Serenity

Epidural Steroid Injections:

​

An epidural steroid injection (ESI) is an injection of corticosteroids (similar to cortisone) into the space just outside the covering of the spinal cord in your neck/back.  So a needle is placed into your spine but stops before reaching your spinal fluid.  These injections are performed when it is thought that spinal nerve inflammation is part of the process that is causing the pain.  Common indications for an epidural steroid injection include herniated discs, degenerative disc disease, radiculopathy or radiculitis, and spinal stenosis.  These procedures are performed on an outpatient basis in a series of three injections spaced one week to one month apart for maximum effect.  The complications of lumbar epidural steroid injection are related to the injection and to steroid effects. Bleeding, pain, headache, and infection can result from the injection. Weight gain, water retention, suppression of the immune system, and suppression of the body’s own natural steroids can result from steroid use. These considerations should be taken into account before any steroid injections.

• Cervical epidural steroid injections are a frequently used treatment for neck and head chronic pain syndromes as well as for cervical radiculitis (radiating pain down the arms)

• Lumbar epidural steroid injections are a common procedure performed to alleviate low back pain and shooting leg pain. 

 

​

Transforaminal ESI and Selective Nerve Root Block:

 

A transforaminal epidural steroid injection (TFESI) is the injection of steroid into the opening at

the side of the spine where the nerve root exits.  These injections may also be known as selective nerve root injections.  The main advantage of transforaminal ESI is that the doctor can deliver the medicine into the neural foramen that contains the actual nerve root in question, which can increase the likelihood of success in reducing the patient’s pain. Another advantage is that the doctor can inject and anesthetic like lidocaine that works immediately (but temporarily) to numb the nerve root.  If the anesthetic immediately relieves your pain, the doctor then knows that the correct level has been treated.  This can help ensure that steroid injections in the future or surgery that will be done are focusing on the correct nerves.

 

​

Facet Steroid Injections and Medial Branch Blocks:

 

The facet joints link the vertebrae together and give them the flexibility to move against each other. There are two facet joints between each pair of vertebrae, one on each side.  The facet joints enable bending and twisting movements of the spine.  The medial branch is the branch of the spinal nerve that carries sensation and pain signals from the facet joint back to the spinal cord.

The facet joints are just like any other joint in the body, they are susceptable to acute injury (sprain or strain) as well as degenerative arthritis. In the back, the facet joints may cause low back pain, hip and buttock pain, and leg pain. The pain is especially bad when leaning backwards or twisting your spine. The pain also tends to be worst first thing in the morning and in the evening.

• Facet Steroid Injection: A needle is directed using x-ray guidance into the joint or joints in question and then a mixture of medication is injected.  This injection includes both a long-lasting steroid and an short-acting anesthetic (lidocaine, bupivacaine). The steroid reduces the inflammation and irritation and the anesthetic works to numb the pain.

• Medial Branch Block: The needle is placed over the nerve that provides sensation to the facet joint and then a small amount of local anesthetic like lidocaine is injected to numb the nerve and likely the pain.  This injection serves primarily as a diagnostic test to determine if facet joint pain is a cause of your back/neck pain.  A steroid to reduce inflammation and irritation can also be added if the  physician chooses.

 

 

SacroIliac Joint Injection and other joint injections:

 

A sacroiliac (SI) joint injection is an injection of numbing medication and an anti-inflammatory steroid that reduces the inflammation in the joint space in the low back.  The sacroiliac joints are located in the back where the sacral spine (commonly referred to as the tailbone) joins the pelvis.

 

Other joints that can be injected under x-ray or ultrasound guidance include:

• the shoulder

• the hips

• the knees

• the wrist/fingers

• the foot and ankle 

 

​

Trigger Point injection and other muscle injections:

 

Trigger point injections are used where bundles of muscle fibers become tight, knotted and unable to relax.  They can occur as a result of injury, spinal or skeletal abnormality or poor biomechanics. Treatment to relieve trigger points include targeted trigger point injections of local anesthetic with or without steroids, chiropractic care, massage, stretching, and physical therapy.  In difficult cases botox injections often provide substantial and lasting relief. 

