Author: Jasmeet Singh

VERTEBROPLASTY

Vertebroplasty, or vertebral augmentation, is a minimally invasive, out-patient procedure that alleviates chronic back pain caused by vertebral (spinal bones) compression fractures.

This treatment option is particularly helpful when conservative therapies have failed to relieve pain (De Negri 2007).

A vertebral compression fracture occurs when the vertebrae develop small cracks, break, or collapse/compress, compromising the spine and other nearby structures in the body.

Other Conditions commonly treated with Vertebroplasty include:

Osteoporosis
Bone cancer metastasis
Injury or Trauma

Procedure

Once the area is sterilized, a local anesthesia, and possibly a sedative, are administered, the physician makes a small incision in the patient’s back. A. narrow and hollow tube is inserted into the vertebra to withdraw any dead or damaged tissues.

Image devices, such as fluoroscopy or X-ray, are used to guide the physician, so that correct needle and bone cement placement are confirmed. Medical bone cement is injected from the needle through the hollow tube to sure up the fractures. They are inserted directly into the damaged vertebral body. The bone cement quickly dries, forming a support structure within the vertebra. This provides improved spinal stabilization and strength.

Benefits

Vertebroplasty is a widely-accepted procedure that has provided great pain relief for many patients. Additionally, it increases vertebral body height, and decreases wedge angle (improper shape) without worsening of the retropulsion (backward movement) of the vertebrae (Hiwatashi 2007).

Many Patients with compression fractures often have kyphosis, which is a pronounced, or moderate, curving of the upper back. There is more than one cause, but the most common is vertebral compression fractures, which often occur with osteoporosis. Severe kyphosis is a health concern. It can be debilitating and will create an obvious spinal curve.

Risks

Vertebroplasty is generally considered a safe and appropriate non-surgical minimally invasive procedure for most patients with chronic back pain, caused by vertebral compression fractures. However, as with any procedure there are potential risks.

Some of the risks common the leakage of bone cement outside the vertebral body. This is extremely rare, and so is, infection, bleeding, numbness, tingling, headache, and paralysis may result from misplacement of the needle or bone cement.

Bone cement misplacement is made far less common by the usage of fluoroscopy or x-ray, or other radiological imaging devices to ensure proper placement of the bone cement and needle.

Vertebroplasty as a safe treatment for painful vertebral compression fractures, and complications are rare with the procedure (DaFonseca 2006) (Hiwatashi 2007)

Outcomes

Fracture Prevention

Overall good health can prevent factures. This includes, eating balanced diet, regular exercise, weight lifting, calcium and vitamin D supplements are healing and preventive for the spine.

Bisphosphonates medications (Fosamax) may prevent additional compression fractures, due to osteoporosis, by strengthening bones and preventing further bone density losses.

Those suffering from painful compression fractures, that have not responded to the prevantatives listed above, may be good candidates for minimally invasive procedures like vertebroplasty and kyphoplasty (Old 2004).

For more information about Vertebroplasty or Kyphoplasty, or any other items mentioned, please see your pain physician.

Resources

Adam Sewell MD

SYMPATHETIC BLOCK

A sympathetic nerve block is the injection of a local anesthetic into a sympathetic ganglion to diagnose and/or treat pain disorders involving the sympathetic nervous system.

The sympathetic nervous system is a collection of nerves that spread tall areas of the body but that originate in the spinal cord. They branch out, influencing many bodily functions, such as blood pressure, urination, defecation, and sexual arousal.

A ganglion is a bundle of nerves that come together. The stellate ganglion (upper body) as well as the sympathetic chain (lower body) supply the entire body’s sympathetic nervous system. The blood supply to your hands, feet, or other areas may be affected and can produce pain or sensory changes when these nerves are irritated or injured. Headaches, neck pain, and facial pain can be a result of sympathetic nerve dysfunction.

Procedure

A sympathetic nerve block involves injecting a local numbing anesthetic (lidocaine, bupivacaine) and a corticosteroid into the space where the sympathetic nerve ganglion are located. A local skin anesthetic will numb the area, and then a needle is inserted near the ganglion. X-ray guidance will ensure proper needle placement, and your doctor may offer you IV sedation. The procedure takes less than 20 minutes to perform.

Benefits

Sympathetic nerve blockade is commonly used techniques for a variety of diagnostic and therapeutic purposes (Elias 2003). The block may offer complete pain relief, but if the pain does not go away, your physician may determine that your pain is not originating from the sympathetic nervous system and the block has had diagnostic value instead of therapeutic.

Regardless of the outcome, sympathetic nerve blockade is a minimally invasive treatment that has relieved pain for many people with chronic pain. One of the most successful aspects of the block is its ability to immediately relieve pain in some patients.

Risks

Sympathetic ganglion blocks are considered an appropriate and safe non-surgical treatment for many patients who suffer from pain. Complications of the ganglion block include infection, bleeding pneumothorax (collapsed lung), nerve damage, and pharmacological complications related to the drugs utilized (Elias 2000). Some temporary symptoms may include, drooping of the eyelid and stuffy nose, but these usually resolve within a matter of hours.

Outcome

Sympathetic nerve blocks are effective in relieving some chronic pain conditions, especially, where Complex Regional Pain Syndrome is concerned.

Pain that originates from the sympathetic nervous system, that is not easily treated by oral pain medications, may respond well to a sympathetic nerve block.

