 |
|
| 
|
Comprehensive Evaluation
There is no room for guesswork when it comes to effective pain management. A precise diagnosis must precede precise treatment. Our treatment of each patient begins with a detailed, pain-oriented history and physical examination. Medical records and previous treatments are thoroughly reviewed. If required, additional tests are ordered. Each patient then receives the latest pain diagnosis and treatment specific to his or her unique condition.
Blocks
The use of neural blockade for the safe diagnosis and treatment of persistent pain is a well-established practice. Regional anesthesia techniques perfected over the past century are commonly used at Somnia Pain Management to diagnose and treat difficult pain problems. Since pain impulses are transmitted by specific nerves, blockade of these nerves can provide useful information regarding the sources of pain. For instance, by blocking somatic (body wall) nerves, we can sometimes determine whether pain is originating within the body wall structures as opposed to the internal organ structures. This knowledge can improve the accuracy in diagnosing pain syndromes and guide surgical therapy or interventional pain treatment.
NERVE ROOT BLOCKS
Overview
A root block is an injection of local anesthetic and steroid under x-ray guidance into the area where the nerve exits within the spinal column. The procedure is usually ordered by your doctor for pain in the arm or leg that follows the path of a single nerve.
A root block may be diagnostic and/or therapeutic. One of three things may happen:
1. The pain does not go away – which provides diagnostic value indicating that the pain is probably not coming from the nerve at the level of the injection.
2. The pain goes away and stays away for a few hours but the original pain comes back and does not get better again. This would provide diagnostic value – that the pain is probably coming from the nerve at the level of the injection, but the steroid was not of benefit.
3. The pain goes away after the block, the pain may come back later that day, but then the pain gets better again over the next few days. Therefore, the block was of therapeutic value and the steroid had a long lasting effect on the pain.
If you receive good and lasting benefit from the injection, the block may be repeated. Sometimes your surgeon will ask that the block be done to help identify whether or not surgery might be helpful and at what level the surgery might be most beneficial.
Risks
As with most procedures, there is a remote risk of bleeding, infection, nerve injury, or allergic reaction to the medications used. Some short-term side effects may occur. You may develop numbness that follows the path of the nerve that was blocked. You may develop weakness as well. If you get weakness that interferes with your ability to walk, you will have to remain at Somnia Pain Management until this resolves – usually several hours. You may have increased pain for a few days after the injection, including localized pain at the injection site. Diabetics may have short-term elevation of blood sugars. People prone to fluid retention may have increased fluid retention for 1 to 2 weeks. Acne and hair changes may also occur.
What to Expect
After signing a consent form and checking your blood pressure, the procedure will be done in the fluoroscopy (x-ray) room, while you are lying on your stomach. For many procedures, an intravenous is started and sedation is given to help you relax. The back is then cleansed with an antiseptic soap or betadine. Sterile drapes are placed over the area to prevent infection. The skin is anesthetized (numbed) with a local anesthetic. This is felt as a stinging or burning sensation. Using x-ray guidance, the needle is advanced to the proper location. A dye may be injected at this point (please make sure to notify the doctor if you have any allergies to dye). Local anesthetic and steroid are then injected through the needle and the needle is removed. Your skin will be cleansed and a bandage applied (the bandage can be removed the next morning).
Most people say the stinging/burning of the numbing medicine is the most uncomfortable part of the procedure, though each person's response to any procedure is individual. As the injection is right near a nerve, it is possible to get a temporary "electric-shock" sensation.
Your level of pain may improve immediately after the injection from the local anesthetic. It is important to keep track of how you feel for the remainder of the day. The steroid usually takes two or three days to have an effect in most people and may peak in approximately two weeks.
Some local tenderness may be experienced for a couple of days after the injection. You can use an ice pack three or four times a day to relive the pain. After the injection, you may take your usual pain medication.
It is important that you keep track of the amount of pain relief you received as well as how long the pain relief lasted. Please report this to your pain doctor or to his assistant.
Preparation/Restrictions
Procedures cannot be performed if you have an active infection, flu, cold, fever, very high blood pressure or if you are on blood thinners, vitamin E or aspirin products. Please make your doctor aware of any of these conditions. This is for your safety!
No heat is to be used in the injected area for the remainder of the day.
No tub bath or soaking in water (i.e. pool, Jacuzzi, etc.) for the remainder of the day.
If you are going to receive IV sedation, it is important that you have nothing to eat or drink for at least 6 hours before your procedure. Regularly scheduled medications can be take with a glass of water. After your procedure, you may eat, drink and take medications unless told otherwise by your doctor.
When to Call Us
If you experience severe back pain, new numbness or weakness of your legs, loss of bowel or bladder function, or signs of infection in the area of the injection (fever, chills, fatigue), you should call Somnia Pain Management immediately at 888-559-PAIN (888-559-7246).
