Author: Jasmeet Singh

PERCUTANEOUS DISCECTOMY

Percutaneous Discectomy, also known as Dekompressor (Stryker) is a non-percutaneous-discectomysurgical effective treatment for back and neck pain associated with herniated disc disease. The pain relief associated with this therapy is due to taking the pressure off of the spinal discs and facet joints. This reduces the pressure exerted onto the spinal cord and nerve roots, which is causing the pain (Boswell 2007). Separating each individual spinal vertebrae are discs that act as cushions to minimize the impact that the spinal column receives. Since the discs are designed to be soft and provide support, they have a tendency to herniate (bulge) backwards through the outer disc segment and ligaments. These bulging discs can cause irritation to the adjacent nerves. Disc disease is one of the most common causes of chronic neck and back pain and accounts for approximately 10% of all lower back pain complaints. Disc disease may be acute, it may be herniation resulting from trauma, or more commonly, from chronic disease. Degenerative disc disease is a process, which is due to a thinning and degeneration of the discs over time. Commonly seen, neck and back pain may go into painless remission with periods of decreased or absent symptoms, however, the pain often returns causing a chronic pain syndrome. If your pain has lasted longer than four weeks or is severe in nature you should see a pain specialist about treatment options. Ongoing research has hinted that early intervention decreases the incidence of developing chronic pain. Decompression therapy is often considered when the pain has not improved after a month and is radiating, resulting from irritation of the nerve roots.

Procedure

Percutaneous Discectomy uses a single-use probe called the “Stryker Dekompressor,” which is placed using X-Ray guidance. You will be pre-treated with a sedative that will help you to relax, but you will remain awake for the procedure. Before the treatment begins, you will be comfortably positioned on your stomach, with your knees supported on the table. Your physician will inject a local anesthetic with a small needle to numb the area. Once the area is numb, a larger needle is placed into the affected disc with X-Ray guidance. The probe is placed through this needle and the procedure is initiated. You may feel pressure during this part of the procedure, but should not experience pain. The Dekompressor uses a pump method to remove excessive disc material from bulging or contained herniated discs, thus reducing pressure in the disc and providing pain relief.

Benefits

A discectomy using the Dekompressor is a lower-risk treatment option for neck and back pain. The procedure may decrease pain, increase mobility, and eliminate the need for traditional surgery. This treatment is designed to correct the underlying problem, not just relieve the symptoms. The procedure is a minimally invasive procedure that causes much less scarring and fibrosis that is commonly associated with other interventions. A study reported in 2007 stated that “discectomy is minimally invasive, safe and effective for treating disc herniations and that 89% of patients treated by this method stated they achieved successful outcomes from the therapy“ (Tzaan 2007).

Risks

As with all medications and surgical procedures, there is always a risk of complications. With lower risks than traditional back surgery, discectomy is considered an appropriate treatment for many patients who suffer from back pain (Boswell 2007). The most common complaint is mild 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, hematoma, or infection. These particular risks are decreased by the use of X-Ray and sterile technique.

Outcome

The American Society of Interventional Pain Physicians developed a large evidence-based practice guideline for the management of chronic spinal pain with interventional techniques. The 2007 article stated that for percutaneous discectomy using the Dekompressor resulted in greater than 70% improvement in pain in 79% of patients undergoing the treatment for postero-lateral disc herniations. (Boswell 2007). The reduction in pain allows patients to experience enough relief to become active again. Often patients regain the ability to resume their normal daily activities. If you are suffering from chronic back or neck pain contact Arizona Pain Specialists today to see if you can benefit from this advanced treatment.

Journal Articles

Adam Sewell MD

OCCIPITAL NERVE BLOCK

Performed By Top Pain Management Doctors in Fort Smith, Arkansas

Anatomy

Just beneath the scalp, in the back of the head, are the greater and lesser occipital nerves. The greater nerve arises through the top two vertebrae, the cervical vertebrae, and comes from the cervical nerve root deep into the paraspinous musculature (literally, muscles next to the spine). The nerve comes closer to the surface just below the superior nuchal line (muscular line that divides the back of the skull). It goes next to the occipital protuberance of the skull, which is next to the occipital artery. Basically, the nerve starts in the top vertebrae, and goes up towards the surface near the mid-line of the back of the skull.

The lesser occipital nerve arises through the second and third cervical nerve roots in the upper vertebrae. It travels through the cervical paraspinous musculature (muscles next to the spine), and comes close to the surface over the inferior nuchal line of the skull (muscular line that divides the back of the skull). Basically, the nerve starts in the top vertebrae and goes up towards the surface near the lower line that divides the back of the skull.

