Pain Management

Nerve Blocks

What is a Spinal Nerve Block?

A spinal nerve block is the injection of an anesthetic and steroid medication around the spinal nerve root to diagnose or treat pain.

Indications for Spinal Nerve Blocks

Spinal nerve blocks are indicated to relieve pain, weakness, numbness and tingling sensations in your neck, back, and extremities due to nerve injuries such as a pinched nerve or narrowing of the spinal column (stenosis).

Preparation for a Spinal Nerve Block

You should not eat or drink anything after midnight the night before the procedure. You may take your medications with water. You may have to temporarily discontinue certain medications such as blood thinners or diabetic medication. The procedure is not performed if you have an ongoing infection or elevated blood pressure.

Procedure for a Spinal Nerve Block

  • A spinal nerve block is an outpatient procedure. You will lie on your stomach on an X-ray table and your doctor will administer a sedative intravenously to help you relax during the procedure.
  • Your vitals are constantly monitored. Your doctor locates the target site with the help of X-ray imaging.
  • A contrast dye is used to ensure that the needle is accurately placed and the medication is then delivered to the target site.
  • If the nerve block is performed as a diagnostic procedure, you will be instructed to note any changes in pain at different intervals.
  • This helps your doctor evaluate which nerve is causing pain. The entire procedure takes approximately 15 to 30 minutes.

What will I Experience After a Spinal Nerve Block?

You may have pain relief immediately after the injection, but pain may return after a few hours as the anesthesia wears off. The effects of the treatment will be usually noticed 2 or 3 days after the treatment. If you respond well to the first injection, you may be advised to have another injection after a period of time for better relief.

Risks and Complications Associated with Spinal Nerve Blocks

As with any procedure, a spinal nerve block may be associated with certain risks and complications such as pain (temporary), bruising, infection at the site of the injection and nerve damage.

Radiofrequency Ablation

What is Radiofrequency Ablation?

Radiofrequency ablation (RFA) also called rhizotomy or neurotomy is a novel non-surgical technique which employs radiofrequency waves to produce heat that damages the nerves transmitting pain signals to the brain.

How is it Done?

You will be taken to the pre-op area where trained nursing staff will get you ready for the procedure. Before the procedure, an intravenous (IV) line may be placed in a vein in your arm and a local anesthetic and mild sedative may be used to relax you during RFA. You will be lying on your stomach. Only a small area over your back which requires treatment is cleansed and numbed. This procedure is performed under the guidance of fluoroscopy. The fluoroscope is a special kind of X-ray machine that helps doctors to visualize the placement of the needle electrode when it is inserted.

During the procedure, your doctor will direct a special radiofrequency needle electrode close to the facet joint in such a manner that the needle tip lies almost near to the medial branch nerve. Medial branch nerves are very small nerves that innervate the facet joints of the spine. Facet joints are the joints connecting the different vertebra of the spine to each other. The joints are present on both sides of the spine from the neck to the lower back. Once the needle and electrode placement are verified, a small amount of electrical current is sent through the needle so the nerve gets cauterized and destroyed, subsequently reducing the pain. The needle is removed, and the injection site is covered with a dry, sterile bandage.

How Long does it Take?

The RFA procedure will take one to two hours to perform, depending upon the on the area of the body treated and a number of treatments performed.

Pre-procedure Preparation

To prepare for radiofrequency ablation treatment, you should take the following precautions:

  • Stop eating or drinking anything after midnight the night before your procedure. If you must take medications, take them with only a small amount of water.
  • You will need to bring someone with you to take you home as you should not drive for at least 24 hours after the procedure.
  • If you have diabetes you will have to adjust your dose of insulin. After the procedure, you may take your diabetes medication.
  • You may need to discontinue any blood thinning medications with the permission of your doctor.
  • Do remember to bring with you all the medications that you have been taking so that you can take them after the procedure. Do not discontinue any medication without approval from your primary care physician.

Post Procedure Protocol

Following radiofrequency ablation, you may be able to go home within one hour. You may resume your normal diet. Do not drive or perform vigorous physical activity for the first 24 hours after the procedure. If pain increases, pain medication may be prescribed to make you comfortable. People who have problems with constipation should eat more high-fiber foods, drink plenty of fluids and if needed, use over–the–counter stool softeners. If you notice swelling and redness at the injection site, apply ice over a towel for 20 minutes every hour to the area to ease the discomfort.

Although the results of radiofrequency ablation vary, the pain relief achieved lasts from 3 to 12 months in most patients. In some cases, the pain may return as the nerve regenerates. Your follow-up appointment will be scheduled a week or two after the procedure to see how well the treatment has worked.