Back to Top
STELLATE GANGLION BLOCKS (SYMPATHETIC)
Overview
A stellate ganglion block (sympathetic block) is an injection of local anesthetic into the front of the neck. It is typically ordered by your doctor for pain located in the head, neck, chest or arm caused by sympathetically maintained pain (reflex sympathetic dystrophy), causalgia (nerve injury), herpes zoster (shingles), or intractable angina. Stellate ganglion blocks are also used to see if blood flow can be improved in circulation problems typically associated with Raynaud's or CREST syndrome.
Stellate ganglion blocks may be therapeutic and/or diagnostic. One of three things may happen:
1. The pain does not go away and there is other evidence of a sympathetic block. This is of diagnostic value, indicating the pain is not responsive to sympathetic blocks;
2. The pain does not go away and there is no evidence of a sympathetic block indicating that the block is a technical failure;
3. The pain goes away after the injection and stays away longer than the life of the local anesthetic, providing therapeutic value. The procedure will most likely have to be repeated to get long lasting benefits. The timing of injections will be based on the length of pain relief between injections (usually you will get progressively longer benefits after each injection).
Risks
The risks of the procedure, though infrequent, include seizure – if the medication is injected into a blood vessel, pneumothorax (collapsed lung), brachial plexus block (numb arm that lasts for hours), spinal or epidural block (temporary weakness or numbness from the neck down), allergy to medication, nerve damage, bleeding, infection and bruising at the injection site.
There are some expected changes that result from blocking the sympathetic nerves. These changes last for the life of the local anesthetic (about 4 to 6 hours). They include drooping of the eyelid on the injected side, "bloodshot eye" on the injected side, stuffy nose on the injected side and a temperature increase on the injected side. You may also experience hoarseness.
What to Expect
After signing a consent form and checking your blood pressure, an intravenous will be started. Skin temperature monitors will be placed on both your hands. You will be asked to rate the level of pain on a scale of 0 to 10. The procedure will be done with you lying on your back with a sheet rolled up between your shoulder blades. Your neck will be cleansed with an antiseptic soap. The doctor will press on your neck to identify where to place the needle. At this time, we will ask that you try not to talk, cough, or swallow. When the needle is in the correct place, the medicine (local anesthetic) is injected through the needle. The needle is removed and the procedure is complete taking approximately 5 to 10 minutes. If your pain usually occurs in your head, you will remain lying down; if your pain usually occurs in your arm, you will be asked to sit up so the medicine spreads down. The medicine can take 10 to 20 minutes to take full effect during which time you will be monitored. Your doctor will be checking to see if the expected changes take place, as well as to see what effect, if any, there is on your pain. In addition, your pulse and blood pressure will be checked. If all is well, your intravenous will be removed. Your doctor will authorize your discharge when you are ready and your ride is present.
The doctor has to press on your neck to locate the area to be injected. Many patients find this awkward and somewhat uncomfortable. The injection itself is done using a very small needle. The local anesthetic stings/burns going in.
Your neck may be tender or bruised after the injection. One eye will be droopy. This may affect your sense of balance. You may also experience hoarseness. If you do, you must be careful swallowing to avoid choking.
If your arm gets numb or heavy, you will have to protect it (sling) until sensation returns – usually 4 to 6 hours. You may take your usual pain medications after the injection.
It is important that you keep track of the amount of pain relief you received from the procedure, as well as how long the pain relief lasted. Please report this to your doctor.
Preparation/Restrictions
The procedure cannot be performed if you have an active infection, flu, cold, uncontrolled cough, fever, very high blood pressure or if you are on blood thinners, taking vitamin E or aspirin products. Please make your doctor aware of any of these conditions. This is for your safety!
No heat is to be used in the injected areas for the remainder of the day.
No tub bath or soaking in water (i.e. pool, Jacuzzi, etc.) for the remainder of the day.
If you are going to receive IV sedation, it is important that you have nothing to eat or drink for at least 6 hours before your procedure. Regularly scheduled medications may be taken with a sip of water. After your procedure, you may eat, drink and take your medications unless told otherwise by your doctor. Be careful swallowing after the injection (sips of water first) especially if you experience hoarseness.
When to Call Us
If you experience shortness of breath 24 to 48 hours after the injection, or any signs of infection in the area of the injection (fever, chills, fatigue), you should call Somnia Pain Management immediately at 888-559-PAIN (888-559-7246).
Back to Top
FACET AND MEDIAL BRANCH BLOCKS
Overview
A facet block is an injection of local anesthetic and steroid into a joint in the spine. A medial branch block is similar but the medication is placed outside the joint space near the nerve that supplies the joint called the medial branch (a steroid may or may not be used). You may require multiple injections depending upon the doctor’s estimate of the number of joints involved.
Facet blocks and medial branch blocks are typically ordered for patients who have pain primarily in their back coming from arthritic changes in the facet joints or for mechanical low back pain.
A facet block or medial branch block may be therapeutic and/or diagnostic. One of three things may happen:
1. The pain does not go away. This has diagnostic value that the pain is probably not coming from the blocked facet joints.