These two nerves, the greater and lesser, help give sensation to the back of the scalp. These nerves are commonly involved in patients suffering from Cervicogenic headaches and Occipital Neuralgia.

Procedure

Essentially an Occipital Nerve block is the numbing of the greater and lesser occipital nerve. The block is an injection composed of an anesthetic and a corticosteroid next to the greater and lesser occipital nerves. It is most often used in the diagnosis and treatment of Occipital Neuralgia and Cervicogenic headaches (Afridi 2006). Occipital Neuralgia will typically follow a trauma to the nerves over the occiput (back of the head) and is characterized by an acute onset of pain in the the occipital nerves. A Cervicogenic headache is more chronic, it comes on slowly. It is characterized by pain in the same area. Most patients with Cervicogenic headaches have associated spondylosis, or problems of the cervical facet joints in the neck, and therefore may need an additional block in the cervical facet joint to completely alleviate their symptoms. In one medical study, a group of people suffering from Cervicogenic headaches was split into two categories, one of which received the Occipital Nerve Block. The study found that the taking of pain relievers such as aspirin, duration of headache and its frequency, nausea and vomiting, light and sound sensitivity, decreased appetite, and limitations in functional activities were significantly less in the blocked group compared to control group. In other words, the people who had the Occipital Block fared better in all areas than their counterparts who did not have the block. The study therefore concluded “the nerve stimulator-guided occipital nerve blockade significantly relieved cervicogenic headache and associated symptoms at two weeks following injection.” (Naja 2006).

The procedure involves inserting a small fine needle through the skin beneath the scalp in order to get the anesthetic and corticosteroids around the area of the nerve. In order to minimize this discomfort your pain specialist may numb the skin in the injection area with an even smaller needle with a local anesthetic before inserting the block needle. The injection blocks both the greater and lesser occipital nerves. There are two major benefits to using this block. Not only is it useful in treating Occipital Neuralgia, relieving or reducing pain in the back of the head in the scalp, but if symptoms improve after the injection then the block is also useful in diagnosing Occipital Neuralgia. Typically if you respond well to the injection and have pain relief then it is recommended that you return and receive repeat injections. Usually, a series of block injections is needed to treat the problem adequately, however the response to the block varies from patient to patient. Also, if you respond well to the Occipital Nerve block then you will most likely benefit even more with the addition of Occipital Nerve Stimulation. A 2006 study reported that if a patient receives repeated nerve stimulator guided Occipital Nerve blockade for the treatment of Cervicogenic headache, the patients experienced significant reduction of symptoms with no recurrence for at least six months in addition to alleviation of associated symptoms. Eighty-seven (87%) of the patients who experienced relief required more than one injection to achieve a six-month period of pain relief (Naja 2006).

Risks

Occipital Nerve Block injections are considered safe, however, with every procedure there are associated risks, side effects, and possible complications. With nerve blocks in general, the most common is the superficial pain from the scalp where the needle was inserted. This pain comes after the local anesthetic wears off, but this pain is temporary and typically mild. Another frequently seen occurrence is bleeding, since the scalp is highly vascular (there is an abundance of tiny blood vessels near the surface of the skin). Bleeding is common but is easily stopped and temporary. This risk is significantly reduced if ice is placed at the injection site immediately after the procedure. The other less common risks involve excessive bleeding, infection, and nerve damage. Patients with an allergy to any of the anesthetics used, are on blood thinning medications, have an active infection, or are pregnant should consult with your pain physician before receiving the procedure.

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Adam Sewell MD

MEDIAL BRANCH BLOCKS

Performed By Top Pain Management Doctors in Fort Smith, Arkansas

Description of Procedure

The facet joints are the small joints that help stabilize each vertebrae. Medial Branch pain is inflammation arising from the facet joints. There are even smaller nerves stimulating the facets of the spine. When these nerves are inflamed and irritated, signals of pain are sent to the brain. This is a common cause of mid-to-lower back and neck pain. A procedure that has become more popular is called a Medial Branch Block (MBB). An MBB temporarily reduces or stops those pain signals from reaching the brain.

An MBB is a medical (nerve) block. It is an injection that disrupts pain and keeps those impulses from reaching the brain. A nerve block helps diagnose the source of a patient’s pain. It may provide temporary relief, and is often used to determine the outcome of a surgery that is meant to permanently block the activity of certain nerves.

When oral medications and physical therapy fail to work, it is often recommended that the patient receive an MBB for facet joint related pain. Medial branch nerves near the facet joints are responsible for small muscles in the neck, mid and lower back. These nerves often cause chronic neck and lower back pain, in addition to having the brain misinterpret the source of the pain and cause referred head pain.