If you are suffering from chronic pain and are in need pain relief, call Arkansas Pain today to see what they can do for you.

Articles

Adam Sewell MD

SUPERIOR HYPOGASTRIC PLEXUS BLOCK

Post author By Jasmeet Singh
Post date April 13, 2020
No Comments on SUPERIOR HYPOGASTRIC PLEXUS BLOCK

A superior hypogastric plexus block is a type of injection that is used to control pelvic pain that has been resistant to oral medications. This block can also be indicated if the patient cannot endure the side effects of the same oral medications.

The superior hypogastric plexus controls pain to and from the bladder, urethra, uterus, vagina, vulva, perineum, prostate, penis, testes, rectum, and descending colon, so this block can potentially alleviate pain originating from these regions. Recent literature shows that the superior hypogastric plexus block has been used successfully to treat both malignancy-associated anal-rectal pain and nonmalignant penile pain.

The Superior Hypogastric Plexus Block can Halt Pain originating from:

Bladder
Urethra
Uterus
Vagina
Vulva
Perineum
Prostate
Penis
Testes
Rectum
Descending colon

Pain secondary to:

Cancer that metastasized to the pelvis (cervical, prostate, testicular, colorectal etc.)
Endometriosis
Radiation Injury

Anatomy:

The superior hypogastric plexus is a collection of nerves situated on the vertebral bodies in front of the bifurcation of the abdominal aorta. Its location allows it to innervate the vast majority of the pelvic region (including the bladder, urethra, uterus, vagina, vulva, perineum, prostate, penis, testes, rectum, and descending colon).

Procedure:

The superior hypogastric plexus block is usually performed with a posterior approach. If you can lie down on your abdomen, face down without significant distress your physician will most likely use the this approach. If you cannot lie down in this position, he or she may choose the anterior approach, or the transdiscal approach. The anterior approach can be done with fluoroscopy, computed tomography-guidance, or via ultrasound. The transdiscal approach uses fluoroscopy or ultrasound and allows you to lay down on your abdomen or your side. With this technique, your physician advances the needle through the skin and muscles of your back and the L5-S1 intervertebral disc to reach the superior hypogastric plexus.

The posterior approach remains the most common ways to perform this block and can be done under fluoroscopy or computed tomography-guidance. Fluoroscopy tends to be the preferred imaging method since there is less radiation exposure to the patient.

You will be asked to lay down on your abdomen, with a pillow under the pelvis to help flatten out the lower lumbar spines natural curvature. Your lower back will be prepped and draped in a sterile manner and anesthesia will be administered. When your skin is adequately anesthetized, two needles will be advanced under fluoroscopy guidance until correct needle placement is obtained. Their correct placement will also confirmed by administration of contrast dye, and once position is confirmed, either a diagnostic block or a therapeutic block will be performed.

A successful block is marked by profound pain relief.

Local anesthetic is usually administered for diagnostic superior hypogastric plexus block or for patients with noncancer-related pain. For patients who have a documented response to administration of local anesthetic onto the superior hypogastric plexus, a therapeutic block is preformed with administration of the neurolytic agent like phenol. Radioablation of the superior hypogastric plexus is also another treatment modality for longer-lasting pain relief.

The procedure is short, taking less than 30 minutes. Sometimes your physician will recommend intravenous sedation to make you more comfortable. Your vital signs will be monitored during, and after, the procedure.

Superior hypogastric plexus block is a short, minimally invasive procedure that is effective at treating some chronic pelvic pain, especially if it’s caused by cancer.

Risk:

This procedure has a low risk of complications. They include: Needle misplacement, bleeding, especially into your retroperitoneal space, nerve injury and/or paralysis, puncture of surrounding organs, puncture of adjacent vessels, and distal ischemia. Risks that can result from the anesthetic include: Drug allergy and seizure (if the medication is injected into a blood vessel), and the risk of infection always exists with insertion of any needle.

Outcomes:

Superior hypogastric plexus block is a well-established treatment modality for chronic pelvic pain, especially if it results from cancer. In several recent studies, it has proven more effective that continuous opioid usage (De Leon-Casasola et al). Most patients experience some paint with the initial block, but more can be performed if optimal pain relief has not been reached the first time.

If you are suffering with chronic pelvic pain or pain that you or physician believe is originating from the bladder, urethra, uterus, vagina, vulva, perineum, prostate, penis, testes, rectum, and descending colon, the superior hypogastric plexus may be of great benefit for you.

Contact Arkansas Pain today to see if you’re a good candidate for a superior hypogastric plexus block. We are happy to offer this exciting treatment option to patients in Melbourne and Merritt Island, FL. Call today for an appointment.

Journal Articles:

Adam Sewell MD

STELLATE GANGLION BLOCK

A stellate ganglion block has a wide array of therapeutic and diagnostic indications, including:

Pain Syndromes

Sympathetically-maintained pain syndromes
Complex Regional Pain Syndromes Type 1 and 2
Reflex sympathetic dystrophy
Shoulder/hand syndrome
Causalgia (nerve injury)
Phantom limb pain
Intractable angina
Herpetic neuralgia from herpes zoster (shingles)

Vascular Insufficiency in Upper Extremities

Arterial insufficiency
Raynaud’s phenomenon
Scleroderma

Miscellaneous

Hyperhidrosis (excessive perspiration) of the face and upper extremities
Hot flushes and sleep dysfunction related to hot flashes
Posttraumatic stress disorder (PTSD)

Anatomy:

The stellate ganglion is the ganglion formed by the fusion of the inferior cervical and the first thoracic ganglion where they meet over the vertebral body of C7 It is in close proximity to the carotid sheath, phrenic nerve, and recurrent laryngeal nerve.