2. The pain goes away and stays away for a few hours but the original pain comes back and does not improve again. This is also of diagnostic value indicating that the pain is probably coming from the joints, but that the steroid was of no benefit.
3. The pain goes away after the block, the pain may return later that day, but then the pain improves again over the next few days. This indicates that the block was of therapeutic value and that the steroid had a long lasting effect on the pain.
If you experience good and lasting benefits from the injections, the block may be repeated, if required. If you experience good but short-term benefits, another procedure (radiofrequency lesioning) may be performed, which may last anywhere from months to years.
Risks
As with most procedures, there is a remote risk of bleeding, infection, nerve injury, or allergic reaction to the medications used.
Some short-term side effects may occur. If the local anesthetic spreads to nearby nerves, you may experience weakness or numbness that can last for several hours. If this happens, you may have to remain at Somnia Pain Management until this resolves. You may have increased pain for a few days after the injection, including localized pain at the injection site. Bleeding, infection and nerve damage are very rare occurrences. Diabetics may have short-term elevation of blood sugars. Those patients prone to fluid retention may have increased fluid retention for 1 to 2 weeks.
What to Expect
After signing a consent form and checking your blood pressure, the procedure will be performed in the fluoroscopy (x-ray) room while you are lying on your stomach. An intravenous is started and medication may be given to help you relax. The back is then cleansed with an antiseptic soap and sterile drapes are placed. The skin is anesthetized (numbed) with a local anesthetic, which is felt as a stinging or burning sensation. Using x-ray guidance, needles are then advanced to the appropriate locations (the joints or the medial branch). Once the needles are in the proper location, local anesthetic (with or without steroid depending on the procedure) is injected through the needles and the needles are removed. Finally, your skin will be cleansed and bandages applied. (The bandages can be removed the following morning). Your blood pressure will be checked and you will be discharged to leave with your ride after your doctor's authorization.
Most people say the stinging/burning of the numbing medicine is the most uncomfortable part of the procedure, though each person’s response to any procedure is individual.
Your back pain may be improved immediately after the injection from the local anesthetic. It is important to keep track of how you feel for the remainder of the day. The steroid, when used, takes two or three days to have an effect in most people. The benefits peak in approximately two weeks.
Some local tenderness may be experienced for a couple of days after the injection. The discomfort can be alleviated by using an ice pack three of four times a day. After the injection, you may take your usual pain medication.
It is important that you keep track of the amount of pain relief you received, as well as how long it lasted. Please report this to your pain doctor or his assistant.
Preparation/Restrictions
The procedure cannot be performed if you have an active infection, flu, cold, uncontrolled cough, fever, very high blood pressure or if you are on blood thinners, vitamin E or aspirin products. Please make your doctor aware of any of these conditions. This is for your safety!
No heat is to be used in the injected areas for the remainder of the day.
No tub bath or soaking in water (i.e. pool, Jacuzzi, etc.) for the remainder of the day.
If you are going to receive IV sedation, it is important that you have nothing to eat or drink for at least 6 hours before your procedure. Regularly scheduled medication may be taken with a sip of water. After your procedure, you may eat, drink and take your medications unless told otherwise by your doctor.
When to Call Us
If you experience severe back pain, new numbness or weakness of your legs, or any signs of infection in the area of the injection (fever, chills, fatigue), call Somnia Pain Management immediately at 888-559-PAIN (888-559-7246).
Back to Top
PERIPHERAL NERVE BLOCK
Overview
A peripheral nerve block is a medical procedure that involves administration of a dose of local anesthetic usually into your arm, hand, leg, or ankle region. A peripheral nerve block usually involves a series of three to five injections, repeated at regular (weekly) intervals. This treatment has brought relief to many patients who suffer from pain caused by chronic inflammation such as that which occurs after surgery or after trauma.
What to Expect
Overall:
Your physician will be injecting a small amount of local anesthetic (possibly with steroid medication) into an area usually either in your arm, hand, leg, or ankle region. This peripheral nerve block will be performed depending upon your overall medical condition, as well as the desired nerve that is intended to be blocked.
The procedure:
First, an intravenous line will be placed, generally in your hand. We will then bring you to the operating room and place several monitors on you, to monitor your heart rate, blood pressure, and pulse during the procedure. Following placement of the monitors, we will begin to give you an intravenous medication to decrease anxiety, as well as provide you with some pain relief.
You will then be asked to either lie on your side or remain lying on your back. After cleaning a small patch of your skin, a local anesthetic is injected into the skin to decrease any pain associated with performance of the procedure. Your physician will then administer the local anesthetic (possibly with steroid medication) through a small needle. The procedure itself is usually brief, and lasts less than 10 or 15 minutes. Occasionally, patients will describe a recurrence of their normal pain during administration of the medication or a pins and needles sensation. This is viewed as a reassuring sign that the medication is going to the right place, and the sensation should disappear very quickly.
After the peripheral nerve block is performed, we will continue to monitor you in the recovery room for 30 to 40 minutes. If there are no signs of any problems, you will be ready to leave.