MBB is a minimally invasive treatment and is commonly used to treat lower back pain. The facet joints that are located around the groove of the lower back are called the Lumbosacral medial branch nerves. These nerves are often associated with lower back pain. Up to 45% of patients suffering from lower back pain have inflammation or irritation of their facet joints (Boswell et al, 2007). In one clinical study, 57 patients with lower back pain were given an MBB. After eight weeks, 30 of those patients had relief. Upon reevaluation six months after the initial injection, the number of patients who had relief increased to 39 (Anand et al, 2007).

MBB is also used to treat neck pain. There are cervical facet joints that are located at the back or side of the head. There has been a recent study that states that up to 67% of patients suffering from head and neck pain can attribute that pain to irritated or inflamed facet joints (Boswell et al, 2007).

Procedure

MBB treatment is minimally invasive. It gives relief immediately. It is a non-surgical injection that takes an average of 15 to 30 minutes to perform.

After being numbed with a local anesthetic, the site of the MBB is injected with a long-lasting steroid and a local anesthetic. This injection is guided by a live X-Ray (fluoroscopy). This type of injection uses the anesthetic to numb the medial nerve branch. The impulses that caused so much pain are blocked. The steroid reduces inflammation and irritation. It is important for the patient to rest for 20-30 minutes after the injection (Baker). This treatment is considered a success if the patient has a significant decrease in pain. The MBB may be repeated at least two months after the initial injection. Patients should not receive more than six per year (Manchikanti et all).

When using the MBB to diagnose, patients should not receive more than four injections per year (Manchikanti et al). When the MBB is successful, the patient may be a candidate for radiofrequency ablation, which is a longer-lasting treatment for pain management (Baker). Radiofrequency ablation uses heat to deaden a nerve. This heat is produced by electric currents (RF currents) and creates a lesion on the nerve. This prevents pain signals from reaching the brain.

Benefits

One of the greatest benefits of having MBBs are that not only do they relieve pain immediately, they are low-risk and minimally invasive. They are very effective with prognostic and diagnostic treatment (Manchikanti et al). Traditional therapy is not very effective when trying to diagnose lumbar and cervical facet joint pain. MBBs have greatly improved diagnosing whether or not the facet joints are causing the patient’s pain. The American Society of Interventional Pain Physicians created a guideline for chronic spinal pain management. They specifically stated that MBBs are extremely beneficial for diagnosing lumbar and cervical facet joint pain (Boswell et al, 2007).

When used as a pain management procedure, an MBB provides pain relief very rapidly. This pain relief will often last from one month up to a year (Boswell et al, 2007). The patient may also be a candidate for radiofrequency ablation if the MBBs are successful.

Risks

MBBs are considered a safe procedure, but as with all medical procedures there are associated risks, possible side effects and complications that vary with each patient.

Pain at injection site. The patient might experience tenderness at the injection area for a short period of time as the local anesthetic wears off.

Minor infection. In less than 1% to 2% of patients, minor infections occur.

Increased pain. The patient might experience a worsening of pain symptoms.

Excessive bleeding, or infection. The patient might suffer excessive bleeding, infection and nerve damage as a result of undergoing an MBB treatment while on blood thinning medications, pregnant, allergic to any of the anesthetics used or they have an active infection.

Nerve or spinal cord damage. Very rarely, a patient suffers from nerve or spinal cord damage or paralysis resulting from direct trauma from the needle, from an infection, bleeding resulting in compression or injection into an artery causing blockage (Baker).

Outcomes

When a patient suffers from chronic neck, back and lower back pain, the Medial Branch Block is a very effective treatment for management of that pain. Not only does relief take place very quickly, MBBs are excellent tools that may be used in the prognosis and diagnosis of the patient’s pain. They will also determine if radiofrequency ablation is a worthwhile treatment. Having an MBB is a very low-risk procedure, with very little recovery time. This makes this a very popular pain management solution.

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Adam Sewell MD

KYPHOPLASTY

Performed by top pain management doctors in Fort Smith, Arkansas.

Kyphoplasty, which is very similar to Vertebroplasty, is a minimally-invasive procedure that is designed to help people suffering from severe back pain most likely caused by cracked, fractured, compressed or collapsed vertebrae. Kyphoplasty is a surgical procedure that is used when other treatments fail to relieve pain. (DeNegri 2007.)

Anatomy

The backbone consists of individual bony structures called vertebrae that interlock together to give strength and structure to the spine. These vertebrae allow us to move and also protect the spinal cord. The vertebrae may develop fractures, compress or collapse. Bone fragments may then irritate the nerves of the spine or the spinal cord.