Procedure:

A stellate ganglion block is an injection of local anesthetic into the sympathetic nerve tissue in the neck area. These nerves are part of the larger sympathetic nervous system and are located on both sides of the voice box. There are several methods by which the stellate ganglion block can be performed, and all of them take under one hour. Correct placement is also confirmed by administration of contrast dye. Once position is confirmed local anesthetic is administered. A successful block is marked by profound pain relief and improved vascular flow to ipsilateral upper extremity. A local anesthetic is usually injected to assist with the discomfort. For patients who have a documented response to administration of local anesthetic onto the stellate ganglion, a therapeutic block can be performed. Radioablation of the stellate ganglion is also another treatment for longer-lasting pain relief.

Some patients may experience symptoms from Horner’s Syndrome (drooping of the upper eyelid, pupil constriction, and decreased sweating on the side that the block was preformed). This is normal and will usually subside when the anesthetic wears of (usually ~4-6 hours after the block is preformed).

Sometimes your physician will recommend intravenous sedation to make the procedure more comfortable. Your physician will monitor your pain and vital signs for a while after the procedure and place you in a sitting position to facilitate the spread of the anesthetic.

Benefit:

Stellate ganglion block is a short, minimally invasive procedure that can effectively treat a wide array of conditions that have not responded to other treatments. These include relief for sympathetic-related facial pain, chest and upper extremity pain, circulation improvement in upper extremities and face, decreasing perspiration in upper extremities and face, decreasing hot flashes and associated sleep disturbances, and it is even showing promise as a novel treatment for PTSD.

Risk:

The risks for the procedure are typically low. As with all medical procedures, there is some risk, however. These include – misplacement of the needle resulting in: bleeding, nerve injury, pneumothorax (collapsed lung), or esophageal perforation.

There are, also, risks that can occur because of the anesthetic. These include, drug allergy, seizure (if the medication is injected into a blood vessel), brachial plexus block (numb arm on side of block that lasts as long as the life of the anesthetic injected), spinal or epidural block (transient weakness and/or numbness from neck down as long as the life of the anesthetic injected), hoarseness (from anesthetizing recurrent laryngeal nerve), and shortness of breath (from anesthetizing phrenic nerve).

Lastly, as with all punctures of the skin, the risk of infection always exists. The most common side-effects related to the procedure are drooping of the upper eyelid, pupil constriction, and decreased sweating on the side that the block as well as voice becoming more hoarse. These side effects usually subside after the anesthetic wears off.

Outcomes:

After the block is preformed one of three things may occur:

Your pain is gone or greatly improved and stays that way for longer than the life of the anesthetic. This shows your physician that the block has therapeutic value for you and he or she can come up with a treatment plan that maximizes your pain control
Your pain is unchanged but, there is evidence of a sympathetic blockade. This is of diagnostic value to your physician and tells him or her that your pain is not responsive to a sympathetic block and he or she can try other treatment modalities to treat your pain.
Your pain is unchanged but there is no evidence of a sympathetic blockade. This indicates that the block was a technical failure.

Stellate ganglion blocks are a well-established treatment method for providing relief from sympathetically-maintained pain syndromes. However, their benefits do not end there. Listed above, are the many of the benefits. Additionally, some people tend to have relief for weeks, while others benefit from the block for years. Fortunately, the procedure is a low risk, nonsurgical treatment that if successful the first time, will most likely continue to provide pain relief with repeat treatments. If you are suffering with pain contact Arkansas Pain today to see if you can benefit from a stellate ganglion block. We are happy to offer this exciting treatment option to patients in the Merritt Island and Melbourne area. Call today.

Journal Articles:

Adam Sewell MD

SPINAL CORD STIMULATOR THERAPY

Post author By Jasmeet Singh
Post date April 13, 2020
No Comments on SPINAL CORD STIMULATOR THERAPY

Spinal Cord Stimulator therapy is a revolutionary treatment for patients suffering from chronic back pain. A small electronic device is surgically implanted close to the spinal cord in the epidural space. Low-level electrical impulses emitted from the device interfere with pain messages transmitted by nerves, blocking the sensation of pain. Implanting a spinal cord stimulator may be effective in helping patients return to a more active and healthy lifestyle.

Conditions that are treated with SCS include:

Spinal Stenosis
Nerve Root Compression
Failed Back Surgery Syndrome
Lumbar Radiculitis or Sciatica
Peripheral Neuropathy
Degenerative Disk Disease
Central Sensitization

Description

Also referred to as a Dorsal Column Stimulator, a Spinal Cord Stimulator system is composed of a pulse generator implanted under the skin of the abdomen or buttock and an extension wire that connects to a pulse generator to the lead implanted close to the spinal cord. The pulse generator is powered by a battery that must be surgically replaced every two to five years, unless it is rechargeable. The lead is a flexible, thin wire with anywhere from 4-16 electrodes. An extension wire attaches the lead to the pulse generator, and a hand-held remote control is used by the patient to program the pulse generator.