Relief is not instantaneous, but most patients report that they feel a sense of relief within 10 to 15 minutes after the procedure. Pain relief may last two to three hours or even longer; after this, you can expect the local anesthetic to wear off and your pain may return. If your doctor has utilized a steroid medication, it may provide you with additional pain relief that will begin roughly 36 to 48 hours after the procedure.
Risks
Occasionally, patients will feel a recurrence of the normal pain during the administration of the medication or the temporary sensation of pins and needles. This is viewed as a reassuring sign that the medication is going to the right place, and the sensation usually disappears very quickly. Other possible risks or complications include bleeding, infection, as well as injection of medication into a small blood vessel. These risks or complications, however, are extremely rare and your physician will monitor your vital signs to guard against them.
Preparation/Restrictions
The procedure cannot be performed if you have an active infection, flu, cold, fever, very high blood pressure or if you are on blood thinners, vitamin E or aspirin products. Please make your doctor aware of any of these conditions. This is for your safety!
You may not drive for the remainder of the day after your procedure. An adult must be present to drive you home or to go with you in a taxi or on public transportation. The procedure will be cancelled if you do not have a responsible adult with you!! Again, this is for your safety.
If you are going to receive IV sedation, it is important that you have nothing to eat or drink for at least 6 hours before your procedure. Regularly scheduled medications may be taken with a sip of water. After your procedure, you may eat, drink and take your medications unless told otherwise by your doctor.
When to Call Us
If you experience severe back pain, new numbness or weakness of your legs, or any signs of infection in the area of the injection (fever, chills, fatigue), call Somnia Pain Management immediately at 888-559-PAIN (888-559-7246).
Injections
The fluoroscope is a powerful tool that is being increasingly used in the modern pain clinic for the precision diagnosis and treatment of persistent pain. During fluoroscopy, the patient is positioned between an x-ray source and a fluorescent screen. The live images generated by the x-ray source onto the fluorescent screen allow physicians to see the size, shape, and structure of a patient’s internal bony structures to aid in diagnosis and treatment.
Back to Top
DISCOGRAPHY
Overview
Discography is the injection of local anesthetic and dye into a disk in the back. Discography is used to determine which disk level(s) is painful, and is usually used as a diagnostic tool for your surgeon. The procedure involves a minimum of two, but usually three disks. If there is evidence of disk problems at many levels, you may need more disks injected.
Risks
The main risk of the procedure, though it happens less than 1% of the time, is diskitis. Diskitis is an infection in the disk that can lead to an infection in the spine. Every effort is made to prevent this from happening including antibiotics before the procedure, sterile technique, and sometimes the use of antibiotics mixed with the dye.
There is also a chance of paresthesia – a shooting, "electric-shock" type pain. This generally occurs when the medicine is injected into the disk, which puts additional pressure on the nerve. The pain generally passes quickly but on rare occasion it continues. As with most procedures, there is also a remote risk of bleeding, infection, nerve injury, or allergic reaction to the medications used in the procedure.
Some short-term side effects may occur as well. If the local anesthetic spreads to nearby nerves, you may have weakness or numbness that can last for several hours. Should this happen, you may have to remain at Somnia Pain Management until the pain passes. You may have increased pain for a few days after the injection, including localized pain at the injection site. As always, bleeding, infection and nerve injury are other rare complications.
What to Expect
Overall:
Your skin will be numbed with a local anesthetic. This is usually felt as a stinging/burning sensation. Once the needle is in the disk, however, it may be painful as the medicine is injected, as the goal of the procedure is to try to reproduce your usual pain.
The procedure:
After signing a consent form and checking your blood pressure, the intravenous will be started and a mild sedative may be given. You will then be escorted into the fluoroscopy (x-ray) room and asked to lie on the table on your stomach. Your back will then be cleansed with an antiseptic soap and sterile drapes will be placed. The skin is then anesthetized (numbed) with a local anesthetic. You will feel a stinging/burning sensation. Using x-ray guidance, the needle is advanced to the appropriate position (into the disk) and the local anesthetic and dye are injected. You will be asked to let the doctor know whether or not this causes your usual pain. The needle will then be removed. This process will be repeated at as many levels as indicated. Finally, your skin will be cleansed and bandages will be applied. (The bandages can be removed on the next morning). Your blood pressure will be checked and you will be discharged to leave with your ride once you receive authorization from the doctor.
Preparation/Restrictions
The procedure cannot be performed if you have an active infection, flu, cold, fever, very high blood pressure, or if you are on blood thinners, vitamin E or aspirin products. Please make your doctor aware of any of these conditions. This is for your safety!
If you are going to receive IV sedation, it is important that you have nothing to eat or drink for at least 6 hours before your procedure. Regularly scheduled medications may be taken with a sip of water. After your procedure, you may eat, drink and take your medications unless told otherwise by your doctor.
No heat is to be used in the injected areas for the remainder of the day.
