin insulated medical wires that are placed in the epidural space of your spine to deliver electrical impulses from the neurostimulator to the nerves along the spinal cord
• The pouch holds your temporary external neurostimulation system and clips onto your waistband so you can go about your daily activities
• The hand-held, programmer works like a remote control and allows you to adjust the stimulation levels.

During the Procedure

Your screening test will likely take place on an outpatient basis in the doctor’s office, day surgery center, or hospital. You may be able to go home on the same day as the procedure.

Generally, these are the steps your doctor may take during the procedure:

• You may be given a local anesthetic to keep you comfortable during the procedure
• You will be placed on your stomach on a surgical table
• Your back will be cleaned with a solution
• Like an epidural, a special needle will be used. Instead of injecting medication into the epidural space, temporary medical wires called leads will be placed.
• Your doctor will use fluoroscopy (X-ray) to evaluate the position of the leads in the epidural space
• The leads are connected to a screening cable and the external neurostimulator
• Your doctor will ask you questions about the stimulation you are feeling and where it is located to be sure the leads are in the best location
• The temporary leads will be taped or secured to your back for the duration of the trial
• You will be taken to a recovery room until it is time to go home

After the Procedure

In the recovery room, your Medtronic representative will work with your doctor to program the external neurostimulator to provide you with the greatest amount of relief.

You will be taught:

• How to use the handheld programmer
• How to care for the area around the leads
• What activities and movements to avoid during the screening test
  You may experience some discomfort in the area in your back where the needle was placed. This is temporary and will resolve in the hours and days following the procedure.

Typically, the procedure takes 30 to 90 minutes to complete.

At Home with Your Temporary Neurostimulation System

You will be sent home with your temporary neurostimulation system for approximately 3 to 7 days, depending on your doctor’s preference. During this time, you will be supported by your doctor for medical concerns and spinal cord stimulator company representative for device-related questions. If you have any questions, they are just a phone call away.

When you are home, engage in your normal activities as this will help you and your doctor evaluate how well the spinal cord stimulation addresses your pain. During the screening test, your doctor will want to know if the stimulation is:

• Reducing your pain by at least 50% or greater
• Improving your ability to perform daily activities
• Allowing you to reduce or eliminate your pain medications
• Improving your sleep habits

If you are not receiving adequate relief, your doctor can adjust your settings. By simply having your settings changed, you may have better pain relief during your screening test.

During the screening test your doctor may restrict certain activities, such as:

• Taking a shower or bath or submerging your body in water (you may have a sponge bath)
• Physical activity levels that are more than moderate
• Lifting more than 5 pounds
• Reaching over your head, turning side to side, stretching, climbing, or extended reaching
• Bending forward, backward, or from side to side
• Climbing too many stairs or sitting for too long at one time
• Sexual activity
• Operating power equipment or heavy machinery
• Having your back manipulated by a chiropractor or a health care provider

If you are uncomfortable during the screening test, you can have the system removed.

Complications can occur with the screening test and may include infection and movement of the leads within the epidural space.

After the Screening Test

At the end of your screening test, your doctor will:

• Remove the temporary neurostimulation system
• Discuss your experience during the screening test
• Ask you if you were satisfied with your experience with spinal cord stimulation
• Help you determine if you should proceed with the long-term therapy

If you decide to proceed with long-term spinal cord stimulation, in most cases there will be a waiting period after the screening test and before your implant procedure. This will give the area in your back where the needle was placed time to heal, for your insurance provider to be notified, and for the surgery to be scheduled.

Kyphoplasty

Description of Kyphoplasty

The goals of a kyphoplasty procedure are designed to stop the pain caused by a spinal compression fracture, to stabilize the bone, and to restore some or all of the lost vertebral body height due to the compression fracture.

Performing Kyphoplasty

1. During kyphoplasty, a small incision is made in the back through which the doctor places a narrow tube. Using fluoroscopy (x-ray) to guide it to the correct position, the tube creates a path through the back into the fractured area of the involved vertebrae (bone).
2. Using X-ray images, the doctor inserts a special balloon through the tube and into the fractured bone, then gently and carefully inflates it. As the balloon inflates, it elevates the fracture, returning the pieces to a more normal position. It also compacts the soft inner bone to create a cavity inside the vertebrae.
3. The balloon is removed and the doctor uses specially designed instruments under low pressure to fill the cavity with a cement-like material called polymethylmethacrylate (PMMA). After being injected, the pasty material hardens quickly, stabilizing the bone.

Kyphoplasty is performed at a hospital under local or general anesthesia. Other logistics for a typical kyphoplasty procedure are:

• The kyphoplasty procedure takes about one hour for each vertebra involved
• Patients will be observed closely in the recovery room immediately following the kyphoplasty procedure
• Patients may spend one day in the hospital after the kyphoplasty procedure

If the patient is released the day of the kyphoplasty, he/she will need to arrange for transportation from the hospital. Patients can not drive themselves home after the procedure.

Recovery from Kyphoplasty

Pain relief will be immediate for some patients. In others, elimination or reduction of pain is reported within several days. At home, patients can return to their normal daily activities, although strenuous exertion, such as heavy lifting, should be avoided for at least six weeks.

Candidates for Kyphoplasty

Kyphoplasty cannot correct an established deformity of the spine, and certain patients with osteoporosis are not candidates for this treatment. Patients experiencing painful symptoms or spinal deformities from recent osteoporotic compression fractures are likely candidates for kyphoplasty. The procedure should be completed within 12 weeks of when the fracture occurs in most cases.

Risks and Complications of Kyphoplasty

Some general risks apply to kyphoplasty, including a reaction to anesthesia and infection. Other risks that are specific to the kyphoplasty procedure include, but are not limted to:

1. Nerve damage or a spinal cord injury from malpositioned instruments placed in the back
2. Nerve or lung injury or spinal cord compression from leaking of the PMMA into veins or epidural space
3. Allergic reaction to the solution used to see the balloon on the x-ray image as it inflates
4. Restoring the compressed bone to its original height may not be possible

It is not known whether kyphoplasty,or vertebroplasty, will increase the number of fractures at adjacent levels of the spine. Bench studies on treated bone have shown that inserting PMMA does not change the stiffness of the bone, but human studies have not been done. Osteoporosis is a chronic, progressive disease. As stated earlier, patients who have sustained fractures from osteoporosis are at an increased risk for additional fractures due to the loss of bone strength caused by osteoporosis.

Vertebroplasty

The goal of the vertebroplasty is primarily to relieve the pain caused by the fracture, although it may aslo help stabilize the fractured bone as well. Vertebroplasty is considered a minimally invasive surgical procedure because the procedure is done through a small puncture in the patient’s skin (as opposed to an open incision). A typical vertebroplasty procedure, described below, usually takes about 1 hour to complete.

1. The patient is treated with local anesthesia and light sedation, usually in an x-ray suite or operating room on an outpatient basis.
2. A biopsy needle is guided into the fractured vertebra (bone) under x-ray guidance through a small puncture in the patient’s skin.
3. Specially formulated acrylic bone cement (PMMA) is injected under pressure directly into the fractured vertebra, filling the spaces within the bone—with the goal of creating a type of internal cast (a cast within the vertebra) to stabilize the vertebral bone.
4. The needle is removed and the cement hardens quickly (about 10 minutes), sealing the fragments of the fractured vertebra and stabilizing the bone.
5. The small skin puncture is covered with a bandage.