 

​

Lumbar Sympathetic Block:

 

The Lumbar Sympathetic Nerve Block is a procedure used to block or decrease pain in the lower extremities caused by injury or disease of the sympathetic nervous system.  The lumbar sympathetic nerves are located on either side of the lumbar spine at the front portion of the spine.  A needle will be placed using x-ray guidance at this location at the indicated levels and medication injected.  If the block relieves your pain, the doctor will then perform a series of blocks at a another time, in an attempt to break the pain cycle and provide long lasting pain relief.  The number of blocks you will need depends on how long the pain relief lasted between injections.  Usually you will get more and longer pain relief after each injection.  If the series of blocks do not relieve your pain, a radiofrequency lesion may be done, or consideration of stimulator implant may be necessary.

 

Occipital Nerve Block:

 

An occipital nerve block is useful in diagnosing and treating occipital neuralgia (intense head pain caused by inflamed occipital nerves).  It is used to relieve or reduce the pain in the back of the head and the scalp.  The block may be done on either the left or right side of the back of the head.

During the procedure, your pain management doctor will inject a local anesthetic and steroid into the affected area beneath the scalp.  Immediately after the injection you may notice that your pain has subsided or lessened considerably.

 

​

Medial Branch RadioFrequency Ablation (RFA):

 

RadioFrequency Ablation, also called Neurotomy or Rhizotomy, reduces or stops pain coming from the spinal facets.  A slight electric current is used to cauterize the nerves that transmit the pain from specific facet joints.  This is an outpatient that can be done in the office.  It is performed with specialized needles placed under X-ray guidance.  Correct placement of the needle is checked in at least 3 different ways to ensure treatment of only the small nerve in question.   The surgeon then sends very high frequency current through the electrode to heat the nerve.  This part is relatively painless as the area has been numberd.  Once one level is treated, the surgeon may do the same procedure to one or more nerves.

 

There may be a slight increase in pain for about a week after the procedure but full relief from pain is usually felt within a month. Successful RF treatments last significantly longer than steroid injections or medial branch blocks.  Typically the relief lasts many months (>6) – sometimes up to 12.  Sometimes when the nerves recover the pain does not return.  If the pain does return, the procedure can be repeated.

​

 

Spinal Cord Stimulation

 

Spinal cord stimulation uses low voltage stimulation applied directly to the spinal cord to block/decrease the feeling of pain.  It helps you to better manage your pain 24/7.  It traditionally has been an excellent option if you have long-term (chronic) leg or arm pain, and have not found relief through traditional methods; however, improving technology has also made it a better option for strictly back or neck pain.  

 

A small battery-powered generator implanted in the body transmits an electrical current to your spinal cord, much like a pacemaker for the spinal cord. By interrupting pain signals, the procedure has shown success in returning some people to a more active lifestyle.

 

Stimulation does not eliminate the source of pain, it simply interferes with the signal to the brain, and so the amount of pain relief varies for each person.  Also, some patients find the tingling sensation unpleasant.  For these reasons a trial stimulation is performed before the device is permanently implanted. The goal for spinal cord stimulation is a 50-100% reduction in pain.  However, even a small amount of pain reduction can be significant if it helps you to perform your daily activities with less pain and reduces the amount of pain medication you take.  Stimulation does not work for everyone. But unlike virtually any other surgery or procedure, you are able to get a preview or "test-drive" that will give you a clear idea of what type of relief to expect.  Both the trial stimulation and the permanent implant procedure are same-day outpatient procedures.  

 

​

Discography:

 

Discography is a diagnostic test typically requested by your spine surgeon to determine whether certain discs of the spine are the source of your back pain.  It simply provides information for your surgeon to help formulate a treatment plan.  Essentially, a needle is directed under x-ray guidance into the disc/s in question and then a small amount (about 1/2 teaspoonful) solution of x-ray contrast, antibiotics, and saline is injected into the disk.  This places pressure on the disc from the inside out in order to replicate the pressure you place on your back with daily activity.  The goal is to see if this artificial pressure reproduces the pain that you feel in your daily life.  The results are recorded and sent your surgeon.  While during the procedure, your input is vital so sedation is minimal, as soon as the testing process is over you are given IV medication to ensure that you are comfortable.  This procedure is ideally performed in an operating room for maximal sterility, but it is still an outpatient procedure.

 

Your spine surgeon may instruct you to go for a CT exam directly after the discogram to better visualize the contrast spread.