Conditions commonly treated with Kyphoplasty and Vertebroplasty include:

Osteoporosis
Trauma or Injury
Bone cancer metastasis

Procedure

The patient lies on his or her stomach. After the back is sterilized, a local numbing cream is applied. The patient may also take sedatives in order to relax. An X-Ray or other such guiding machine is used to ensure correct placement of small needles that are carefully placed into the vertebral body.

In balloon-assisted Vertebroplasty, a strong inflatable balloon is inserted through a tube in into the vertebral body.

The small balloon is slowly inflated. The balloon fills the center of the vertebrae. Using low pressure, the balloon later is filled using special bone cement.

Benefits

Kyphosis is a condition that is known to give the patient a pronounced curve or hump on his or her upper back. The most common cause is from compressed fractures of the vertebrae. Severe Kyphosis may cause debilitating pain and is a serious medical condition.

The benefits of having Kyphoplasty is that one’s height may be restored, pain is relieved and vertical alignment is improved. In a 2006 study, after having this procedure, 80% of patients recovered their height. 90.7% of patients had fracture improvement. (Shindle 2006). If height recovery is a goal, then the Kyphoplasty procedure may have some added benefits from Vertebroplasty.

Risks

Kyphoplasty is considered a generally safe procedure. There are some risks, but it is considered appropriate to alleviate the pain of vertebral compressed fractures. The potential risks include the slight chance that there may be cement leakage out of the vertebral body. Serious complications are rare; but may include: infection, bleeding, numbness, tingling, headache, and paralysis from improper placement of the needle or cement. The risk of improper needle placement is decreased by using an imaging device, during the procedure.

Studies have shown that Kyphoplasty is a very safe treatment for debilitating and painful fractures of the vertebra, with only rarely having complications. (DaFonseca 2006)(Hiwatashi 2007).

Outcome

Kyphoplasty and Vertebroplasty are procedures that have significant benefits to those suffering the severe pain of Kyphosis. Patients experience immediate relief, improved movement and mobility, and 95% of patients reporting partial or complete pain relief (Hiwatashi 2007).

Fracture Prevention

Good general health is the best prevention; and includes a balanced diet, regular exercise, weight lifting, calcium and vitamin D supplements. Bisphosphonates medications (Aredia and Fosamax) for Osteoporosis treatment may prevent future compression fractures. These types of medications improve bone strength and bone density. Individuals with compression fractures may be good candidates for proven minimally invasive, including Kyphoplasty (Old 2004).

There is a guideline available to people who experience chronic spinal pain that was written by the American Society of Interventional Pain Physicians. It is a practice guideline for management with surgical techniques. The evidence suggests that vertebral augmentation procedures such as Kyphoplasty and Vertebroplasty give relief (Boswell 2007).

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

Resources/Journal Articles:

Adam Sewell MD

INTRATHECAL PUMP IMPLANTS

Intrathecal Pumps (ITPs) are devices used in the treatment of many chronic pain states. The pumps have shown effective in treating cancer pain, severe back pain, neuropathic pain, and muscle spasticity. ITPs are an automated piece of equipment that are programmed to deliver medication into the spinal fluid through a small catheter. This exciting pain relief technique has been shown to be both safe and effective

The purpose of the pump is to interrupt pain signals that travel through the spinal cord. Pain signals which normally travel to the brain are lessened and pain relief is perceived. Medication is delivered into the intrathecal space surrounding the spinal cord. The ITP delivers pain medication directly to the pain receptors in the spinal cord and smaller doses of medication are required to gain relief.

ITP implants are considered when oral pain medications and other methods of pain control have been exhausted or proven ineffective.

Procedure:

Before an ITP is placed, an intrathecal medication trial is performed. Medication is placed in the spinal fluid. If pain relief is adequate, an ITP can be permanently placed to control your pain.

Placement of the ITP can be performed in an outpatient setting or in the hospital. The implantation of the device is done with local anesthesia and sedation (general anesthesia is usually not required). After a sterile scrub, local anesthesia is used to numb the needle entry location. Once the area is numb, a larger needle and catheter are placed into the intrathecal space using x-ray guidance.

Once the catheter is in the proper location, the pump is then connected and placed under the skin on the lower part of your abdomen. The catheter and pump are tunneled under your skin and all wounds are surgically closed.

The pump delivers pain medication (opiates, local anesthetics, and/or muscle relaxants) directly into the intrathecal space around the spinal cord. The medication reservoir in the pump is refilled periodically (every four to six weeks) by your pain physician by injecting the medication through your skin into the pump.