Shortly after the cement has hardened, the patient is free to leave the medical facility and can go home the same day. Patients are usually advised not to drive themselves home the day of the procedure. If the patient needs further observation after the procedure, is particularly frail, or will not have assistance at home, a short stay in the hospital may be recommended.

Recovery from Vertebroplasty

Activities may be increased gradually and most regular medications can be resumed. There may be some soreness for a few days at the puncture site which may be relieved with an ice pack. Results can vary, but pain relief typically occurs in one to seven days. Patients with persistent pain after vertebroplasty may have other causes of pain that could require different treatments.

Potential Risks and Complications of Vertebroplasty

Complications are rare with vertebroplasty but include infection, bleeding, numbness/tingling, increased back pain, and paralysis. Other risks include cement leaking into the vertebral canal leading to spinal cord or nerve root compression, venous embolism (a blood clot that forms within a vein), pulmonary embolism (one or more blood clots blocking an artery in the lungs), and risks of anesthesia. It is not yet known whether vertebroplasty increases the risk of another fracture in the spine or ribs, but it is known that a patient sustaining an a compression fracture from osteoporosis is at risk for additional fractures.

Facet Injection/Block

FACET SYNDROME

Facet syndrome cannot be diagnosed by x-ray, CT scan, MRI, Bone scan, or any other radiology process. It is suspected on physical exam by tenderness directly over the facet joint, experiencing pain on extension (bending backwards), and on your history. The diagnosis is made by injecting a local anesthetic, with or without a steroid, to the painful area or around the nerve that goes to this area. If your pain is relieved by this injection you may benefit from another procedure called Radiofrequency Denervation/Rhizotomy/Ablation/Neurolysis.

Because facets are joints, they can develop arthritis due to injuries, excessive bone formations, thickening, damage to the fibrous capsule that surrounds the facets, or damage to the cartilage inside the joints. Certain types of activity may encourage the development of facet syndrome. If you are over 45 or your job has involved lifting for a number of years, you are more likely to develop facet syndrome. Whiplash injuries often involve pain facet joints.

WHAT ARE FACET JOINTS?

Facet joints link the bones of the spine together in the posterior (back) part of the spine. Two facet joints are present at each spinal segment. They are named for the spinal bones which they connect. For example, in the neck (cervical spine) the facet joints between Cervical #5 and Cervical #6 are called Cervical 5-6. The facet joints are important in restricting the motion of the cervical and lumbar spine. They allow motions of twisting, flexion, and extension.

WHY DO FACET JOINTS CAUSE PAIN?

Facet joints are possible sources of neck (cervical), mid-back (thoracic) and lower back (lumbar) pain. A small nerve that branches out from a spinal nerve provides sensation to the facet joint. Trauma or arthritic changes can cause the release of pain generating substances that sensitize the nerve endings located in the joint.

Facet joints can cause pain in one or both sides of the low back. It can be made worse with extension (bending backwards or twisting). The pain can also travel to the buttocks or back of the thighs. Patients with facet joint pain from the neck (cervical spine), can have neck pain, headaches, shoulder pain or shoulder pain.

WHAT IS A FACET JOINT BLOCK?

A facet joint block involves the injection of a medication into the facet joint or around the nerve to the facet joint. In a diagnostic block, a local anesthetic is used to determine if the injected area is causing the pain. In some cases a steroid is also injected. The purpose of facet joint blocks is twofold. The first is as a diagnostic block. If the patient receives an appropriate reduction in pain (as determined by the evaluation after the injection), there is an increased probability that the facet joint is an important component in the patient’s pain syndrome. The block may then be repeated to confirm the diagnosis.

The Procedure

Patients undergoing facet joint injections may receive a sedative medication, but this is not required. This medication is given in order to relax you. The injection is performed in a procedure or operating room using fluoroscopy (x-ray) to insure proper needle placement and to maximize safety. As you recover from the procedure, you may feel some tenderness at the site of injections and an ice pack may be placed for temporary relief of this discomfort. If used, the steroid injected around the facet joint may take 3-7 days to take effect. If the injection does not help, then the facet joint may not be the source of your pain. The patient will follow up with the physician on the next scheduled office visit (usually within one week) to determine if additional procedures may be needed for more long term pain relief.

Radiofrequency Ablation/Denervation

Radiofrequency ablation (or RFA) is a procedure used to reduce pain. An electrical current produced by a radio wave is used to heat up a small area of nerve tissue (usually the dorsal medial branch nerve to a facet joint) which disrupts the nerves ability to send painful signals to the brain and spinal cord.

Which Conditions Are Treated With Radiofrequency Ablation?

RFA can be used to help patients with chronic (long-lasting) low-back, mid-back and neck pain from trauma, arthritis and other painful conditions affecting the facet joints.

How Long Does Pain Relief From Radiofrequency Ablation Last?

The degree of pain relief varies, depending on the cause and location of the pain. Pain relief from RFA can last from six to twelve months and in some cases, relief can last for years.

Is Radiofrequency Ablation Safe?

RFA has proven to be a safe and effective way to treat some forms of pain. It also is generally well-tolerated, with very few associated complications. There is a slight risk of infection and bleeding at the insertion site. Your doctor can advise you about your particular risk.

What Are the Side Effects of Radiofrequency Ablation?

The main side effect of RFA is some discomfort after the procedure, including swelling and bruising, at the site of the treatment, but this generally goes away after a few days. A small percentage of patients may see an increase in pain for a few weeks after the procedure that is often described as an “internal sunburn” sensation. There is no way of predicting which patients may experience the “internal sunburn” sensation, but should it occur, it usually resolves on its own in few weeks. Rarely, a cortisone injection is required to help expedite the burning sensation. Another risk that is extremely rare is the small nerve to the facet joint (dorsal medial branch nerve) sometimes has another nerve sprouting off of it that goes to the skin next to the injection sites. If you have this “nerve sprout” to the skin, a small numb or sensitive area may develop close to the injection sites that may not go away (i.e. the nape of the neck, angle of the jaw, buttocks, or side of the thigh-depending if your neck or low back is being treated). If this numb area does occur, it does not usually cause any problems, just one small patch of skin is not as sensitive as other areas.

Who Should Not Get Radiofrequency Ablation?

As with any medical procedure, RFA is not appropriate for everyone. For example, radiofrequency ablation is not recommended in people who have active infections or bleeding problems. Your doctor can tell you if you should not have RFA.

How Do I Prepare for Radiofrequency Ablation?

To prepare for radiofrequency ablation treatment, you should take a few precautions, including:

• Do not eat or drink within six hours of your appointment.
• If you have diabetes and use insulin, you must adjust the dosage of insulin the day of the procedure. Your primary care doctor will help you with this adjustment. Bring your diabetes medication with you so you can take it after the procedure.
• Continue to take all other medications with a small sip of water. Bring all medication with you so you can take it after the procedure. Please note: Do not discontinue any medication without first consulting with your primary or referring doctor.
• You will need to bring someone with you to drive you home after the procedure. You should not drive or operate machinery for at least 24 hours after the procedure.