No tub bath or soaking in water (i.e. pool, Jacuzzi, etc.) for the remainder of the day.
When to Call Us
If you experience severe back pain, new numbness or weakness of your legs, or any signs of infection in the area of the injection (fever, chills, fatigue), call Somnia Pain Management immediately at 888-559-PAIN (888-559-7246).
Back to Top
SACROILIAC JOINT INJECTIONS
Overview
The sacroiliac joint is a large joint in your lower back and buttocks region. When the joint becomes irritated, it can cause pain in its immediate region or it can refer pain into your groin, abdomen, or leg.
A sacroiliac joint injection serves several purposes. First, following the injection of numbing medicine into the joint, the amount of immediate pain relief you experience will help confirm or deny the joint as a source of your pain. Additionally, the temporary pain relief may allow a physical therapist or chiropractor to treat the joint. The injection of time-release cortisone into the joint will also serve to reduce any presumed inflammation within your joint and further assist the physical therapist or chiropractor, if necessary.
What to Expect
An intravenous (IV) may be started so that relaxation medicine can be administered. After lying on your stomach, the skin over your buttocks will be well cleaned. The physician will numb a small area of skin, which stings for a few seconds. Next, the physician will use x-ray guidance to direct a very small needle into the joint; he will inject several drops of contrast dye to confirm that the medicine goes into the joint. Then, a small amount of numbing medicine and anti-inflammatory cortisone will be slowly injected.
20 to 30 minutes later, you will walk and try to provoke your usual pain. We will ask you to report the percentage of pain relief. We will also record the relief you experience during the next week in a “pain diary” we will provide for you. Please mail the completed pain diary back to Somnia Pain Management and we will contact you once we receive your diary.
On occasion, your leg may feel temporarily numb or weak for several hours. If this happens, do not walk without assistance. Your physician may also refer you to a physical therapist or chiropractor immediately afterwards while the numbing medicine is effect and over the next two weeks while the cortisone is working.
Preparation/Restrictions
The procedure cannot be performed if you have an active infection, flu, cold, fever, very high blood pressure, or if you are on blood thinners, vitamin E or aspirin products. Please make your doctor aware of any of these conditions. This is for your safety!
If you are scheduled to receive anesthesia, it is important that you have nothing to eat or drink for at least 6 hours before your procedure. Regularly scheduled medications may be taken with a sip of water. After your procedure, you may eat, drink and take your medications unless told otherwise by your doctor.
Back to Top
CAUDAL INECTIONS
Overview
The membrane that covers the spinal cord and nerve roots in the spine is called the dura membrane. The space surrounding the dura is the epidural space. Nerves travel through the epidural space to the back and into the legs. Inflammation of these nerve roots may cause pain in these regions due to irritation from a damaged disc or from contact in some way with the bony structure of the spine.
An epidural injection places anti-inflammatory medicine into the epidural space to decrease inflammation of the nerve roots, hopefully reducing the pain in the back or legs. The epidural injection may help the injury to heal by reducing inflammation. It may provide permanent relief or several months of pain relief while the injury/cause of pain is healing.
What to Expect
An intravenous (IV) is started so that relaxation medication can be administered. The patient is placed lying on their stomach on the x-ray table and positioned in such a way that the physician can best visualize the low back using x-ray guidance. The skin on the back is scrubbed using 2 types of sterile scrub (soap). Next, the physician numbs a small area of skin on the low back with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, the physician directs a small needle, using x-ray guidance, into epidural space. A small amount of contrast (dye) is injected to ensure proper needle position in the epidural space. A mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) is injected.
Patients are returned to the recovery area where they are monitored for 30 to 60 minutes. Patients are then asked to record the relief they experience during the next week on a post-injection evaluation sheet. This will be given to the patient when they are discharged. A follow-up appointment will be made for a repeat block, if indicated. These injections are usually done in a series of three (3), approximately two (2) weeks apart. Legs may feel weak or numb for a few hours. This is to be expected; however, it does not always happen.
Preparation/Restrictions
The procedure cannot be performed if you have an active infection, flu, cold, fever, very high blood pressure or if you are on blood thinners, vitamin E or aspirin products. Please make your doctor aware of any of these conditions. This is for your safety!
If you are going to receive IV sedation, it is important that you have nothing to eat or drink for at least 6 hours before your procedure. Regularly scheduled medications may be taken with a sip of water. After your procedure, you may eat, drink and take your medications unless told otherwise by your doctor.
When to Call Us
If you experience severe back pain, new numbness or weakness of your legs, or any signs of infection in the area of the injection (fever, chills, fatigue), call Somnia Pain Management immediately at 888-559-PAIN (888-559-7246).
