Interventional Spinal Procedures
Spinal Epidural Injections
Epidural Injections are a common treatment option for many forms of neck and back pain and arm or leg pain. They have been used for spinal problems for decades and are still an integral part of the non-surgical management of radiculopathy and neck and back pain. The main goal of the injection is pain relief. At times the injection alone is sufficient to provide relief, but commonly an epidural steroid injection is used in combination with a comprehensive rehabilitation program to provide additional benefit.
An epidural can be very beneficial for a patient during an acute episode of back/neck and arm/ leg pain. Importantly, an injection can provide sufficient pain relief to allow a patient to progress with a rehabilitative stretching, strengthening and conditioning program. If the initial injection is effective for a patient, he or she may have up to three over 6 to 8 weeks and four in a one-year period if needed.
Epidural injections are done under direct visualization using x-ray guidance, also known as fluoroscopy. This enables the doctor to deliver medication directly to the source of pain generation. In contrast, oral steroids and painkillers have a dispersed, less-focused impact and may have significant side effects. Additionally, since the vast majority of pain stems from chemical inflammation, an epidural steroid injection can help control local inflammation while also “flushing out” inflammatory proteins and chemicals from the local area that may contribute to and exacerbate pain.
Facet Joint Injections
Facet injections are injections of medications into the actual facet joints of the spine. Fluoroscopy (x-ray guidance) is necessary for accurate placement into the facet joints. Facet joints are located between each set of vertebrae in the spine from the neck to the tailbone. Facet joints allow each vertebra to move against the vertebra just above and just below it.
Facet injections are used to reduce the inflammation and swelling of tissue in and around the facet joint. This will reduce pain which is caused by inflammation or irritation of the facet joint and surrounding structures. Usually facet joint pain is felt primarily in the spine; though in some patients there can also be referred pain into the surrounding tissues and even into the arms or legs.
Patients with arthritic or thickened facet joints on X-rays that also have any chronic back or neck pain with movement are usually good candidates for facet injections. However, many patients with fairly normal looking facet joints on X-ray can still have inflammation in the facet joints and may respond well to facet injections. Bending or twisting often aggravates facet joint pain in the neck or back.
Facet joint injections combine a local anesthetic and a corticosteroid anti-inflammatory medication. This mixture relieves both pain and inflammation coming from the involved joint. A successful result supports the diagnosis that the facet joint is indeed the “pain generator” and the cause of the patient’s pain.
Sacroiliac Joint Injections
A sacroiliac joint injection is primarily used to diagnose and treat low back pain and/or sciatica like symptoms associated with sacroiliac joint dysfunction. The sacroiliac joints lie next to the spine and connect the sacrum with the pelvis on both sides. Joint inflammation and/or dysfunction in this area can cause pain.
A diagnostic SI joint injection is used to confirm a suspected diagnosis of sacroiliac joint dysfunction. This is done by numbing the sacroiliac joint with local anesthetic (e.g. lidocaine). The injection is performed under fluoroscopy (x-ray guidance) for accuracy. Once the needle has entered the sacroiliac joint, the numbing medication is then injected into the joint. After the numbing medication is injected, the patient is asked to try and reproduce the pain by performing normally painful activities. If the patient experiences 75-80% pain relief for the normal duration of the anesthetic, a diagnosis of SI joint dysfunction is made
A therapeutic SI joint injection is done to provide relief of the pain associated with sacroiliac joint dysfunction. The injection is performed using the same technique as a diagnostic SI joint injection, except that anti-inflammatory medication (corticosteroid) is included in the injection to provide pain relief by reducing inflammation within the joint. If the patient experiences prolonged pain relief after a therapeutic sacroiliac joint injection they can begin a physical therapy and rehabilitation program to further reduce pain and return the patient to normal activity levels. It may be repeated up to four times per year, if necessary.