Procedure

The procedure is performed in two stages. First is the insertion of a temporary trial implant. You will be positioned lying on your side or stomach, and then given a local anesthetic and light sedation to prepare for the SCS implant insertion. The surgeon will make a small incision in the middle of your back. Using fluoroscopy guidance (X-Ray), the doctor will insert SCS leads into your epidural space. Sutures are used to keep the leads secure above the spinal cord. At this time, a trial stimulator, rather than a permanent implant, is worn for a week to assess effectiveness of spinal cord stimulation in treating your pain. The trial stimulator will be taped to your back. If the SCS is successful in relieving pain, a second surgery is performed. During this second surgery, the extension wire is tunneled under the skin from the epidural space to the location of the generator implant (either abdomen or buttock). The surgeon makes a four to six inch incision to place the generator between the skin and muscle, where it is sutured securely. After the procedure, you should be able to go home that day.

Benefits

The spinal cord stimulator produces a low voltage current which keeps the brain from being able to sense pain. Instead of pain, you will feel a tingling sensation. Using the remote, you will be able to control the intensity of the stimulator or turn the system on and off. The spinal cord stimulator has been proven to relieve lumbar back pain in patients with a variety of conditions, especially Failed Back Surgery Syndrome. Patients who receive a spinal cord stimulator implant rely less on pain medication.

Risks

Just as with any surgical procedure, possible risks include:

Infection at the surgical site
Bleeding
Scar tissue formation
Failure of electronic device to operate properly
Unpleasant sensations or motor disturbances, such as uncontrolled movement caused by the electrical stimulation of the device
Battery leakage or failure
Leaking of the cerebrospinal fluid from the epidural space
Migration of the leads, making the nerve stimulation ineffective
Skin breakdown at the site of the generator
Rarely, surgical intervention may be needed to fix problems with the device or leads.

Outcome

Once the SCS device is in place, your doctor will work with you to be able to find the best pulse strength to help you. You will be taught how to use the stimulator remote at home. Typically, patients use the spinal cord stimulation for one or two hours at a time, three to four times a day. The spinal cord stimulator should be turned off while driving and swimming. SCS pulse generators have three programmable settings.

You may find that the device feels differently depending on whether you are sitting down or standing up. This is because the electrical impulses spread differently depending on how the leads and wires move with your body.

According to the American Society of Interventional Pain Physicians, there is evidence that you will experience strong relief short-term, and moderate relief long-term with this surgery. The SCS implant may be effective in helping those who suffer from chronic back pain lead a more active lifestyle. However, there may be a gradual decline in effectiveness of SCS, as your body can develop tolerance to the treatment.

Resources

Adam Sewell MD

SPHENOPALATINE GANGLION BLOCK

Post author By Jasmeet Singh
Post date April 13, 2020
No Comments on SPHENOPALATINE GANGLION BLOCK

Sphenopalatine-Ganglion Pain, especially in the face and head, is a condition that may be secondary to these conditions.

Acute and cluster headaches
Trigeminal neuralgia. (3,7)
Temporomandibular joint (TMJ) pain.(7)
Herpes zoster. (12)
Sluder’s neuralgia. (6)
Paroxysmal hemicrania. (4)
Atypical facial pain. (14)
Head and neck cancers
Complex regional pain syndrome (CRPS) (9)
Reflex Sympathetic Dystrophy (RSD) (9)
Vasomotor rhinitis
Pre- and postoperative anesthesia in oral and maxillofacial surgery. (11)

Benefit:

Sphenopalatine Ganglion Block is a short, minimally invasive procedure that is effective at treating some acute and chronic facial and head pain.

Anatomy:

The Sphenopalatine Ganglion is a collection of nerves that is close to the surface. It is located in the depression of the skull behind the middle nasal bone, and in front of the nasal canal. The Sphenopalatine Ganglion is covered by a layer of connective tissue and mucous membrane which allows its block to be applied either topically or by injection (17,18,19).

Procedure:

There are many approaches your physician can use to perform the Sphenopalatine Ganglion Block, including the transnasal, transoral, and lateral approach. The transnasal approach is the simplest and most common technique among the three. You will be asked to lie down on your back and extend your neck into a sniffing position. Your physician will inspect your anterior nares (inside your nostrils) for any visible polyps, tumors, or significant septal deviation before beginning. A small amount of 2% viscous lidocaine is instilled into the nostrils being treated, after which you will be asked to briskly inhale. This draws the local anesthetic toward the back of your nose, lubricating it and anesthetizing it in the process, while making the procedure more comfortable for the patient. If your physician decides to perform the Sphenopalatine Ganglion Block topically, he or she will introduce a sterile 10-cm cotton tipped applicator dipped in anesthetic and slowly insert it in your nose. The applicator is usually left in place for approximately 20-30 minutes. If your physician decides to perform the Sphenopalatine Ganglion Block via injection, your physician will anesthetize part of your cheek. Next he or she will advance a small needle under X-Ray guidance through the anesthetized tissue. Your physician will carefully advance the needle to the correct location, after which he or she will confirm correct positioning under fluoroscopy before injecting the anesthetic. No matter whether placed topically or via injection, a successful block is marked by profound pain relief. For patients who have a documented response to administration of local anesthetic onto the Sphenopalatine Ganglion, you and your physician may decide upon performing a neurolysis or radioablation of the sphenopalatine ganglion for longer duration of pain and symptom relief. Depending on whether your physician performs this block topically or via injection, this procedure may take anywhere from 15 minutes to 30 minutes at most. Sometimes your physician will recommend intravenous sedation to make the procedure more comfortable. Your physician will monitor your pain and vital signs (pulse, blood pressure) after the procedure.