What Happens During Radiofrequency Ablation?

An intravenous (IV) line may be placed in a vein in your arm before the procedure and a local anesthetic and mild sedative may be used to reduce any discomfort during RFA. A sedative is not required for all patients. You may be awake during the process to aid in properly assessing the procedure.

After the local anesthesia has been given, the doctor will insert a small needle into the general area where you are experiencing pain. Using X-ray, the doctor will guide the needle to the exact target area. A microelectrode is then inserted through the needle to begin the stimulation process.

During the procedure, your doctor will ask if you are able to feel a tingling sensation or thumping in your neck or back. The object of the stimulation process is to help the doctor determine if the electrode is in the optimal area for treatment.

Once the needle and electrode placement are verified, a small radiofrequency current is sent through the electrode into the surrounding tissue, causing the tissue to heat. You should not feel discomfort during the heating portion of the procedure.

What Happens After Radiofrequency Ablation?

Following radiofrequency ablation:

• You will stay in a recovery room for observation, where a nurse will check your blood pressure and pulse.
• A bandage will be placed over the injection site.
• Someone must drive you home.

Can I Resume My Normal Activities After Radiofrequency Ablation?

You will have a few restrictions immediately following radiofrequency ablation:

• Do not drive or operate machinery for at least 24 hours after the procedure.
• You may resume your normal diet.
• Do not engage in any strenuous activity for the first 24 hours after the procedure.
• You may remove any bandages in the evening before going to bed.

What Side Effects May I Have After Radiofrequency Ablation?

You may experience the following effects after RFA:

• Leg numbness: If you have any leg numbness, walk only with assistance. This should only last a few hours and is due to the local anesthesia given during the procedure.
• Mild back discomfort: This may occur when the local anesthetic wears off and usually lasts two or three days, if it occurs. Apply ice to the area the day of the procedure and moist heat the day after the procedure if the discomfort persists. You may also use your usual pain medications, if applicable.

If I have RFA done, will I still be able to feel my neck or back after the procedure? I do not want to hurt myself and not know it.

Yes. You should still be able to feel your neck or back after the procedure. If you hurt yourself or do too much, you should know it, provided no other medical problem(s) exist that affect your ability to feel pain.

Discogram/Discography

Definition

A discogram, or diskogram, is a test used to evaluate neck and back pain. A discogram may help your doctor determine if your neck or back pain could be caused by an abnormal disk in your spine. Spinal disks look a little like jelly doughnuts, with a tough outer layer and a gel-like substance inside. Disks act as cushions between the vertebrae in your spine.

During a discogram, dye is injected into the soft center of the disk. The injection itself sometimes reproduces your back pain. Several disks may be injected, to try to pinpoint the cause of your neck or back pain. In addition, the dye will move into any cracks in the disk’s exterior and will show up on an X-ray or CT scan.

Why is a discogram done?

Because it’s an invasive test, a discogram is not appropriate for an initial evaluation of back pain. But your doctor may suggest a discogram if your back pain persists despite conservative treatments, such as medication and physical therapy.

Some doctors use a discogram before spinal fusion surgery, to help identify which disks need to be removed.

Risks

A discogram is generally a safe procedure. But as with any medical procedure, a discogram carries a risk of complications. Potential complications include:

• Infection
• Bleeding
• Worsening of chronic back pain
• Headache
• Nausea
• Injury to blood vessels or nerves in and around the spine
• Allergic reaction to the dye

How you prepare?

A discogram takes between 30 and 60 minutes, and you will be able to go home later that same day. Most patients will have a CT scan performed immediately after the discogram to help better evaluate the architecture of the discs.

During a discogram

A discogram is performed in a clinic or hospital room that has imaging equipment, so your disks can be examined during the procedure. You are awake during a discogram, but your doctor may give you an intravenous sedative to help you relax. You may also receive antibiotics to help prevent infection.

During the procedure, you lie on a table either on your stomach or on your side. After cleaning your skin, your doctor will inject a numbing medicine to decrease pain caused by the insertion of the discography needles.

Your doctor will use fluoroscopy, an imaging technique that allows him/her to watch as the needle enters your body. This allows precise placement of the needle into the center of the disk to be examined. A contrast dye is then injected into the disk and an X-ray or CT scan is taken to see if the dye spreads.

If the dye stays in the center of the disk, the disk is normal. If the dye spreads outside the center of the disk, it means the disk is damaged. It may have begun to rupture or it may have tears in its outer ring. Typically, if a damaged disk is the source of your back pain, you feel pain during the injection that’s similar to the back pain you have day to day. If a disk is normal, there’s little pain during injection.

After a discogram

After a discogram, you remain in the procedure room for approximately 30 minutes to one hour for observation. Because of the sedation, have someone else drive you home following a discogram. You may have some pain at the injection site for several hours after you go home. A temporary increase in your low back pain may occur that could last from several hours to several days. If the pain is severe, call your doctor right away.

Results

Your doctor will review the images taken during the discogram, along with the information you provided during the procedure about the pain you experienced. Both the images and your description of the pain are important to help determine if the disks examined are the source of your back pain. Your doctor will use this information to guide your ongoing treatment or prepare for surgery.

Intradiscal ElectroThermal Therapy

What is IDET Therapy?

With age or due to injury, cracks or fissures may develop in the wall of the disc. Filled with small nerve endings and blood vessels, these fissures are a chronic source of pain in many patients. Additionally, the inner disc tissue (nucleus) will frequently bulge (herniate) into these fissures in the outer region of the disc, likewise stimulating pain sensors within the disc.

IDET therapy is a minimally invasive treatment in which the physician applies controlled levels of thermal energy (heat) to a broad section of the affected disc wall. This heat contracts and thickens the collagen of the disc wall. Therapy may result in contraction or closure of the disc wall fissures and a reduction in the bulge of the inner disk material.

Who May Benefit from IDET Therapy?

IDET therapy acts exclusively upon the tissues of the disc itself, and should not be expected to relieve symptoms arising from other spinal structures, such as nerve roots or spinal joints. It is therefore very important for your physician to diagnose that the disc is the primary source of your back pain. In addition to a clinical examination, your physician may use Magnetic Resonance Imaging (MRI) or injections of dye into the disc (discography) to confirm the diagnosis. Once satisfied that one or more discs are the primary source of your lower back pain, your physician may recommend IDET therapy.

The Procedure

IDET therapy is usually performed on an outpatient basis. Local anesthesia and mild sedation may be used to reduce discomfort during the procedure. You will be awake and alert so that you can provide important feedback to the physician. With the guidance of x-ray images, your physician will advance a needle into the disc. A catheter will be passed through the needle and into the disc.

Once it is in the appropriate position, the temperature of the heating section of the catheter will be gradually increased, raising the disc wall temperature. During the heating protocol, your physician will monitor your condition and comfort level closely. You will most probably feel a reproduction of your usual lower back pain. This is a strong indication that the heat is being applied to the appropriate areas. Once the therapy is completed, the catheter and needle are removed, and you will likely be sent home with a Band-Aid over the needle insertion site.