Back to Top
EPIDURAL STEROID INJECTIONS
Overview
An epidural steroid injection is an injection of local anesthetic and steroid into the epidural space. The epidural space is a space located in the spine just outside of the sac containing spinal fluid. The goal of an epidural steroid injection is to provide pain relief by reducing the inflammation (swelling) of the nerve roots as they exit the spine. An epidural steroid injection will not correct the preexisting medical problem (i.e. spinal stenosis, herniated or bulging disc, arthritis, etc.), but may improve the level of pain. It is not unusual for someone to need more than one injection to achieve long-term benefit. The injections are done in a series of three (3), several weeks apart, if needed. If the pain is significantly improved, no further injection is required unless the pain begins to come back.
What to Expect
Your first visit is an initial evaluation. This appointment consists of the review of your medical history, medications taken, x-rays, treatments already tried, and any other pertinent information. (Bringing any records you have will help facilitate this medical review). A physical exam will be performed and a plan of care will be formulated. If an epidural steroid injection is found to be appropriate, it will be scheduled as soon as possible. Injections can only be done on the first visit if pre-certification arrangements have been made with your insurer, which allow for both an initial visit and a procedure on the same day.
Most people say the stinging/burning of the numbing medicine is the most uncomfortable part of the procedure, though each person’s response to any procedure differs.
After signing a consent form and checking your blood pressure, the procedure will be done while you are sitting or lying down. An intravenous (IV) is started and a medication that causes a mild sedation may be administered. The back or neck is then cleansed with an antiseptic soap and a sterile drape is placed. The skin is anesthetized (numbed) with a local anesthetic. You will feel a stinging or burning sensation. The needle is advanced into the epidural space. You will most likely feel pressure; if you sense pain, more local anesthetic will be administered. Once in the epidural space, the medication is infused and the procedure is complete. Your skin will be cleansed and a bandage applied. (The bandage can be removed the following morning). Your blood pressure will be checked and you will be discharged to leave with your ride once you receive authorization from your doctor.
Most people do not feel a significant change immediately after the injection, though the pain may be temporarily improved or worsened. In most patients, the steroid takes two or three days to have an effect and may peak in approximately a week or two. Therefore, it may be a while before you experience a change.
Some local tenderness may be experienced for a couple of days after the injection. You may use an ice pack three of four times a day to alleviate the pain. After the injection, you may take your usual pain medication.
Risks
The main risk that occurs at a rate of approximately 1/100 is the risk of a dural puncture (this rate is higher in patients who have had previous back surgery). A dural puncture occurs when the needle is unintentionally advanced one layer beyond the epidural space, puncturing the membrane that surrounds spinal fluid. If this occurs, there is a risk of developing a spinal headache, which may be severe and may last for days. Lying down, drinking plenty of fluids and caffeinated beverages may reduce the pain. There is another procedure (an epidural blood patch) that can treat the headache if it occurs and does not improve within 48 hours.
Other risks are remote but include bleeding, infection, nerve injury and an allergic reaction to the medication.
Some short-term side effects may occur. If the local anesthetic spreads to nearby nerves, you may have weakness or numbness that can last for an hour or two. If this happens, you will have to remain at Somnia Pain Management until you are feeling better. You may have increased pain for a few days after the injection. Some patients may temporarily develop a mild rash, acne or hair changes. Diabetics may experience short-term elevation of blood sugars. People prone to fluid retention may have increased fluid retention for a week or two.
Preparation/Restrictions
The procedure cannot be performed if you have an active infection, flu, cold, fever, very high blood pressure or if you are on blood thinners, vitamin E or aspirin products. Please make your doctor aware of any of these conditions. This is for your safety!
No heat is to be used in the injected area for the remainder of the day.
No tub bath or soaking in water (i.e. pool, Jacuzzi, etc.) for the remainder of the day.
If you are going to receive IV sedation, it is important that you have nothing to eat or drink for at least 6 hours before your procedure. Regularly scheduled medications may be taken with a sip of water. After your procedure, you may eat, drink and take your medications unless told otherwise by your doctor.
When to Call Us
If you experience severe back pain, new numbness or weakness of your legs, loss of control of your bladder and bowel movements, or any signs of infection in the area of the injection (fever, chills, fatigue), call Somnia Pain Management immediately at 888-559-PAIN (888-559-7246).
Back to Top
TRIGGER POINT INJECTIONS
Trigger point injections are utilized in the treatment of chronic myofascial pain. Trigger points are the hallmark of this disorder, characterized as discrete, painful points in a muscle body that, when palpated, will reproduce the patient’s symptoms. The painful points are usually felt as a taut band within the muscle. Palpation can also produce a radiation of the pain, usually in a fairly classic manner.
The basis for the trigger point injection is that injection causes a relaxation of an area of intense, chronic muscle spasm. By relaxing the muscle, adequate perfusion is restored to this area, allowing for clearance of noxious metabolites. Ideally, these injections should be done in conjunction with aggressive physical therapy or stretching exercises to prevent the recurrence of the spasm. Usually, a series of injections is required, but one can see significant improvement of symptoms with a short course of therapy.