Indications for Radiofrequency Ablation

Radiofrequency ablation is performed to treat painful facet joints in the spine that usually cause chronic low back pain, neck pain and pain related to the degeneration of joints from arthritis.

Radiofrequency ablation treatment is considered only after it is confirmed that the cause of back pain lies in the facet joints, by performing a diagnostic facet joint injection.


Benefits

Benefits of radiofrequency ablation include:

  • Longer lasting pain relief compared to facet joint injection
  • Reduction of your pain
  • Allows you to do more activities
  • Allows you to reduce your pain medication intake
  • Minimally invasive with no skin incision
  • Short recovery time

Risks/Side effects

Radiofrequency ablation procedure is a safe treatment with low risks for complications. However, with any procedure, there are possibilities of complications. Some risks and complications associated with radiofrequency ablation include:

  • Infection:An infection can occur just below the skin, in a muscle, or in the facet joint. Check for signs of infection including fever and chills, redness, swelling, and increasing pain. Antibiotics are usually needed to treat the infection. If an abscess develops, surgery to drain the pus may be needed.
  • Nerve damage: Nerve damage can occur if the needle electrode used during the procedure accidentally hits a nerve.
  • Increased pain: Sometimes, the procedure can result in increased pain. Pain that starts several days after the procedure may indicate an infection.
  • Allergic reactions: Allergic reactions may occur if you have allergies to the medications or contrast dye that may be used during the procedure. Pay close attention to any rashes and difficulty breathing as it may indicate a need for emergency attention.
  • Neuritis: Neuritis refers to an inflammation of the nerves resulting in pain and tenderness in the back. Injection of a local anesthetic along with a steroid medication can reduce inflammation around the nerve and ease your symptoms.

Percutaneous Discectomy

What is Percutaneous Discectomy?

Percutaneous discectomy is a minimally invasive technique in which the herniated disc material is removed through a very small cut made in the skin. A herniated disc is a condition in which the outer fibers (annulus) of the intervertebral disc are damaged causing the soft inner material of the nucleus pulposus to rupture out of its space. If the herniated disc presses on a spinal nerve, it can cause pain.

How is it Performed?

There are several ways in which a percutaneous discectomy procedure may be performed. Almost all the methods require insertion of small instruments in between the vertebrae and into the middle part of the disc. You will be given a local anesthetic and mild sedative to relax you during the procedure. During the procedure, an instrument is inserted through a needle and placed in the middle part of the disc. The position of the small instruments is monitored with the help of X-rays. Your surgeon may remove the disc tissue by one of the three methods: cutting the disc out, suctioning out the central portion of the disc, or burning down the disc contents with a laser. This relieves the pressure on the surrounding nerves and eliminates the pain from the herniated disc. The injection site is covered with a dry, sterile bandage.

How Long does it Take?

A percutaneous discectomy procedure takes about 30 minutes to perform.

Preprocedural Preparation

All patients will be evaluated before the procedure. The evaluation includes your medical history, physical exam, and diagnostic tests. Diagnostic tests such as MRI, CT scan, or myelogram may be done to view a non-ruptured bulging disc.

There is very little preparation for this procedure. You will need to bring someone with you to take you home as you should not drive for at least 24 hours after the procedure. Inform your doctor about any medications you are currently taking.

Post Procedure Protocol

You may return back home the same day after percutaneous discectomy. During the recovery period, you may feel slight pain which can be taken care of with pain medications. You will be advised to avoid lifting heavy weights or strenuous exercises for several weeks. Physical therapy exercises may be prescribed for faster rehabilitation.

Indications for Percutaneous Discectomy

Percutaneous discectomy is used to treat non-ruptured herniated disc or a bulging disc which can cause symptoms such as low back pain and leg pain. Percutaneous discectomy may be considered as a treatment option if diagnostic tests performed have confirmed the presence of a bulging disc that has not separated into the spinal canal. Your doctor may also recommend this treatment if your symptoms get worse and interfere with normal activities without improvements even after four weeks of conservative treatment. Signs of nerve damage becoming worse may also necessitate percutaneous discectomy procedure.


Benefits

Benefits of radiofrequency ablation include:

  • Little tissue trauma
  • Relieve your symptoms of leg pain and back pain
  • Pain relief is sustained through one-year post-procedure
  • Fewer risks of complication
  • Less recovery time


Risks/Side Effects

With lower risks of complications, percutaneous discectomy is considered an appropriate treatment for many patients who suffer from back and leg pain symptoms. You may feel slight pain after the procedure which can be taken care of with pain medications.