After the Procedure

The discomfort generated when the disc is heated may take several days to subside, and your physician may prescribe medication. During the disc healing process, up to 12 to16 weeks following the procedure, it is very important to treat your discs with care. Your physician will provide you with activity and physical rehabilitation guidelines. Patients report that it is during this time that they usually begin to experience relief from their lower back pain symptoms, a reduction or elimination of any medication use, and an increase in their functional abilities. Improvements may continue up to 12 months following the procedure.

Important Information About IDET Therapy

IDET therapy, like any surgical procedure, has some risks. Not all patients will find relief for their back pain and relieved symptoms may recur over time. Other risks include, but are not limited to, bleeding, infection, increased pain, nerve injury and headache. Many additional factors may prevent your physician from recommending IDET therapy for your condition. Such factors may include, but are not limited to, very narrow disc height, severe disc herniation, spinal instability, very advanced stages of disc degeneration, or various general health concerns.

Intrathecal Pumps

About Drug Delivery Therapy

Drug pumps (also called “intrathecal drug delivery systems”) deliver pain medication and/or muscle relaxers directly to the fluid around the spinal cord. This may result in more effective pain relief and/or decreased muscle tightness (spasticity) with fewer side effects than oral medication, which goes through your circulatory system.

How It Works

The drug pump delivers pain medication/muscle relaxers directly to the fluid around the spinal cord, in an area called the intrathecal space.

The drug pump is connected to a thin, flexible tube called a catheter. Both the pump and the catheter are fully implanted under the skin.

Because the pump releases medication directly to the pain receptors near the spine instead of going through your circulatory system, pain relief can be achieved with a small fraction of the oral medication dose.

The Effect of Oral Medications

Studies have also reported that drug delivery therapy provided pain and spasticity relief in many patients who could not achieve adequate control even with high doses of oral pain medications.

Realistic expectations are essential to satisfaction with any pain treatment. Drug delivery therapy cannot eliminate the source of your pain or cure any underlying disease, but it may help you to better manage your pain and/or spasticity.

Drug Delivery System Components

Drug delivery therapy uses the Medtronic SynchroMed® II infusion system, which includes:

• A programmable drug pump – A battery-powered device that stores and dispenses medicine according to instructions programmed by your doctor
• Intrathecal catheter – A thin, flexible tube that connects to the pump and delivers medication from the pump to the area where fluid flows around the spinal cord
• Physician programmer – A computer at your doctor’s office that lets your doctor tailor your therapy to best meet your needs

The pump system is implanted just under the skin of the abdomen. Your doctor will work with you to ensure that it is comfortable and does not interfere with your movements.

During the surgery, your doctor fills the pump with saline using a needle. After the incision heals, the pump will be filled with medication in the office. The pump sends the medication through the catheter to the spinal area where pain receptors are located. You return to your doctor’s office for more medicine when the pump needs to be filled.

Most pump systems used in this office are programmable, allowing doses to be scheduled and changed using an external programming device.

What to Expect at Your Refill Appointment

During the refill appointment, your doctor will check your system to make sure you are receiving the most appropriate therapy.

The pump system will be emptied with a needle inserted through your skin. The pump will then be refilled with new medication. This is a relatively short and painless procedure. On average, a refill appointment lasts 35 to 45 minutes.

Benefits of Intrathecal Drug Delivery Therapy

Intrathecal drug delivery therapy offers a number of benefits, including:

• Significant reduction in pain – Approximately 50% or greater reduction in pain
• Improved ability to function and participate in activities of daily living
• Lower medication doses – Compared with oral medications, which may result in reduced side effects
• Less oral pain medications
• Proven safe and effective when used as directed
• Reversible – Therapy can be turned off, or if desired, it can be surgically removed

In addition, this treatment:

• Does not involve permanent changes to the spinal cord or nerves
• Can be adjusted to dispense medication according to your activity level and need
• Lets you try the therapy for a short period of time before you receive a permanent implant

Risks of Drug Delivery Therapy

The implanted drug pump and catheter are surgically placed under the skin. Surgical complications are possible and include infection, spinal fluid leak, and headache. You should not undergo the implant procedure if you have an active infection at the time scheduled for implant.

Once the infusion system is implanted, device complications may occur which may require surgery to resolve. Drug overdose or underdose can result because of these complications and have serious and even life-threatening adverse effects. Possible complications include the catheter or pump moving within the body or wearing through the skin. The catheter could leak, tear, kink, or become disconnected. The pump could stop because the battery has run out or because of failure of another part of the infusion system. Additionally, inflammatory mass has been reported at the tip of the catheter which may lead to complications, including paralysis.

Advantages Over Other Therapies

Drug delivery therapy offers several advantages over other therapies for chronic pain.

1. A screening test serves as a temporary evaluation period so you can see if drug delivery therapy relieves your pain before committing to long-term therapy
2. It does not have to be a permanent procedure like back surgery. The system can be turned off or surgically removed
3. Unlike oral medications, drug delivery therapy releases medication directly into the fluid surrounding your spinal cord rather than traveling throughout your body in your bloodstream. This may lead to fewer side effects, such as nausea and constipation
4. Drug delivery therapy may provide relief when other treatments – like medications or injections – have not

Coccyx Injections/Ganglion Impar Blocks

Ganglion Impar Block

The Ganglion Impar Block can be used both as a diagnostic and therapeutic tool in patients suffering from coccydynia/coccygodynia (pain in the tailbone), pain in the perineum, distal rectum and anus, vulva, and distal third of the vagina.

The technique can be performed with local anesthetic and steroid for nonmalignant pain conditions, such as coccygodynia, or perirectal pain from tumor involvement. Neurolytic blockade can be performed, but only after a diagnostic block is performed. The advantage of the Ganglion Impar block over other neurolytic procedures for rectal pain is that bowel and bladder function is generally unaffected. However, this should be confirmed first with the local anesthetic block

The Procedure

The procedure is performed in a procedure or operating room. Sedation can be given to help the patient relax, but is not required or always necessary.

The patient will be placed on his/her stomach and the target area near the tail bone will be identified using live X-ray (fluoroscopy). After numbing the skin, a needle will be advanced to the desired area under fluoroscopic guidance. Prior to injection of the local anesthetics (numbing medicine), the correct position of the needle will be verified using contrast solution, provide the patient does not have another medical condition preventing its use, like an allergy to contrast. The procedure may take between 20-30 minutes to be performed. After completion of the procedure, Band-Aids may be applied to the needle sites. A nurse will monitor the blood pressure and pulse, and then review the discharge instructions with the patient before going home on the same day.

After the Procedure

The patient should not drive for 24 hours after the procedure. Mild discomfort may be experienced at the injection site, but it is unlikely that any prolonged recovery time is needed. Patients should be able to return to their normal activities the following day. A steroid, if used, typically takes several days to a week to begin working. A follow up appointment with the doctor is usually scheduled approximately one week after the injection. The injection may need to be repeated to maximize diagnostic accuracy and treatment benefits, or before considering other treatments like neurolysis (destroying the nerves) and spinal cord stimulation.

