Advanced Pain Clinic offers various pain management procedures to diagnose and treat your intractable pain in conjunction with Physical Therapy, Oral Medications, Home exercise program. Here are some of the procedures the Clinic offers to its patients.
Steroid (cortisone) injection is a method of injecting one form of powerful anti-inflammatory medicine into the spinal area, namely epidural space, facet joints, sacroiliac joints, etc. The epidural space is a space which exists between the bony roof (lamina) of the spine and actual spinal sack. The epidural space is a site where medications can be delivered via epidural injections, epidural catheter and transforaminal nerve root injections. One of the medications used in "Nerve Block" is steroid, which is a very powerful anti-inflammatory medication. The steroid (cortisone) can be instrumental in reducing swelling caused by certain types of chemicals released by ruptured disc, stress or wear and tear due to aging and mechanical injury or compression in the case of disc herniation and bone spur. Thus, injection of the steroid in the area can reduce pain related to the inflammation as a result of a ruptured disc, osteoarthritis, or spinal stenosis. Unlike opioid pain medications, steroid injection in the spine treats the root cause of pain which is swelling, rather than masking it. Usually the patient who receives spinal steroid injections is one that has undergone conservative management in the form of non-steroidal anti-inflammatory, and physical therapy without significant reduction in pain. The steroid injection can be considered at peripheral nerves like Carpal Tunnel, Tarsal Tunnel, Groin nerve block to treat groin pain, Scar Neuroma to treat surgical scar pain etc to achieve pain relief.
There are several types of steroid "Nerve Block" injections:
* Lumbar or thoracic or cervical facet joint as well as sacroiliac joint injections: The facet joints are located on the back and side of the bony spinal column on both sides. Spinal injury, age related wear and tear or stress, inflammatory disease, etc. could cause swelling and then arthritic changes into the joints. Cortisone injection into the joints under fluoroscopic guidance relieves swelling and pain. If pain relief does not last following the series of cortisone injections, then deadening of the nerve (denervation) for the joints would be considered to achieve lasting pain relief from the arthritic joint pain.
* Transforaminal approach requires needle placement into the opening (foramen) of the spine where the spinal nerve roots come out. This technique is especially useful when the patient has one sided pain with a high degree of suspicion for particular nerve roots as being causative in the pain complaint in the legs(sciatica) or arms. This technique should be performed with fluoroscopic guidance. Because of the use of fluoroscope and much thinner needle compared to the traditional epidural needle, the tissue trauma and incidence of thecal sac puncture is less in the transfoaminal approach. Besides, this approach delivers medicine closer to the problem site (ruptured or herniated disc) than epidural approach. Because of great efficacy and safety, this approach is being used more and more by pain physicians.
* The Caudal injection technique is used for very low lumbar spine pathology such as L5-S1 disc herniation. The needle is passed into the sacral canal, which is essentially near the tailbone area. The procedure may or may not be performed with fluoroscopy. This procedure is relatively safe because the spinal cord is far from the needle.
Spinal injections are associated with risks and potential complications. With x-ray guidance, and with experienced hands, the complication rate is felt to be lower. This is especially true when a transforaminal approach is utilized. The risks and complications are as follows: increased pain, bleeding, infection, failure to produce desired result, puncture of the spinal sac causing spinal headache, spinal cord injury causing paralysis, infection of the spine (meningitis), and reaction to medications resulting in anaphylactic reaction with a possible heart attack, stroke, or death. The excessive steroid use could cause weight gain, temporary increased blood sugar and blood pressure.
The patient is placed on his / her stomach, fluoroscopy is placed to visualize the spinal elements. The area of the injection is prepared with disinfectant. Local anesthetic is injected for the epidural injection. Under direct fluoroscopy imaging, the needle tip is advanced either into epidural space, foramen (for the transforaminal nerve block) or into the facet or Sacroiliac joint. Then the steroid medication mixed with saline and local anesthetic would be deposited. Contrast dye may be used to confirm the needle tip placement if it is in question.
Following the procedure, the patient will be observed for 30 minutes in the office. All vital signs will be checked to assure the patients well-being. After confirmation of no problems related to the "Nerve Block", the patient will be released home with all necessary instructions. The next block will be scheduled in a week to 10 days for a total of three times. More pertinent information would be discussed with the individual patient for the pertinent "Nerve Block".
V. L. Rajyaguru, MD, DABPM..
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