Risk:

The risk for this procedure is very low. The most common side effects of this procedure include developing a bitter taste in your mouth from the local anesthetic potentially dripping down from the nasopharynx. You may develop a slight numbness in the back of the throat from the local anesthetic dripping down into your throat. You may develop a nose bleed from your physician accidentally abrading your internal nare from the placing of the block. Some patients may also experience slight lightheadedness that usually resolves after 20-30 minutes after the procedure. With any procedure that involves local anesthetic there is a slight risk of drug allergy and seizure. Lastly, as with any penetration of skin and soft tissues, the risk of infection always exists.

Outcomes:

Sphenopalatine Block is a well-established treatment for acute and chronic facial and head pain. Having a Sphenopalantine Radiofrequency Ablation is a proven and effective treatment for patients with chronic cluster headaches.

References:

Adam Sewell MD

SACROILIAC JOINT INJECTIONS

Post author By Jasmeet Singh
Post date April 13, 2020
No Comments on SACROILIAC JOINT INJECTIONS

Sacroiliac Joint (SIJ) Disease is one of the major causes of lower back pain. The sacroiliac joint is located at the junction between the spine and the pelvis. The sacroiliac joint is a weight-bearing joint as the weight from the upper body is transmitted down the spine, through the sacroiliac joint and into the pelvis, hips, and lower extremities. The sacroiliac joint is supported by many muscle groups and ligaments that are richly innervated by free nerve endings and spinal nerve roots. When there is inflammation to the sacroiliac joint, the abundance of nerves become irritated and patients experience intense lower back pain. Patients typically complain that pain associated with sacroiliac joint worsens when sitting for long periods of time or performing twisting motions and will usually resolve with exercise.

Treatments

Sacroiliac Joint Steroid Injections: involve injecting a steroid into the joint space of the SIJ, where the irritated nerve roots are located. This injection includes both a long-lasting steroid and a local anesthetic (lidocaine, bupivacaine). The steroid reduces the inflammation and irritation and the anesthetic works to numb nerves in the area. The combination medicine then spreads throughout the joint and surrounding areas, reducing inflammation and irritation. The entire procedure usually takes less than 15 minutes.

SIJ Traumeel Injections: Traumeel is a homeopathic natural anti-inflammatory medication that has very few side-effects and can be injected into the SIJ when steroid medications are not desired.

Medial and Lateral Branch Blocks: The medial and lateral branches innervate (supply with nerves) the sacroiliac joint. Blocking these nerves is diagnostic and therapeutic. If your pain is better after the injections, than you may be a candidate for radiofrequency procedure.

Radiofrequency Ablation: The medial and lateral branches innervate (supply with nerves) the sacroiliac joint and can be destroyed with radiofrequency. The nerves typically grow back, but people report pain relief from ranging from three months to three years.

Spinal Cord Stimulation: A small electrode is typically placed in the epidural space and electrical current is directed through the electrode. If pain relief is attained, a permanent system with battery and electrodes can be placed under the skin.

Chiropractic Manipulation: The sacroiliac joint can sometimes be manipulated into place if it is believed to be out of alignment.

TENS unit: Electrical current is directed over the skin to the most painful area. The brain cannot perceive the pain it previously felt, but now feels the “tingling or buzzing” sensation that is commonly used to describe TENS therapy. TENS therapy may also cause the brain to release endorphin (the body’s natural pain fighters).

Physical Therapy: Is extremely important to increase range of motion and continue to maintain strength in a painful shoulder.

Acupuncture: Acupuncture is an alternative treatment that was originally started in China over 2000 years ago and is quickly gaining acceptance and popularity in Western Medicine for the treatment of many conditions (Facco 2007). Research continues to explore the use of acupuncture in the treatment of many chronic pain conditions.

Benefits

Chronic lower back pain is one of the most difficult conditions for physicians to treat. Commonly seen, the pain may go into remission with periods of decreased or absent symptoms. However, the pain frequently returns and causes a chronic pain syndrome in most people. Sacroiliac Joint Injections are a minimally invasive, low risk procedure that can cause a significant decrease in symptoms without disrupting your daily activities. In patients suffering from chronic sacroiliac joint pain, Sacroiliac Joint Injections are preferred to the more conventional methods of treatment (Pereira 2000).

Risks

SIJ injections are considered an appropriate non-surgical treatment for many patients who suffer from lower back pain. The associated risks, although rare, include nerve damage, bleeding, and infection. Some of the potential side effects of the corticosteroid may include elevated blood sugars, weight gain, arthritis, stomach ulcers, and transient decrease in the immune system.

Outcome

Patients have reported that Sacroiliac Joint Pain began spontaneously or had an insidious (slow) onset. Others recognize a specific event that triggered the occurrence of the pain. Frequently, the pain can be due to a traumatic injury to the spine resulting in residual sacroiliac joint inflammation. While conservative treatment, such as NSAID’s and physical therapy may be effective, Murakami and Tanaka reported in 2007 that the effect of periarticular injection (injections occurring around a joint) into the SIJ was 96% effective in pain improvement in patients with sacroiliac joint complaints, with minimal complications (2007 Murakami).