Risks
Like many medical procedures, injections around the coccyx and to the ganglion impar have risks. Those risks, while rare, include, but are not limited to, bleeding, infection, no effect on pain, nerve injury, and incontinence. Unless performing neurolysis (destructiion of the nerve – typically done with phenol or alcohol), incontinence, if it occurs, is typically short lived (minutes to hours).

Sacroiliac (SI) Joint Injections

Diagnosing and Relieving SI Joint Related Back Pain

Sacroiliac (SI) joint dysfunction is a common source of pain in the lower back, buttocks, groin, and legs. These generalized symptoms, however, can be easily confused with other causes of back pain. The SI joint injection enables physicians to confirm that irritation or damage to the SI joint is the source of your symptoms. This precise diagnostic tool is also a therapeutic procedure, offering significant pain relief. At Spine & Neuro Pain Specialists, we are experts in utilizing this tool to effectively resolve your symptoms.

How does SI joint injection help?

SI joints connect the pelvic bones to the spine. They are small and do not move much, but they absorb all the forces of the upper body before balancing and transferring the weight to the hips and legs. When one or both of these joints become irritated or injured, they can cause chronic discomfort and pain.

SI joint injections can accurately pinpoint and alleviate this pain. Guided by fluoroscopy (x-ray imaging) or ultrasound, a pain specialist injects a local anesthetic into the affected SI joint. A corticosteroid medication is also injected. This strong, long-acting medicine reduces inflammation and can provide pain relief over an extended period of time.

How long does it take?

SI joint injections are safely performed on an outpatient basis. The procedure typically requires 20 to 30 minutes, including preparation time, and is followed by a short period of observed recovery time.

What are the expected results?

Although they are not a cure, SI joint injections are very effective in reducing inflammation of the joint and providing considerable to complete pain relief for an extended period of time in many patients. Should you experience good short term relief, but no long term relief, there are other options for treating the SI joint. These include, but are not limited to, radiofrequency ablation/deneravtion/rhizotomy, advanced, regenerative procedures, such as prolotherapy and platelet rich plasma (PRP) therapy.

Sympathetic Nerve Blocks/Injections

Sympathetic Nerve Blocks for Pain

A sympathetic nerve block can be an effective method for controlling chronic pain. This therapy targets the sympathetic nervous system, a series of nerves that spread out from your spine to your body to help control several involuntary body functions, or body functions that you have no control over. These include blood flow, digestion, and sweating.

When is a Sympathetic Nerve Block Needed?

A sympathetic nerve block can be used to diagnose or treat pain involving the nerves of the sympathetic nervous system. Examples of conditions for which a sympathetic nerve block might be used include:

1. Phantom pain after an amputation
2. Pain from spasms in the blood vessels after frostbite
3. Chronic tail bone pain, called coccydynia
4. Lingering pain after an attack of shingles
5. Complex regional pain syndrome, also called reflex sympathetic dystrophy
6. Raynaud’s syndrome
7. Excessive sweating, called hyperhidrosis
8. Certain types of abdominal pain
9. Some types of face pain
10. Certain Headaches

Sympathetic Nerve Block Procedure

The location of your pain usually determines where you’ll receive the nerve block. Your sympathetic nerves come together outside your spine area in thick networks of nerves called ganglions. If you have pain in the upper part of your body, you may get pain relief from blocking the in your neck area. If you have pain in the lower part of your body, a ganglion near the lower spine may be targeted with a lumbar sympathetic block.

This is what may happen during a sympathetic block procedure:

1. You will be asked to fast for about six hours before the procedure.
2. The medical team will start an intravenous line and monitor your vital signs carefully.
3. You may be given some medication through the IV line to make you relaxed and sleepy.
4. Before the actual block, you will be given a local anesthetic (numbing medicine).
5. X-rays may be used to help the specialist find the right ganglion.
6. Once the ganglion is located, it is blocked by injecting it with a local anesthetic solution with or without a steroid.

What to Expect After Your Sympathetic Nerve Block

A sympathetic nerve block is a relatively safe procedure. You can usually go home afterward and return to your normal activities after a day of rest. You will need to have someone drive you home.

Side effects after a sympathetic block may include, but are not limited to, temporary soreness, a feeling of warmth, or some weakness. If you’ve received a nerve block in the stellate ganglion (neck), you may experience some temporary voice changes, eyelid droop, or difficulty swallowing. Until swallowing is back to normal, avoid large bites of food and sip liquids carefully.

In some cases, the sympathetic block may need to be repeated to get the best possible response. These injections also have diagnostic benefit and can help determine if you may benefit from other medications.

Sympathetic blocks do not work for everyone, and the pain relief they give may decrease over time. However, sympathetic blocks may provide weeks or months of pain relief, and permanent relief is possible.

Examples of sympathetic nerve blocks include, but are not limited to, stellate ganglion block, Celiac Plexus Block, Ganglion Impar Block, and Lumbar Sympathetic Plexus Block.

Botulinum Toxin/BOTOX® for Spasticity

What Is Botulinum Toxin?

Botulinum toxin is a muscle-relaxing medication used to decrease spasticity related to stroke, multiple sclerosis, and other neurological conditions including cervical dystonia and torticollis.

Botulinum toxin is derived from the bacterium Clostridium botulinum and is in a class of drugs called neurotoxins. There are three types of botulinum toxin available for therapeutic use:

• OnabotulinumtoxinA (Botox/Botox Cosmetic)
• RimabotulinumtoxinB (Myobloc)
• AbobotulinumtoxinA (Dysport)
• IncobotulinumtoxinA (Xeomin)

Your doctor will decide which type of botulinum toxin is appropriate for you.

What Is Spasticity?

Spasticity refers to a wide range of involuntary muscle contractions that result in muscle spasms or stiffness. Spasticity interferes with voluntary muscle movement and usually involves the muscles of the legs and/or arms.

Spasticity may vary, based on many factors, including infections, stress, pain, temperature, position and time of the day. Over time, severe spasticity may cause decreased range of motion in the affected limbs.

Spasticity is the result of an imbalance in the central nervous system, caused by a trauma or disease in the brain and/or spinal cord. This imbalance causes hyperactive muscle stretch reflexes, which result in involuntary contractions and increased muscle tone.

How Does Botulinum Toxin Work?

Normally, the brain sends electrical messages to the muscles so that they can contract and move. This message is transmitted to the muscle by a substance called acetylcholine. Botulinum toxin works to block the release of acetylcholine; therefore the muscle does not receive the message to contract.

How Are Botulinum Toxin Treatments Given?

Botulinum toxin is given as an intramuscular injection (in the muscle). Your doctor will determine the muscle(s) in need of treatment.

If the muscles to be injected are small or difficult to reach, it may be necessary to send short electric impulses, or to record electric signals from the muscles, to ensure that the appropriate muscles are receiving the injected medication.

A very fine needle is used for the injection. Some people report minor and temporary discomfort from the injection. The medication does not sting or cause irritation after it has been injected.