The entire procedure typically takes one to two hours and may be performed on an outpatient or in-patient basis.

Benefits:

ITPs can be used to treat a variety of painful conditions. Nociceptive pain, or pain from tissue irritation can usually be effectively treated with uploads like morphine. Nociceptive pain transmission is interrupted at the spinal cord and pain relief is experienced.

Neuropathic pain, peripheral or central nervous system pain, tends to be receptive to treatments with local anesthetics more than opioids. Examples of neuropathic pain syndromes include CRPS (complex regional pain syndrome or reflex sympathetic dystrophy), cancer pain, phantom limb pain, post herpetic neuralgia (shingles), carpal tunnel syndrome, failed back surgery syndrome, and peripheral neuropathy (Diabetes Mellitus, vitamin deficiencies).

Spasmodic pain can also be successfully treated by ITPs. This type of pain is effectively treated with anti-spastic muscle-relaxing medications like Baclofen. Spasticity may be caused by impairment in the brain or spinal cord and is seen in several conditions, such as stroke, brain injury, spinal cord injury, cerebral palsy, and multiple sclerosis (Rawlins 2004). Spasticity is an abnormal increase in muscle tone and tightening of the muscles.

Risks:

Intrathecal pump implants are effective and safe devices used for pain management. The complications associated with implants are mostly pharmacological and transient (Kamran). Some of the common side effects due to the medications that are dispersed through the pump are:

Nausea & Vomiting
Itching
Weakness
Facial flushing
Constipation
Sleepiness
Respiratory Depression

More serious complications that can ensue are:

Hematoma
Bleeding
Infection
Infection/Meningitis
Catheter malfunction

ITP implants are considered an appropriate treatment for many patients who suffer from chronic difficult to control pain. As with any medication taken, there are always risks and potential side effects that may occur. All patients receiving a pump implant should be evaluated by their physician and risks of ITPs should be discussed.

Outcomes:

A large clinical study involving twenty four European centers showed that intrathecal pump implant therapy is clinically effective, well tolerated and may offer improvements in pain relief and function. Muscle tone, spasm levels, and pain intensity reductions were observed. Also cognition and motor function showed improvements (Guillaume 2005).

Intrathecal Baclofen therapy is considered safe and so effective that it has evolved into the standard treatment for severe spasticity (Rawlins 2004). Most patients and caregivers express satisfaction with the therapy and would recommend it to other patients. Spasm frequency appears to be the single most common variable positively affected by therapy (Vender 2006). Another study showed excellent long term efficacy in the treatment of lower extremity spasticity (Ethans 2007).

Another study observed the effects of intrathecal Morphine when delivered to patients with painful cancer. In this study all patients and their families reported an improved quality of life with an increased level of activity, and it was deemed “efficacious and safe” (Gilmer-Hill 1999). Another benefit with ITPs in terminal cancer is that continuous intrathecal narcotic infusion is a very effective method to control terminal cancer pain and enables treatment in an outpatient setting (Motsch 1988).

Pain can be a debilitating condition physically, as well as emotionally. ITPs can dramatically help those with painful conditions that are unrelieved by other therapies. Call Arkansas Pain today and see what they can do to relieve your pain.

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Adam Sewell MD

INTRADISCAL ELECTROTHERMAL THERAPY

Post author By Jasmeet Singh
Post date April 13, 2020
No Comments on INTRADISCAL ELECTROTHERMAL THERAPY

IDET therapy is a relatively new technique for the treatment of back pain that originates from the intervertebral discs. IDET essentially is administered by inserting a probe into the irritated disc and applying heat to it through a catheter. This causes the collagen in the disc to thicken and change form, destroying painful nerves located nearby the disc (Wang 2005).

The spine is positioned so that individual vertebrae (bones of the spine) provide a flexible support structure for the spinal cord. Separating individual vertebrae, are discs that act as cushions that absorb the physical impact that the spinal column receives. These are not as firm as the surrounding bone and have a tendency to herniate backwards through the outer segment. This can cause irritation to adjacent nerves. Discs are made of concentric layers of collagen, one on top of the other. Sometimes, the layers tear, and disc material can leak outside of the disk. This causes nerve irritation. Small pain fibers can grow inside discs, causing pain, and even simple everyday activities can become impossible to complete. Disk disease is one of the most common causes of chronic back pain in the world, and it accounts for approximately 10% of all low back pain complaints.