How We Can Help You

Arizona Pain Specialists is a Pain Center of Excellence and we realize the burden Sacroiliac Joint Pain can have on your life. We believe a compassionate patient-centered program integrating allopathic (alternative) and complementary treatments is the most effective method to obtain long-term pain relief.

During an initial visit, a pain physician will evaluate and diagnose your painful condition and build a customized treatment program that is specific for you. If you or someone you know could benefit from treatments we offer please contact Arizona Pain Specialists today.

Articles

Adam Sewell MD

RADIOFREQUENCY ABLATION

Radiofrequency Ablation (RFA) is a minimally invasive out-patient procedure and treatment for a range of conditions and pain syndromes. This cutting-edge procedure uses a specialized device that uses radiofrequency heat energy to stop nerve signals from transmitting pain to the brain.

RFA is often used in pain management to treat chronic back pain, neck pain and muscle pain. During RFA, a radiofrequency probe is inserted through a small needle into the skin. Controlled and targeted heat is delivered through the probe. RFA may be used to destroy the irritated nerve through targeted heat, eliminating pain signals. Pulsed-RFA is used to interrupt painful nerve impulses.

Anatomy

An understanding of spine anatomy and its physiological function is a critical piece in the evaluation of a person with spine-related pain.

The spine consists of individual vertebrae (spinal bones). The vertebrae create a flexible support structure and protect the spinal cord. Facet joints are on the top and bottom of each vertebra and connect the vertebrae to one another. Facet joints hold the spine together and assist with spinal stability. The facet joint structure has lubricating fluids, which allows for ease in a range of back movement. Each vertebra has two facet joints.

Facets are supplied by the medial branch nerve, small nerves which branch out from the vertebra, at the facet joint. They provide sensations to the joints. The facet joints may become arthritic, damaged or irritated, causing severe pain with movement.

When the facet joints are compromised, the medial branch nerves send pain signals to the brain. The nerve is located at the junction of the transverse process and superior articular process of the facet joint.

A recent study found that Medial Branch Radiofrequency Ablation is a minimally invasive outpatient procedure that reduces back pain by interrupting the nerve supply from painful facet joints in the neck or back (Murtagh 2006).

Sphenopalatine Ganglion

A ganglion is a structure containing a bundle of nerve cell bodies. The sphenopalatine ganglion provides sensations to the face and head region. It’s located at the back of the nose. Often times face pain or headaches are treated successfully with a sphenopalatine ganglion blockade or ablation. A recent article showed that the ganglion can be targeted with radiofrequency for chronic headaches or other conditions causing atypical facial pain (Bayer 2005).

Pain conditions commonly treated with RFA:

Peripheral Neuropathies
Sympathetically Mediated Pain
Complex Regional Pain Syndrome
Trigeminal Neuralgia
Headaches
Neck pain
Back pain
Some Stroke Related Pain
Other RFA Techniques
IDET
Disc Dennervation

Procedure

The skin area is sterilized and a local-numbing agent is administered through a needle. IV sedation is available and administered if needed. Another needle is placed through the numb tissue and the entire procedure is performed using an imaging device such as a fluoroscopic (X-Ray) to guide the needle placement.

To ensure proper needle placement, an electrode is passed into the center of the needle. First stimulation is verified with sensory stimulation and then with motor stimulation. When the needle position is correct, local anesthetic and sometimes a steroid medication are injected.

The radiofrequency probe produces a lesion created by localized and targeted heat. When the lesion is created over a painful nerve, pain signals are interrupted to the brain.

Radiofrequency thermo-coagulation – The electrode is heated to 50-80°C and kept at that temperature for several minutes. The generated electro-thermal heat allows for destruction of surrounding nerve tissue, thus eliminating or decreasing pain.

Pulsed Radiofrequency – This is similar to thermo-coagulation RFA, except that the electrode is heated at a lower temperature. This lower temperature doesn’t destroy the nerve tissue, but instead stuns the nerve. During the procedure, this technique is generally more comfortable, with often only a mild-pulsating sensation.

After a brief recovery period, patients are typically allowed to go home. Patients may experience mild discomfort following the RFA.

Benefits

In a recent clinical research study for patients treated with radiofrequency therapy, 21% had complete pain relief, and 65% reported mild to moderate pain relief.

The majority of the patients in this study reported reductions in their pain medication usage. None of the patients developed significant infection, bleeding, hematoma formation, or numbness as complications from the procedure. (Bayer 2005).

RFA has been used for many years, and continues to evolve with better results and fewer risks. It offers patients a long-term and significant pain relief treatment, with a minimally invasive out-patient procedure

Risks

RFA is considered a safe minimally invasive option for many patients who have chronic pain. However, like any procedure there are possible complications and risks.

Potential complications include: bleeding, infection, worsening of pain symptoms, discomfort at the point of injection, and rarely motor nerve damage. Radiofrequency therapy averages three to six months pain relief.

Outcomes

Radiofrequency treatment is an extremely safe and widely accepted technique to treat many chronic pain causes (Menno). If a patient has pain relief from an initial treatment, a second treatment may be beneficial. There is strong clinical evidence that RFA has “an important role in the management of trigeminal neuralgia, nerve root and spinal pain” (Lord 2002).

In a large study, 92.5% of the participants reported excellent or good pain relief with radiofrequency thermo-coagulation for the symptoms of trigeminal neuralgia (Chen 2001).

A group of 100 patients suffering from trigeminal neuralgia were treated by radiofrequency thermo-coagulation. The study concluded that RFA is the treatment of choice for trigeminal neuralgia when other medical treatments are no longer effective, or the side-effects of medications contraindicate their usage (Motta).