You can expect the appointment to last from one to two hours.

The effects of the medication begin to appear from one to two weeks after the injection. The muscles injected should then relax.

What Are the Advantages of Botulinum Toxin?

The advantages of botulinum toxin include.

1. Improvement of discomfort related to spasticity symptoms.
2. In some cases, improved ability to use the affected part of the body.
3. The medication is effective for two to six months, depending on the individual.

What Are the Disadvantages of Botulinum Toxin?

The disadvantages of botulinum toxin include:

1. The benefit of botulinum toxin is limited to the injected muscles. Therefore, botulinum toxin may not be a good choice of treatment when many muscles are involved or when the spastic muscles are large.
2. The effect of the injections is temporary. Therefore, injections must be repeated over time to maintain the beneficial effects. Injections are not repeated more often than every 3 months to minimize the risk of developing antibodies to the botulinum toxin (see below).

What Are the Side Effects?

Side effects of botulinum toxin include:

1. Temporary weakness of the injected muscle and weakness in some nearby muscles.
2. Brief flu-like symptoms (these may develop one week after the injections and usually only last for about one day).

What Does It Mean to “Develop Antibodies” to Botulinum Toxin?

There is a slight chance that you may develop antibodies to botulinum toxin. Antibodies to botulinum toxin cause the botulinum toxin to be less effective. To minimize the risk of developing antibodies, specific guidelines are followed to restrict the frequency of injections and the dose of medication that is injected.

Is This Treatment Right for Me?

A doctor will perform a complete evaluation to determine if you are eligible to receive botulinum toxin therapy.

Does Insurance Cover This Therapy?

Insurance coverage varies greatly, depending on individual insurance plans. Check with your insurance company before treatment begins.

When Should I Call My Doctor?

Call your doctor:

1. If you think that the medication is not working (please wait at least 2 weeks after the injection).
2. If you are experiencing side effects that you think may be related to botulinum toxin.
3. When the effects of the medication wear off.

How Will I Know If the Treatment Is Working?

You will be examined during frequent follow-up appointments to determine if the treatment is working properly. Typically, you will be re-evaluated every 3 to 6 months to determine if it is appropriate to repeat the injections.

Intercostal Nerve Block

What is an intercostal nerve block?

An intercostal nerve block is an injection of a steroid or other medication around the intercostal nerves that are located under each rib.

What is the purpose of an intercostal nerve block?

The steroid injected reduces the inflammation and/or swelling of tissue around the intercostal nerves, in between the ribs or in the chest wall. This may in turn reduce pain, and other symptoms caused by inflammation or irritation of the intercostal nerve and surrounding structures. Herpes zoster or shingles pain in the chest is commonly treated with intercostal blocks. Pain around a chest scar after a chest surgery may also respond well to intercostal blocks.

How long does the intercostal nerve block take?

The actual injection takes only a few minutes.

What is actually injected?

The injection consists of a local anesthetic (numbing medicine) and typically a steroid medication. Sometimes alcohols, like Phenol, are injected in an effort to provide more long term relief. The decision as to use local anesthetic and a steroid versus an alcohol will be discussed with you by your doctor before the injection is performed. 

Will the intercostal nerve block hurt?

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.

Will I be sedated for the intercostal nerve block?

This is optional and usually the patient’s preference. There are rare instance that arise where sedating a patient is not possible, especially when the patient has other serious medical conditions the make sedation to risky.

How is the intercostal nerve block performed?

The procedure is usually performed in a procedure room or operating room with the use of fluoroscopy (x-ray). The patient is placed on his/her stomach. The skin is cleaned and a local anesthetic is given. Using a very small needle and x-ray guidance, the needle is steered to the desired nerve. If there are no medical conditions preventing its use, a small amount of contrast is injected to insure proper needle placement. The medications are injected.

What should I do after the intercostal nerve block?

You will need to have a driver. We advise the patient to take it easy for several hours after the procedure and not operate heavy equipment or make any major decisions for 24 hours after the procedure, especially if you were sedated. You may want to apply ice to the injected area. You can return to your usual activity the day after the procedure. 

What are the risks and side effects of intercostal nerve blocks?

Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects and possibility of complications. The most common side effect is temporary pain at the injection site. Other uncommon risks include, but are not limited to, infection, bruising, bleeding, worsening of symptoms and a collapsed lung. This is rare, but since the needles are in close proximity to the lung, such a side effect is possible.

How would I know if I had a collapsed lung?

Because of the size of the needle used, a lung usually does not collapse quickly. It may take several hours or the better part of the day. If, after the block, a patient feels winded or cannot seem to catch his/her breath or gasps for air, a collapsed lung should be suspected. Prompt transportation to the nearest Emergency Room and a chest x-ray can confirm the suspicion of a collapsed lung.

Lysis of Adhesions

WHAT IS EPIDURAL LYSIS OF ADHESIONS?

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.

WHAT PATIENTS ARE CANDIDATES FOR LYSIS OF ADHESIONS?

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 IS THE PROCEDURE PERFORMED?

You will be given conscious sedation through an IV (intravenous needle) inserted in your arm/hand and asked to lay on your stomach for the procedure . The doctor and 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 will be guided with x ray to the scarred area. A special medication called hyaluronidase, in conjunction with the Racz catheter, is injected to breakup the scarring. A mixture of steroids and local anesthetic (numbing medicine) will be injected to decreased the inflammation and provide pain relief after the lysis of adhesions. Hypertonic saline (concentrated salt water for medical use) maybe injected after the numbing medicine takes effect to further help dissolve scar tissue and adhesions.

WILL THE PROCEDURE BE PAINFUL?

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.

WHAT ARE THE RISKS AND SIDE EFFECTS FROM THE RACZ LYSIS OF ADHESIONS?

The most common risks are local pain from the needle and catheter which is typically a mild to moderate burning sensation lasting two to seven days. More serious but extremely rare risks are bleeding, infection, nerve injury, paralysis, bowel/bladder incontinence and weakness in the lower extremities.

HOW LONG DOES IT TAKE FOR THE PROCEDURE TO WORK?

The beneficial effects, if any, are usually appreciated two to four weeks following the procedure

Cryoablation

What is Cryoablation Lesioning?

Cryoablation involves freezing a nerve in hopes of interrupting the nerve’s ability to send pain signals to the brain and provide pain relief. While cryoablation can be applied to various organs and tissues and is used in a variety of medical specialties, at Spine & Neuro Pain Specialists, it is primarily used to treat peripheral nerve pain.

What Does Cryoablation Treat?

At Spine & Neuro Pain Specialists, it is used to treat pain caused by peripheral nerves, most commonly occipital neuralgia. Although, other peripheral nerves can be treated.

How is Cryoablation Done?

The procedure is done in the operating room under fluoroscopy. The patient is given a local anesthetic and IV sedation. The doctor will insert a special needle into the target area. Prior to cryoablation, sensory and motor nerve testing is performed to identify the nerve and confirm needle placement. Once the nerve is identified with a nerve stimulation test, the nerve is treated by decreasing the temperature surrounding the nerve to -70 C. Nitrous oxide under pressure is expanded in a closed compartment to create the temperature of -70 C. The cooling of these nerves interrupts the pain messages before they are sent to the brain where the pain is actually perceived.