Procedure

The IDET (intradiscal Electro-Thermal) Annuloplasty, is an innovative technology that generates heat in order to destroy the painful nerves that are causing you low back pain. The procedure uses only a local anesthetic (numbing agent) and a sedative. Using a small needle, your pain physician will inject the area with a local anesthetic, first, to numb the area. When numbness is achieved, a larger needle is placed in the affected disc, and a catheter is advanced to the inside of the disc using x-ray guidance.

The procedure lasts less than an hour and is done on an outpatient basis. After the procedure is completed, the catheter and needle are removed and a small bandage is placed over the needle insertion site.

Benefits

Discogenic pain (pain caused by the disc) is an extremely common cause for back pain complaint. IDET therapy has several advantages over other disogenic pain treatments. It is minimally invasive, has a high success rate, requires no hospitalization, and is performed under a local anesthetic rather than general. Additionally, there is hardly any post-procedure discomfort, and normal activities are quickly resumed. Another advantage to IDET is that this is a highly controlled procedure, making the risk of damaging adjacent structures, very slim. Most often, IDET provides immediate, long lasting relief, but if it doesn’t, it can be repeated as many times as are needed to achieve proper pain relief.

Risks

As with all medications and surgical procedures, there is risk. However, the risks presented by IDET are very minimal. It is considered an appropriate treatment for many patients who suffer from back pain. The most common complaint is mild irritation at the needle site after the procedure anesthetic has worn off, as there is with any procedure utilizing needles. Other, more serious and far less common, complications include: Bleeding, nerve damage, or infection. Many of these risks are decreased with proper sterilization, temporarily stopping any blood-thinning medications, and using x-ray guidance during the procedure.

Outcomes

Although there are many surgical, and other, options for back pain, the most commonly recommended methods are conservative ones. These methods include interventional procedures, medications, physical therapy, cognitive behavioral therapy, biofeedback, diet, exercise, and many other alternative techniques and procedures (Manchikanti 2007). Sometimes, a patient’s back pain is so intense and unrelenting, that more advanced interventions like the IDET are required to control pain.

In a large study, patients that had low back pain for, at least, three months, and failed to respond to conservative care, responded well to IDET. The patients demonstrated an increase in physical function and decreased levels of back pain. The study concluded that pain resulting from disc disease may, not only be reduced, but be ended by IDET (Wetzel 2002). This is an extremely encouraging news for people dealing with chronic back pain and, more specifically, disc-related pain. IDET provides, both, temporary and long-term pain relief.

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Adam Sewell MD

GANGLION IMPAR BLOCK

Performed by top Pain Management doctors in Merritt Island & Melbourne, Arkansas

A ganglion impar block is an excellent treatment for chronic, neuropathic perineal pain from visceral and/or sympathetic pain syndromes, especially if they arise due to malignancy.

If you have vague, perineal pain that is hard to pinpoint, and is frequently accompanied by sensations of burning or urgency, you may benefit from a gangliar impar block. However, since the symptoms of burning and urgency, especially if their associated with urination or defecation, may be due to a secondary medical issue, it is imperative that you, first, consult your general practitioner to make certain you are not experiencing perineal area pain from one of these other causes.

Since the ganglion impar receives afferent pain fibers from the perineum, distal rectum, anus, distal urethra, vulva, and distal third of the vagina, this block has the potential to alleviate pain that originates from the regions mentioned above. The most recent literature shows that ganglion impar blocks have, also, been used successfully to treat non-malignancy-associated perineal pain from various conditions, including sacral post herpetic neuralgia, spinal cord malformations, and failed back surgery syndrome, etc… Emerging evidence also suggests that, due to its sympathetic nerve irritation, a ganglion impar block may provide relief to patients with perineal hyperhidrosis (excessive sweating).

Perineal Pain originating from:

Perineum
Distal rectum
Anus
Distal urethra
Vulva
Distal third of the vagina

Perineal Pain secondary to:

Cancer that metastasized to perineum (cervical, prostate, testicular, colorectal etc.)
Sacral post herpetic neuralgia
Postsurgical thrombosis of perineal veins
Spinal cord malformations
Vaginal protrusion
Failed back surgery syndrome
Testicular ablation

Miscellaneous:

Perineal hyperhidrosis

Anatomy:

The ganglion impar is the only unpaired autonomic ganglion in the body. It marks the end of two sympathetic chains. It is located in front of the sacrococcygeal joint in the retro peritoneum. However, research has revealed that the location, shape, and size of the ganglion impar are variable (Oh et al. 2004). After performing anatomical dissections on 50 sacra and coccyges, it has been discovered, that the location of the ganglion impar can range from the sacrococcygeal junction to approximately 10mm in front of the tip of the coccyx. The majority of the ganglia impar are located approximately 25-30mm in front of the tip of the coccyx .This anatomical variation may contribute to the possible inefficacy of the ganglion impar nerve block in some patients.