Trigger Point Injections

Introduction

Trigger points are tight bands or knots that form when a muscle fails to relax after a contraction. These areas of pain and muscle spasm may develop due to acute trauma, overuse injuries or chronic muscular disorders. They usually occur in the upper back and shoulder muscles and may irritate adjacent nerves causing pain to radiate to the surrounding regions. Trigger point injections or TPI may contain an anesthetic, steroid or a combination of the two. They are administered to relieve pain and improve mobility.

Indications

Trigger point injections are administered to relieve intense pain at the trigger points and surrounding areas. They can be used in the management of conditions such as fibromyalgia, tension headaches, temporomandibular pain and myofascial pain syndrome.

Procedure

The trigger point is usually located by palpation but an ultrasound localization technique may also be used. A topical anesthetic may be applied to numb the area and keep you comfortable during the procedure. Then a small injection containing local anesthetic with or without corticosteroid is directly administered to the trigger point making it inactive and relieving pain.

If you are allergic to the anesthetic, your doctor may use a dry-needle technique where a needle is inserted into the trigger point but no medication is used. This can also relieve pain. The procedure takes just a few minutes.

A single injection may be enough to treat trigger points due to trauma or repetitive use injuries. Chronic conditions usually require periodic administration of trigger point injections.

Post-Operative Care

You will experience some numbness at the site for approximately an hour. You may also develop some pain and bruising at the injection site. Hot or cold packs and over the counter pain medication can help relieve these symptoms. Stretching and other physical therapy exercises are usually recommended after trigger point injections.

Risks and complications

As with any injection, there is a risk of infection or bleeding. Rarely, you may experience an indentation of the skin due to shrinkage of fat when a steroid is administered.

Spinal Stimulation

What is Spinal Stimulation?

Spinal cord stimulation is a procedure that delivers low-level electrical signals to the spinal cord or to specific nerves to block pain signals from reaching the brain.

What is a Spinal Cord Stimulator?

A spinal cord stimulator is a device that sends electrical impulses to the areas of the spinal cord causing pain and interferes with the transmission of pain signals to the brain. It blocks the brain's ability to sense pain in the stimulated areas, thus relieving pain without the side effects that medications can cause. The electrical impulses can be targeted to specific locations and, as pain changes or improve, stimulation can be adjusted as necessary.

Indications for a Spinal Cord Stimulation

Nerve decompression can cause back and leg pain. Among other causes, scar tissue around the nerves or chronic inflammation of the nerves such as arachnoiditis may cause leg and back pain. 
When your neurosurgeon feels that open surgery to decompress the nerves is unlikely to help the pain, an operation to implant a spinal cord stimulator may be suggested.

Preparing for a Spinal Cord Stimulation

Before implanting a permanent stimulator, you will undergo a trial stimulation period to see if the stimulation helps relieve the pain. If it does, a permanent stimulator may be implanted. 

Spinal Cord Stimulation Procedure

There are several ways of implanting the stimulator. The initial implantation of the trial is generally done when you are awake so that you can determine if the stimulator is covering the appropriate spot of the spinal cord and is giving you pain relief.
Either a paddle lead is placed over the spinal cord through a small open incision and removal of the lamina, or a lead is placed through the skin. The permanent implant will be fixed several days later if you achieve good pain relief with the trial stimulator. 

Postoperative Care

You are generally discharged on the same day or the following day of the procedure. You should keep the wounds very clean and dry.

Risks and Complications

The risks of inserting a spinal cord stimulator are low. The potential risks may include bleeding, infection, injury to nerves, injured the spinal cord, paralysis, and death.

Pain Medications

Medications play an effective role in the treatment of back or neck pain. Your doctor may prescribe several medications to help reduce pain and associated symptoms that are caused by unhealthy spinal conditions or deformities.

When healthcare professionals prescribe a pain medication regimen, the precise needs of the patient are considered including severity of the pain, length of time with pain and medical history of the individual. The main goal of prescribing medications is to reduce the patient’s pain and increase their comfort level while reducing adverse side effects and the danger of misuse or abuse of the medications.

Over-the-counter Pain Relievers

Over-the-counter pain relievers are medications available without a doctor's prescription. They include acetaminophen, Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and topical pain relievers.

Acetaminophen (Tylenol) and NSAIDs help to reduce fever and alleviate pain caused by general muscle aches and stiffness. Moreover, NSAIDs can also reduce inflammation. NSAIDs help relieve pain by reducing the level of prostaglandins (hormone-like substances) that cause pain.

Topical pain relievers (Aspercreme, Ben-Gay, and Capsaicin) include creams, lotions and sprays that are applied to the skin of painful muscles or joints to ease pain.

Your doctor may also prescribe prescription strength NSAID’s for pain relief which have a higher amount of medication requiring a prescription. Alternately, your physician may recommend short term use of opioids or narcotic medications for pain relief.

Talk to your doctor and discuss all available options based on your particular situation.  

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