Back to Top
FACET JOINT INJECTIONS
Overview
The amazing strength and flexibility of the spine is due, in large part, to the unique interaction of the disc in the front part of the spinal column with the facet joints in the back of the spinal column. Like the shoulder and the knee, spinal facet joints have a joint capsule lubricated with fluid and richly innervated by a network of pain-sensitive nerve fibers. Facet joints are numerous, with two at each spinal level. These small, delicate joints are prone to injury, deterioration, and inflammation, and they sometimes become sources for chronic neck and back pain, independent of intervertebral discs and spinal nerves.
Facet joints become especially vulnerable when the intervertebral disc is injured. As the disc degenerates, the volume of the disc is reduced and the disc space tends to flatten out. The disc, therefore, loses height, which narrows the space between the vertebral bodies. The condensed disc space does not provide enough for the facet joints at that particular level, and the joints become subject to increased stress. Facet joint pain is often felt in the spinal area rather than in an arm or leg.
What to Expect
Just as epidural injections are used to treat disc-related pain within the spinal column, facet joint injections are sometimes used to diagnose and treat pain emanating from the facet joints. Injections of steroids directly into the facet joints may reduce pain and facilitate rehabilitative therapy. If pain recurs, the small sensory nerve to the joint (medial branch nerve) can be identified and ablated to obtain long-term pain relief with a technique called radiofrequency medial branch neuroablation. For this intervention, the medial branch nerve is first blocked with local anesthetic to confirm that the joint is the true source for pain. If the nerve block reduces pain for the duration of the local anesthetic, then the nerve can be coagulated with radiofrequency heat current, rendering the joint anesthetic and reducing pain long term.
Back to Top
BOTOX INJECTION
Botulinum toxin has been frequently used to treat conditions of severe muscle spasticity, such as spasmodic torticollis. It has also proven useful in treating myofascial pain, when extended relief is not obtained from simple trigger point injections. A dose of 100 units is injected into a muscle body, with persistent relaxation seen for up to six months duration. Significant muscle weakness is usually not noted with these doses.
Back to Top
IMPLANTABLE PUMPS
Implantable pumps are used to control intractable pain and spasticity. A pump is used for pain that cannot be controlled by conventional means or when the side effects from oral or intravenous narcotics are severe. At Somnia Pain Management pumps that infuse a narcotic (morphine) with or without a local anesthetic are used to treat selected patients with intractable cancer pain. The baclofen pump is used to treat muscle spasticity. An example of this is in a patient whose spasticity persists despite the use of oral medication.
Back to Top
SPINAL INFUSION PUMPS
When chronic pain becomes uncontrollable, even when taking high doses of opioid drugs (narcotics), a spinal infusion pump may be indicated. This is a device that is implanted in the body, usually the lower abdomen, which consists of the pump (which is about the size of a hockey puck) and a small tube, which is tunneled around to the back and placed into the spinal canal. The medication is therefore much more potent because it is placed directly into the fluid that bathes the spinal nerves which transmit the pain. Therefore, usually very low doses of the medication are required. The drugs most commonly used for pain are morphine, Dilaudid and diluted forms of local anesthesia. Also, a spinal infusion pump can be used to deliver the muscle relaxant Baclofen in patients with severe spasticity from a disease like multiple sclerosis.
The spinal infusion pump is usually implanted after a short trial period of spinal infusion of the medication using a catheter. If the trial is successful, then the pump is implanted. The hospital stay may be several days due to the need for the trial. After the pump is implanted, it will take a few weeks to wean the patient off of the oral drugs, while increasing the medication given through the pump. Although the pump medication will control pain, it does not prevent a withdrawal syndrome from the oral medication and therefore, the oral medication has to be decreased slowly.
The spinal infusion pump contains a reservoir, which holds the medication and a small computer that controls the amount administered. The pump can be programmed to deliver different amounts throughout the day, thus making it possible to customize a delivery regimen for a patient that may experience more pain at different times of the day. The reservoir has to be refilled approximately every 2 to 3 months, depending on the dosage that the patient is receiving. The refill procedure is done in the doctor’s office by putting a needle through the skin overlying the pump into the reservoir of the pump. This is a relatively painless procedure.
The spinal infusion pump differs from the spinal cord stimulator in that the patient does not control the pump as they do with the stimulator. The physician has a programmer in the office, which controls the pump via radio frequency signals sent through the skin, and thus programming the regimen the patient needs. Generally, after a few adjustments the patient does not require many changes in the medication delivered by the pump, but this is always easily done with a simple visit to the doctor’s office.
Patients with cancer pain from metastases to bone or those with pain in the back from failed back surgery syndrome make up the majority of patients who receive pumps. However, any patient may qualify, depending upon their disease and the amount of pain medicine that is required to control their pain.
Back to Top
RADIOFREQUENCY ABLATION (RHIZOTOMY)
Overview
A medial branch rhizotomy is a non-surgical procedure, which damages the medical branch nerves (through very localized heating) that allow you to feel pain caused by your facet joints and on occasion the sacroiliac joints to stop the mechanism that radiates the pain. This is indicated if your facet or sacroiliac joints have been proven to be painful by diagnostic injection procedures, but the pain has not been reduced by other treatment methods. Likely, we have previously numbed the medial branch nerves to see if you were a candidate for the rhizotomy.