Nerve blocks are used for pain treatment and management. There are several different types of nerve blocks that serve different purposes. Often a group of nerves, called a plexus or ganglion, that causes pain to a specific body region can be blocked with the injection of medication into a specific area of the body. The injection of a nerve-numbing substance is called a nerve block.
Therapeutic nerve blocks are used to treat painful conditions. Such nerve blocks contain local anesthetic that can be used to control acute pain. Diagnostic nerve blocks are used to determine sources of pain. These blocks typically contain an anesthetic with a known duration of relief. Prognostic nerve blocks predict the outcomes of given treatments. For example, a nerve block may be performed to determine if more permanent treatments (such as surgery, radiofrequency or various regenerative treatments) would be successful in treating pain.
Nerve blocks are delivered as an outpatient treatment and the entire process, including recovery time is typically less than two hours. Side effects after a nerve block may include temporary soreness, a feeling of warmth, or some weakness. If you are administered an IV sedative you may need to have someone drive you home after the procedure.
Radiofrequency neurotomy is a procedure used to reduce back and neck pain from the facet joints in your spine. The facet joints are thumbnail-sized joints that are located in pairs between each bone of your spine. Pain in the back and neck area can be caused by injury, arthritis or other conditions affecting the facet joints.
The procedure uses heat generated by radio waves to damage specific nerves and temporarily interfere with their ability to transmit pain signals. In radiofrequency neurotomy, the radio waves are delivered to the specific nerves via needles inserted through the skin above your spine. Imaging scans are used during the treatment to help the doctor position the needles precisely.
The goal of radiofrequency neurotomy is to reduce chronic pain in the back or neck that hasn’t been adequately relieved by other means, such as medications or physical therapy. Tests are conducted to determine if the nerves commonly targeted by radiofrequency neurotomy are the same nerves responsible for your pain.
Success rates vary, but typically about 50%-75% of patients undergoing this procedure for low back pain will experience significant pain relief for as much as two years. Of the remaining low back pain patients, about 50% will get some pain relief for a shorter period.
As an outpatient procedure the entire process of the treatment itself takes only 30 minutes. During the injection, pain is sometimes increased temporarily and following the procedure you may experience some increased discomfort or soreness for several days.
Lumbar discography is a diagnostic study used to evaluate patients with back pain who have not responded to extensive nonsurgical treatment regimens. The most common use of discography is for surgical planning prior to a lumbar fusion to ensure that this more invasive treatment is warranted. However, intradiscal regenerative treatments may be a less invasive option once disc pain is confirmed. It is common to use MRI and CT myelograms to determine whether there are abnormal looking discs, but they cannot identify those discs that are associated with the severe pain.
Lumbar discography is designed to induce pain in a sensitive disc. A spinal fusion or intradiscal regenerative treatments used to eliminate a painful disc would not be the procedure of choice if pressurization of the disc didn’t reproduce the patient’s pain. Since a spine fusion procedure carries a significant level of risk and healing time, the more information that can be obtained prior to back surgery the better.
The procedure of discography typically lasts 30 minutes with a short recover time following the treatment. As a rule, patients return to normal activity the following day, however, some individuals may experience discomfort for one to two days following discography.
Sympathetic Nerve Blocks
A Lumbar Sympathetic Block is done to relieve leg pain from Complex Regional Pain Syndromes, which may appear after and injury to a joint or limb. Usually a series of these injections is needed to treat the problem. A Stellate Ganglion Block can both diagnose and treat pain coming from the sympathetic nerves. It is common treatment for shingles and Complex Regional Pain Syndrome affecting the head, face, neck and arms. Usually a series of these injections is needed to treat the problem.
Spinal Cord Stimulator Trials
Spinal Cord stimulation (SCS) is used to relieve chronic low back pain and sciatic pain. It uses electrical impulses to prevent pain signals from being perceived by the brain. SCS candidates include people for whom conservative treatments have failed and surgery is not likely to help. A trial implantation is done connecting to a temporary stimulator for several days. If pain decreases by 50 percent during the trial period, the system may be permanently implanted.