The ganglion impar receives pointed pain fibers from the perineum, distal rectum, anus, distal urethra, vulva, and distal third of the vagina. This block can potentially alleviate pain originating from the above mentioned regions. The impar ganglion’s postganglionic fibers pass along the gray rami communicantes to the sacral and coccygeal spinal nerves.

Procedure:

Since its first implementation, via the horizontal approach, researchers continue to introduce modified techniques that attempt to maximize the ease of performing this block, while maintaining patient safety and increasing the chance of maximal pain alleviation for their patients (Plancarte et al. 1990).

Some of these modified techniques include: techniques using fluoroscopic guidance or ultrasound guidance, approaches using the transsacrococcygeal ligament approach, the transcoccygeal joint approach, the paramedial approach, the paracoccygeal corkscrew approach, and using a curved needle technique, or needle-inside-needle technique. Of the many approaches, the transsacrococcygeal approach remains the most popular.

With this technique, your lower back and intergluteal cleft and will be prepped and sterilized before local anesthesia is administered. When your skin is adequately anesthetized, the needle will be advanced under fluoroscopy guidance. This will give the physician correct needle placement. Its correct placement will also be confirmed by a contrast dye. Once positioned properly, either a diagnostic block (to determine if your perineal pain is visceral or somatic), or a therapeutic block, will be performed. When profound pain relief has been achieved, the block is considered successful.

Local anesthetic is usually administered for diagnostic ganglion impar blocks. This is the same for patients that do not have cancer-related pain. For patients who have a documented response to the administration of local anesthetic onto the ganglion impar, a therapeutic block is administered with a neurolytic agent like phenol. Radioablation of the ganglion impar is another treatment that can offer longer-lasting pain relief.

The procedure usually takes less than 15 minutes. Your physician will, sometimes, recommend intravenous sedation to make the procedure more comfortable. Your physician will monitor your pain, and vital signs (pulse, blood pressure, temperature) during and after the procedure.

Benefit:

Ganglion impar block is a short, minimally invasive procedure treating, neuropathic perineal pain from visceral and sympathetic pain syndromes. This is especially true if they are secondary to malignancy. Published literature also highlights significant pain relief. This can also be achieved if the pain is of nonmalignant origin and originates from one of the organs, sending afferent fibers to the ganglion impar.

Risk:

There are very few risks associated with this procedure. In fact, current literature doesn’t note any major complications reported from this block (Plancarte, et al. 1993). Only one case of epidural contrast spread within the caudal canal. However, needle repositioning quickly resolved the problem without any harm to the patient (Plancarte et al. 1990).

Despite these published statistics, the theoretical risk of this procedure exists and includes: Bleeding with needle displacement, especially into your retroperitoneal space, nerve injury and/or paralysis, puncture of surrounding organs (including rectum) and puncture of adjacent vessels. Risks resulting from the anesthetic include – drug allergy and seizure (if the medication is injected into a blood vessel). Additionally, there always exists a risk of infection with any penetration of skin and soft tissues.

Finally, due to where the impar ganglion is situated, an ineffective block is, also, a risk in some patients. If no relief is obtained after your physician has placed the block through the transsacrococcygeal approach, he or she may decide on another approach to best accommodate your anatomy (transcoccygeal joint approach, paramedial approach etc.)

Outcomes:

Ganglion impar block is an excellent treatment for chronic, neuropathic perineal pain from visceral and sympathetic pain syndromes stemming from malignancy.

In 1990, Plancarte et al. not only described the ganglion impar technique, but also demonstrated its helpful results in cancer patients. Patients with advanced cancer (cervical, endometrial, bladder, colon, and rectal) with perineal involvement, who had little response with pharmacotherapy, received a neurolytic ganglion impar block. After the block, nearly eight patients experienced total relief of pain, and the remaining patients reported a 60-90% reduction in their pain.

Agarwal-Kozlowski et al. (2009) evaluated the efficacy of the ganglion impar block on various types of perineal pain (including malignancy, post-surgical thrombosis of perineal veins, postherpetic neuralgia, spinal cord malformations, vaginal protrusion, failed back surgery syndrome, testicular ablation, and what was deemed as perineal pain of unknown origin) in 43 patients. Many of the patients reported immediate and lasting pain relief through the 4-month follow up. This success has continued through subsequent patient observation and experiences.

For some people, the benefits of a ganglion impar block can be temporary, and the extent and duration of pain relief can vary from person to person. Some tend to have relief for weeks, while others, experience a complete remission of pain for years at a time. Fortunately, this is a low risk procedure, and if the first attempt is not successful, it can be repeated.