How Long Does the Pain Relief Typically Last?

While no guarantees can be made, pain relief from this procedure can last from six to twelve months or longer. This is because the nerve damage from the Cryoablation is typically only temporary. These nerves will repair themselves, and the time frame for this repair varies, as every individual patient is unique in their healing process.

Advantages

The greatest advantage is the potential for an extended period of pain relief. Patients who have received temporary pain relief from a nerve block only to have the pain return again, appreciate that the pain relief can last much longer. Recovery from this procedure is usually within one to two weeks. After one day of rest, most patients are able to resume their normal activities. This procedure can be repeated.

Disadvantages

As with any medical procedure, there are risks. Due to the fact that only needles are used for this procedure, the typical risks for bleeding and infection are very minimal. Some patients will experience increased discomfort that can last for 1-2 weeks following this procedure. Other risks, although rare, include, but are not limited to, no effect on pain, increased pain and permanent nerve injury.

Trigger Point Injection

Trigger Point Injection (TPI)

A trigger point injection (TPI) is a procedure used to treat painful areas of muscle that contain trigger points, or knots/taut bands within a muscle. Many times, such knots can be felt under the skin. Trigger points may cause referred pain, or pain that is felt in another part of the body.

What Happens During a Trigger Point Injection?

In the TPI procedure, a health care professional inserts a small needle into the patient’s trigger point. The injection contains a local anesthetic. With the injection, the needle is moved through the muscle to help break up the knot and hopefully dissolve or make the trigger point inactive. Injections are given in the 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.

Side Effects

A TPI is relatively safe procedure, but like all procedures, it does have risks. The most common risk is increaed pain after the injection. This can last for several days, but does not always occur. Other side effects include, but are not limited to, bleeding or bruising at the injection site, dizziness last minutes or hours, and no effect on pain.

Peripheral Nerve Block

A peripheral nerve block is a procedure in which a local anesthetic, and sometimes a steroid (anti-inflammatory), is injected near a peripheral nerve. This procedure can prevent pain signals from reaching the brain. A peripheral nerve block is used to acute and chronic forms of pain, especially when the pain is unresponsive to oral analgesic medication and other treatments. Often, candidates for this procedure have lower back pain, neck pain, sciatica, lumbar canal stenosis, cancer pain, shingles pain, and many others. Peripheral nerve blocks can provide longer-lasting pain relief when oral medications are not helping and can reduce the need for opioid use. At Spine & Neuro Pain Specialists, we use the latest state of the art technology in treating you. As a result, your doctor may use an ultrasound machine to assist with the injection to add additional diagnostic information and insure the medication is being delivered directly where it needs to go. 

Diagnostic Injections

Diagnostic injections are injections are used to help locate the source of the pain. There are several types of diagnostic injections. These include selective nerve root injections and medial branch blocks (nerves that are close to the spinal cord), among others. The choice of injection is based on the patient’s history, examination, and imaging studies (x-rays, MRI’s, CT Scans, and myelograms). While these pictures may show abnormalities like arthritis, degenerative disc disease and bulging/herniated discs, they cannot show pain. Spinal injections are not only used to relieve pain, but are also commonly used to find pain.

Epidural Steroid Injections/Selective Nerve Root Blocks

General Information

Epidural Steroid Injections (ESI’s) are a common method of treating inflammation associated with neck pain, mid-back pain, low back pain, pinched nerves and some causes of headaches.

Why Get an Epidural Steroid Injection?

Narrowing of the spinal passages can occur from a variety of causes, including disc herniations, bone spurs, thickening of the ligaments in the spine, joint cysts, or even abnormal alignment of the vertebrae (‘slipped vertebrae’, also known as spondylolisthesis). The epidural space is a fat filled ‘sleeve’ that surrounds the spinal sac and provides cushioning for the nerves and spinal cord. Steroids (‘cortisone’) placed into the epidural space have a very potent anti-inflammatory action that can decrease pain and allow patients to improve function. Although steroids do not change the underlying condition, they can break the cycle of pain and inflammation and allow the body to compensate for the condition. In this way, the injections can provide benefits that outlast the effects of the steroid itself.

How Are Epidural Steroid Injections Performed?

There are three common methods for delivering steroid into the epidural space: the interlaminar, caudal, and transforaminal approaches. All three approaches entail placing a thin needle into position using fluoroscopic (x-ray) guidance. Prior to the injection of steroid, contrast dye is usually used (provided the patient does not have other medical conditions that would prevent its use, like an allergy to contrast) to confirm that the medication is traveling into the desired area. Frequently, a local anesthetic (numbing medicine) is added along with the steroid to provide temporary pain relief.

An interlaminar ESI, often referred to simply as an ‘epidural injection’, involves placing the needle into the back of the epidural space and delivering the steroid over a wider area. Similarly, the caudal approach uses the sacral hiatus (a small boney opening just above the tailbone) to allow for needle placement into the very bottom of the epidural space. With both approaches, the steroid will often spread over several spinal segments and cover both sides of the spinal canal. With a transforaminal ESI, often referred to as a ‘nerve block’, the needle is placed alongside the nerve as it exits the spine and medication is placed around the nerve. The medication then travels up the nerve and into the epidural space from the side. This allows for a more concentrated delivery of steroid into one affected area (usually one segment and one side). Transforaminal ESIs can also be modified slightly to allow for more specific coverage of a single nerve and can provide diagnostic benefit (referred to as a Selective Nerve Root Block), in addition to improved pain and function.

All three procedures are performed on an outpatient basis, and you can usually return to your pre-injection level of activities the following day. Some patients request mild sedation for the procedure, but many patients undergo the injection using only local anesthetic at the skin.

What Happens After the Injection?

The steroid will usually begin working within a few days, but in some cases it can take up to a week to feel the benefits. Although uncommon, some patients will experience an increase in their usual pain for several days following the procedure. The steroids are generally very well tolerated, however, some patients may experience side effects, including a ‘steroid flush’ (flushing of the face and chest that can last several days and can be accompanied by a feeling of warmth or even a low grade increase in temperature), anxiety, trouble sleeping, changes in menstrual cycle, or temporary water retention. These side effects are usually mild and will often resolve within a few days. If you are diabetic, have an allergy to contrast dyes, or have other serious medical conditions, you should discuss these with your doctor prior to the injection.

Epidural steroid injections have been performed for many decades, and are generally considered as a very safe and effective treatment for back, leg pain, neck and arm pain. Serious complications are rare, but could include allergic reaction, bleeding, infection, nerve damage, or paralysis. When performed by an experienced physician using fluoroscopic guidance, the risk of experiencing a serious complication is minimized. Overall, ESI’s are usually very well tolerated.

Although not everyone obtains pain relief with ESI’s, often the injections can provide you with improvement in pain and function that last several months or longer. If you get significant benefit, the injections can be safely repeated periodically to maintain the improvements. Injections are also commonly coupled with other treatments (medications, physical therapy, etc) in an attempt to either maximize the benefit or prolong the effects. You should consult with your doctor to develop a comprehensive care plan.