Theoretically, the pain relief obtained from numbing the facet or sacroiliac joints themselves and/or their nerve supply (medial branch nerves) should be experienced for 9 to 14 months after locally heating (destroying) these nerves. In about half the patients, the pain never returns. The rhizotomy (if technically successful) theoretically prevents the pain signal from traveling through these nerves (from your joints to your brain) so the patient cannot feel or sense the injured and/or diseased spinal joints. These medial branch nerves do not control any muscles or sensation in your arms or legs. They only allow you to feel these joints and small nearby ligaments and control a short, small muscle (multifidus muscle) in your neck, mid-back or low back.
What to Expect
An intravenous (IV) will be started and an anesthesiologist will give you an adequate amount of IV relaxation and pain medicine to keep the procedure comfortable. After lying on your stomach, the skin over your neck, mid-back or low back will be well cleansed. Next, the physician will numb a small area of skin with numbing medicine, which may sting for a few seconds. The physician will use x-ray guidance to direct a special (radiofrequency) needle along side the targeted medial branch nerve. A small amount of electrical current will be carefully administered through the tip of the radiofrequency needle to assure the needle is precisely next to the target medial branch nerve and not any other larger nerves. This may, for a few seconds, recreate your pain and cause a muscle twitch in your neck or back. The medial branch nerves will then be heated (locally destroyed) for 1 minute. You will be sedated and asleep for this part. This process will be repeated for usually 1 to 5 additional nerves. The entire procedure takes between 30 and 90 minutes.
You will go home 30 to 60 minutes after the procedure and will not be able to drive for the rest of the day.
Your neck or back will usually be very sore during the next 1 to 4 days. This discomfort is usually caused by muscle spasms and irritability while the medial branch nerves are dying from the heat lesion over the next 7 to 14 days. Your physician will give you medicine to treat the expected spasms and soreness. Pain relief usually is not experienced until 2 to 3 weeks after the procedure when the nerves have completely died. On occasion, your back or neck may feel slightly weak for several weeks after the procedure.
The nerves will eventually grow back (regenerate) but the pain may or may not recur in 9 to 14 months, or on occasion, sooner. If the pain does recur when the nerves grow back and the nerve signal is re-established, you may want to have the procedure repeated (equal success is seen in most patients). Some patients never have a return of their pain, but we cannot predict when this will occur.
Patients frequently ask if we remove his or her ability to feel these joints, are they more likely to damage them or other parts of their back?
You will want to substantially limit your activity for 2 days after the procedure, which usually includes not working. We try, if possible, to do the procedure on Friday to allow you to rest over the weekend. Please record your pain relief during the following 2 to 3 weeks in a “pain diary” which we will provide to you. Please mail the completed pain diary back to Somnia Pain Management.
Risks
There is a rare chance (less than 2%) that you may have increased nerve pain following the procedure for 1 to 3 months. Some people believe this occurs from increased nerve irritability when the nerve is partially, rather than completely, damaged. This pain is usually adequately treated with specific medications and resolves in several months. Thus complication is rarer in the mid and low back than in the neck, especially at higher levels of the neck.
Back to Top
Narcotic Management / Detoxification Programs
Many patients with chronic pain are prescribed painkillers for their pain. While this is effective treatment for many patients, these medications are extremely addictive. Patients can experience incredible pain when they take lower doses or stop taking these prescribed medications. At Somnia Pain Management, we can evaluate whether the pain patients are experiencing is related to withdrawal or from the actual anatomical site of pain. Advanced pain management techniques can be used to treat anatomical sources of pain and state-of-the-art detoxification procedures can be utilized for pain associated with withdrawal. We currently offer two different opiate detoxification programs.
OVERNIGHT OPIATE DETOXIFICATION
Also referred to as anesthesia-assisted opiate detoxification. While a patient rests under anesthesia for 2-3 hours, medication removes opiates from nerve receptors. The body is cleansed of residual opiates to remove a patient’s physical addiction. This reduces discomfort typical of acute withdrawal, enabling the patient to focus on recovery, not the fear of a painful withdrawal process. This may be used for dependencies to OxyContin, Vicodin, Percocet, Codeine, Heroin and Methadone.
Back to Top
BUPRENORPHINE DETOXIFICATION
Our Buprenorphine treatment program uses FDA-approved Buprenorphine. Buprenorphine has revolutionized detoxification from opiates, as it decreases or ends drug cravings and withdrawal symptoms. Our doctors are among a select group in the country who are certified to prescribe Buprenorphine. This program addresses addictions to opiate-based drugs like OxyContin, Vicodin, Percocet, Codeine, Demerol and Heroin.
For an appointment, please call Somnia Pain Management at: 888-559-PAIN (888-559-7246).
|
|
|
|
|
|