Another study evaluated 39 patients with trigeminal neuralgia and 92.3% received satisfactory pain relief (Sengupta).

A large evidence-based practice guideline (developed by the American Society of Interventional Pain Physicians) provided recommendations to clinicians and patients in the United States.

It states “for medial branch blocks, repeated injections at defined intervals provided long-term pain relief. For medial branch radiofrequency neurotomy, short-term pain relief was defined as relief lasting less than three months and long-term relief as lasting three months or longer. The evidence for pain relief with radiofrequency neurotomy of cervical and lumbar medial branch nerves is moderate for short and long-term pain relief,” (Boswell 2007).

For more information about RFA, or other items mentioned, please see your pain physician.

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Adam Sewell MD

RACZ PROCEDURE

Adhesiolysis or Epidural Lysis of Adhesions is also known as the RACZ Procedure. The procedure’s name comes from “Adhesion” meaning scar tissue and “Lysis” meaning to dissolve or destroy. The Racz Procedure is a minimally invasive procedure that was developed in the late 1980′s by Dr. Gabor Racz. The procedure has proven effective treating chronic back and neck pain due to scar tissue formation. Scar tissue can form around nerve roots causing constant unrelenting pain. Adhesions are typically formed due to inflammation and irritation in the epidural space (the membrane that surrounds your spinal cord). These adhesions can aggravate nearby nerve roots causing intense pain (Manchikanti 2007). Scar tissue can frequently result in irritated and inflamed nerves, which can cause pain that radiates from the lower back into the legs. Most commonly, people who present with neck or back pain due to scar tissue formation have had prior surgeries or prolonged neck or back pain. After spinal surgery, adhesions develop and are thought to be the cause of recurrent pain.

Procedure

Before performing a procedure your pain physician will review your MRI in order to identify which nerves are likely affected and are responsible for your pain. Initially a series of epidural steroid injections are often performed to localize and treat your pain. If scar tissue is the cause for your pain then there may not be much of a response to the epidural steroid injections. Once scar tissue is thought to be the cause of your pain you will be schedule for the Racz Procedure. This procedure is performed by injecting a local anesthetic with a small needle into the skin above your buttock. Once the area is numb, then using a larger needle a catheter/guide wire is placed into the epidural space using X-Ray guidance for proper placement. Once the catheter is in the proper location where the scar tissue is affecting the nerve root, multiple medications (omnipaque, hypertonic saline, hyaluronidase, local anesthetics, and steroids) are injected into the space in order to dissolve the scar tissue and reduce the inflammation and irritation on the nerve. This procedure can be performed over a two-day period with another injection of materials through the catheter the following day to ensure lysis (disintegration) of scar tissue has been achieved. The entire procedure typically is finished in less than an hour and is performed on an outpatient basis, so typically you are able to go home within a few hours of the procedure. Immediately after the injection you may notice that your legs feel heavy and you may have some sensory changes, but these are temporary. The local numbing anesthetic wears off in a few hours so you may feel some discomfort once that wears off at the injection site. The inflammation-reducing steroid generally starts working at about forty-eight hours.

Benefits

The Racz procedure is considered safe and effective. The purpose of the procedure is to minimize the damaging effects of epidural scarring, which can physically prevent direct application of drugs to nerves (epidural steroid injections) and other tissues in the treatment of chronic back pain. It is designed to dissolve scar tissue therefore reducing pressure on irritated nerves (Boswell 2007). There is strong evidence for short term and moderate evidence for long-term effectiveness of adhesiolysis and most people who receive the treatment experience significant pain relief, 50% or more reduction in pain (Trescot 2007).

Risks

As with all medications and interventions, there are potential risks of complications. The Racz Procedure is considered an appropriate treatment for many patients who suffer from back pain, but it does have risks (Boswell 2007). The most common complaint is mild to moderate back pain at the injection site shortly after the procedure. Other more serious and far less common complications include spinal cord compression, excessive intracranial pressure, bleeding, subdural injection, hematoma, or infection. These particular risks are decreased by the use of X-Ray imaging, sterile technique and adequate training. The results of a large study show that the Racz Procedure with hypertonic saline is safe and effective in managing chronic low back and lower extremity pain in patients who failed to respond to other conservative modalities of treatments, including epidural steroid injections (Boswell 2007).

Outcomes

The American So ciety of Interventional Pain Physicians developed a large evidence-based practice guideline for the management of chronic spinal pain with interventional techniques. In regards to adhesiolysis, the guidelines state that there is strong evidence to indicate effectiveness of adhesiolysis with epidural steroids for short and long term pain control in difficult or unresponsive pain and radiculopathy (where the nerves do not work together properly). One of the large retrospective studies showed at less than three months 100% of the patients treated had pain relief (Boswell 2007). Further long-term observation showed these results: the percentage of patients who achieved pain relief in less than three months were 100%. In three to six months, 90% still had relief. In 12 months, 72%-52% had relief. Another study indicated that overall health status improved significantly in the patients treated with the Racz Procedure. Patients stated that their pain and pain medication use were decreased and their physical health, mental health, functional status, and psychological states were all increased after undergoing adhesiolysis therapy (Manchikanti 2001). Drs Lynch and McJunkin trained under Dr. Gabor Racz the inventor of the Adhesiolysis Procedure (Racz Procedure) and learned this safe innovative technique from him first-hand. If you are suffering from chronic back or neck pain that has been refractory to other treatments contact Arizona Pain Specialists today to see if you can benefit from this innovative treatment.