Nucleoplasty

What is Nucleoplasty?

Nucleoplasty therapy is technique for the treatment of pain coming from a spinal disc. A special probe is inserted into the spinal disc and is used to remove a small amount of disc tissue from the disc nucleus and then to applied controlled thermal energy, or heat, to the disc. This causes the pressure within the disc wall to decrease and allows the disc to bulge or herniation to protrude less.

Am I a candidate for Nucleoplasty?

If you have back or leg pain from a contained disc herniation or protrusion that does not respond to less invasive or more conservative therapies, you might benefit from a nucleoplasty procedure. Most back or leg pain from a contained disc herniation or protrusion gets better on its own in the first month or two, so typically physicians do not consider nucleoplasty until at least a month after the onset of back or leg pain. Also, if your back or leg pain is not severe enough to limit your activities, you probably should not have nucleoplasty.

Is there anything else I should try before having Nucleoplasty?

Before considering nucleoplasty, most patients should try less invasive treatment, such as anti-inflammatory medications, physical therapy and epidural or other spinal injections.

How do I know if my back or leg pain is from a damaged disc?

The wall of the spinal discs can get cracks or fissures as we age, and the discs can degenerate naturally. This is known as internal disc disruption or degenerative disc disease. Disc degeneration, bulging or protrusion can also come from an injury. If the wall is damaged or weakened, the disc might develop a very prominent bulge that we often call a herniated disc. When the disc causes back pain, the pain is usually felt as a deep, aching pain in the back and sometimes in the buttocks and into the thigh. When the disc causes leg pain, the pain is usually felt as a sharp, electric, stinging pain in the buttocks and into the thigh, calf or foot. This leg pain is called radicular or nerve root pain and is commonly referred to as sciatica by many patients. Not all back or leg pain comes from disc damage. MRIs and other studies of the discs can often help to predict if the pain is from a damaged disc.

Can all damaged discs be treated with Nucleoplasty?

No. Nucleoplasty might not be appropriate if the disc is very narrowed, or if the spine is misaligned or otherwise unstable. Discs that do not have an intact annulus or rim are difficult to decompress with nucleoplasty because, in theory, they have already decompressed themselves by extruding disc material through a tear in the annulus or rim. Damaged discs in the neck cannot be treated with nucleoplasty, only discs in the back.

How long does the Nucleoplasty take?

Nucleoplasty usually takes sixty minutes or less.

How is disc Nucleoplasty actually performed?

Nucleoplasty is usually performed as an outpatient procedure. It is performed under sterile conditions. The patient lies face down on an x-ray table. Local anesthesia and mild sedation will be used to make the patient more comfortable during the procedure. Using x-ray guidance, an introducer needle is inserted into the sidewall of the disc. Then the nucleoplasty device is passed through the needle and positioned in the internal portion of the disc under x-ray guidance. Once in proper position, the device is used to cut a small portion of disc material out of the center of the disc and then heat the tissue immediately around the area where tissue has just been removed. When done, the device and needle are removed and an adhesive bandage is placed over the needle insertion site.

Will the disc Nucleoplasty hurt?

Local anesthesia and mild sedation will be used to make the patient more comfortable during the procedure. There is often mild pain and some pressure when the introducer needle is passed through the tissues and into the sidewall of the disc.

Will I be “put out” for the disc Nucleoplasty?

Local anesthesia and mild sedation will be used to make you more comfortable during the procedure. You will need to be awake enough to tell your physician what you are experiencing during the procedure. However, some patients receive enough sedation that they have amnesia and afterward cannot remember parts or all of the procedure.

What should I expect after the disc Nucleoplasty?

There might be a mild flare-up of your back pain for a few days after the procedure. You will be advised to use ice packs initially. Some patients might need extra medication during this time. Other patients feel better right away or within days and actually take less medication. Almost everyone is back to at least their usual level of pain within two weeks.

When can I go back to work?

If everything goes well, most patients can resume limited activity the next day. Return to work with full activity usually begins at about two weeks after the nucleoplasty. Patients with very active jobs might be advised to take it easy a bit longer.

When will my pain get better?

Many patients are substantially improved right away or within the first few days after the nucleoplasty. Your pain should gradually improve over the weeks and months following the nucleoplasty. Improvement can occur as long as 6 to 12 months after the procedure.

What should I do after the Nucleoplasty?

The nucleoplasty is normally an outpatient procedure. You will need to have someone drive you home. You will need to wear an abdominal binder that will support your back and somewhat limit your motion for the first two weeks and occasionally longer. It is very important to limit your activities after the nucleoplasty to allow the disc sidewall to heal and the center of the disc where the material was removed to scar closed.

What are the alternatives to disc Nucleoplasty?

If you have back or leg pain from a damaged disc, the alternatives are to treat the pain conservatively with medication, physical therapy, chiropractic and epidural or other spinal injections. An open surgical spine procedure such as laminectomy, diskectomy or spinal fusion is also an option.

If the Nucleoplasty does not work, will it cause a problem if I then need an open spine surgery?

No. If the nucleoplasty is not effective, there will be no problem if the patient decides or ultimately requires an open spine surgery. The nucleoplasty does not damage or alter the tissue around the spine, nor does it change the internal spine anatomy except for the expected and desired changes inside the disc itself.

If I have had previous spine surgery, can I still have a disc Nucleoplasty?

Maybe. If there has been previous spinal fusion at the level of concern, it will be difficult, if not impossible, to perform a nucleoplasty. If the disc in question is outside the area of previous spine surgery, it is quite possible that a nucleoplasty can be performed.

Electrodiagnostic Studies (EMG/NCV)

Electromyography (EMG) and Nerve Conduction Velocity (NCV) studies are ordered to evaluate for injury or disease of muscle, nerve roots, and peripheral nerves. They test the condition of the nerves from the spine, face, and extremities, including the foot and hand. These studies are normally done together and are usually performed as a workup for complaints of pain, weakness, cramping, numbness, or tingling.

During the nerve conduction portion of the study, mild electrical impulses are sent along the course of a nerve in the arm or the leg. The electrical impulse may make the muscles in your arm and leg contract. The sensation you feel is much like that of a static electric shock. Electrodes are placed along the known course of the nerve. When the nerve is stimulated, it must transmit the signal along its course. An electrode placed further down the arm or leg captures the signal as it passes by. A healthy nerve will transmit the signal faster and stronger than a sick nerve.

The needle EMG portion of the study involves the insertion of very thin pin electrodes into the skin. The electrode is moved around slightly after its insertion. Muscles normally receive constant electrical signals from healthy nerves, and in return “broadcast” their own healthy electrical signals. Once inserted into a muscle, the EMG electrodes record the electrical signal generated by the muscle. If the muscle is diseased or injured, or if it does not receive adequate signals from its nerve supply, then the muscle signals that are broadcast back through the EMG electrode will show the abnormality.

Since the EMG and NCV study can be uncomfortable many patients come to the test anxious. Almost all leave feeling they worried for nothing. Equally important, many are grateful when the source of their pain, weakness, cramping or numbness has been found.