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Adam Sewell MD

PERIPHERAL NERVE STIMULATION

Post author By Jasmeet Singh
Post date April 13, 2020
No Comments on PERIPHERAL NERVE STIMULATION

Peripheral Nerve or Peripheral Field Stimulation procedures are becoming increasingly popular for the treatment of many causes of nerve related pain and peripheral neuralgias. This revolutionary treatment works by placing electrodes along the course of painful peripheral nerves to control pain. The stimulation blocks pain perception from traveling from the nerve to the brain. It involves a small device that is placed near the involved nerve that delivers low-level electrical impulses that interfere with the perception of pain, especially chronic nerve pain. One of the main functions of peripheral nerves is to communicate signals from the periphery to the spinal cord to the brain and the rest of the body. Peripheral neuropathy is a disorder involving the peripheral nervous system (PNS). The central nervous system (CNS) includes your brain and spinal cord. The PNS includes all of the nerves from your spinal cord to the rest of your body. Peripheral neuropathy may be caused by many conditions including vitamin deficiencies, alcoholism, autoimmune diseases, certain medications, trauma, unknown causes, and diabetes. When your peripheral nerves become damaged, they do not function properly, and can eventually produce symptoms of pain, tingling, or numbness. The syndromes that may benefit from peripheral nerve or field stimulation include:

Complex Regional Pain Syndrome
Diabetic Peripheral Neuropathy
Lateral Femoral Cutaneous Neuropathy
Back and Neck Pain
Post-Surgical Pain
Occipital Neuralgia
Trigeminal Neuralgia
Traumatic Nerve Injuries
Peripheral Vascular Disease Neuropathy
Post-Amputation Pain
Herpetic Neuralgia
Trigeminal Neuralgia
Reflex Sympathetic Dystrophy (RSD)
Complex Regional Pain Syndrome (CRPS)
Refractory Angina
Other conditions that have failed conventional therapies.

Procedure:

Peripheral Nerve or Field Stimulation uses an innovative technology that works by introducing an electrical current to the source of chronic pain. Under local anesthetic (numbing agent) and IV sedation your pain physician will place a stimulator lead along the painful nerves. Patients typically undergo a trial for seven days to see if they feel better and have increased activity with the device. If pain improves, a permanent electrode and battery can be placed. If the permanent device is in place, soft thin wires with electrical leads on their tips are placed through a needle under the skin. A small incision is made and the battery is placed under the skin. This device is turned on and releases electrical stimulation to the affected nerves. You pain will be replaced by a tingle instead of the pain originally felt. The entire procedure takes less than a couple of hours to complete, and is done as an outpatient. The stimulator is so small that you can wear bathing suits and continue normal activities without an inconvenience. The stimulator is not visible and lies under the skin. It is a self-contained system much like a pace-maker.

Benefits:

The implanted device produces a low voltage current which creates a sensation that blocks the brain’s ability to sense the pain. It interferes with the perception of pain by creating a pleasant sensation that replaces the pain. The intensity of the stimulator can be changed, and the system can be turned on and off as necessary to provide optimal pain relief as experienced by the patient. Treatment of chronic neuropathic pain in the region of the face, neck, and head are challenging for pain specialists to treat. The pain is typically refractory, meaning difficult and not responsive, to many of the conventional treatment options. Recently peripheral nerve stimulation has become increasing common in difficult-to-treat neuropathic facial pain.

Risks:

Most peripheral nerve stimulation procedures are performed on an outpatient basis. As expected with any surgical procedure, there are potential risks. Side effects that may occur include bleeding, infection, scar tissue, electrode failure, inadequate pain surface area coverage, and nerve damage. While the incision is healing it is important to keep it dry and clean so an infection does not occur. If there is any drainage or redness at the site then you may have developed an infection and your pain specialist must evaluate you. Patients with the following conditions should not receive peripheral nerve stimulation and should talk to their pain specialist about other options:

Cardiac pacemaker
Systemic infection
Pregnancy or lactating

Outcomes:

Peripheral nerve stimulation is reported to be an effective pain treatment because it inhibits the perception of pain by the brain, and pain from the peripheral nervous system (Ristic 2007). In a medical study of people receiving peripheral nerve stimulation treatment for craniofacial pain, three out of four of the patients experienced significant improvement in pain intensity (Konstantin 2006). With the improvement of pain symptoms after treatment, you may be able to decrease pain medications and increase your daily activities. The number of centers using peripheral nerve stimulation for craniofacial pain and other peripheral nerve syndromes is increasing. In the future there will be a wider acceptance of this treatment because it is minimally invasive, can be tested, is reversible in effect, and has adjustable settings. These unique qualities may eventually make peripheral nerve stimulation the preferred treatment for otherwise unresponsive conditions (Konstantin 2006). Peripheral nerve stimulation can be very effective in reducing chronic pain from certain painful conditions, however it does not work for everyone. A trial with a temporary device is usually done before you have a permanent device placed, which ensures good response to therapy. For those that it does help it is an innovative treatment that brings significant relief. You should contact Arizona Pain Specialists now to speak with a physician to see if this treatment can benefit you. We are happy to offer this service as a pain management tool for patients in the Phoenix area.