If you are suffering with chronic perineal pain or pain that you or physician believe is originating from the perineum, distal rectum, anus, distal urethra, vulva, and distal third of the vagina, the ganglion impar block may be an excellent alternative treatment for you.

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Adam Sewell MD

FACET INJECTIONS

Facet injections are a minimally invasive, non-surgical, treatment for many different causes of neck and back pain. They works by reducing the inflammation, and associated pain, in the facet joints of the spine.

The syndromes most commonly requiring Facet Injections include:

Spinal Stenosis
Herniated Disk
Sciatica
Spondylolysis

Procedure:

The facet joint of the spine is a moveable connection. It connects one vertebra (bone of the spine) to another. This injection uses a long-lasting steroid and an anesthetic (lidocaine, bupivacaine). The steroid reduces the inflammation, and subsequent irritation, and the anesthetic numbs the pain. The combination spreads to other levels and areas of the spine, reducing inflammation and pain. The entire procedure usually takes less than 15 minutes.

Facet Injections and Epidural Steroid Injections (ESI) are very similar, but they differ in where the medication is located. In an ESI, the medication is injected into the epidural space. In the facet injections, it is injected directly into the joint.

Benefits:

Facet joint injections are most successful in the rapid relief of symptoms. Pain management occurs quickly, allowing patients to experience enough relief to become active again. They are able to resume their normal daily activities faster than with oral medications and physical therapy.

Facet injections can be used as a diagnostic tool, as well, to see if the pain is actually coming from the facet joints. Sometimes, it is radiating from other locations. If your pain disappears with the injection, then it is originating from the joint. Therapeutic lumbar facet joint nerve blocks with local anesthetic, with or without steroids, may be effective in the treatment of chronic low back pain of facet joint origin. (Manchikanti 2007). However, if your pain is unresponsive, then your physician will look for another source for your pain.

The American Society of Interventional Pain Physicians affirm the accuracy of facet joint nerve blocks as highly accurate in the diagnosis of lumbar and cervical facet joint pain (Boswell 2007).

Risks:

Facet injections offer only a very minimal amount of risks, and they are considered an appropriate non-surgical treatment for many patients who suffer from back pain. The risks associated with the procedure are – misplacement of the needle, advancing the needle too deeply or positioning it incorrectly. This can, potentially, cause nerve damage, bleeding, infection, and a headache following the injection.

As with any medication or treatment, there are always risks and potential side effects. Some additional minor risks with facet injections can be directly caused by the medication given. Some of these side effects are much higher in a person taking oral corticosteroids. Potential side effects of corticosteroids are elevated blood sugars, weight gain, arthritis, stomach ulcers, and a lowered immune system. All patients should be thoroughly assessed before by their physician before receiving a facet injection.

Outcome:

Lumbosacral injections have increased dramatically in the last decade, because they have proven very successful in the treatment of back pain.

Recent research reveals that 53% of patients with back pain, who received facet injections for eight weeks of treatment, reported improvement of their pain. By 6 months of treatment, over 68% reported the same (Anand 2007). The duration of pain relief varies from person to person, but if the first facet injection provides only minimal relief, the procedure can be repeated up to three times in one year.

Articles:

Adam Sewell MD

EPIDURAL STEROID INJECTION (ESI)

Post author By Jasmeet Singh
Post date April 13, 2020
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Epidural steroid injections (ESI) are used to treat a variety of conditions that cause unrelenting back pain. In some cases, ESI can delay the need for surgery. Some estimates suggest that, between, 10%-20% of the population suffers from some sort of chronic back pain. There are many reasons someone might experience continued back pain – issues with facet joints, torn or inflamed ligaments, strained muscles, and irritated nerve roots. ESI treats all of these issues. For most people, ESI should result in a reduction of chronic back pain, disability and can even diminish the depression that tends to go along with this time of constant pain.

Anatomy

The spine consists a track of bones called vertebrae. They are stacked on top one another, leading from the pelvis to the base of the skull. They form a channel that protects the spinal cord. The vertebrae are composed of many structures. At the beginning is a solid, circular body connected to two transverse processes on either side by thin bony structures termed pedicles. The transverse processes are bony projections, on either side, where the muscles attach. These transverse processes are then connected to the back-facing protrusion that can be felt through the skin. Added to these, are two additional thin, bony structures called the lamina. This design leaves a hollow central clearing between the processes, the lamina, the pedicles and the vertebral body.

Each vertebra is separated by inter-vertebral discs composed of a tough, fibrous outer layer and filled with a soft, gelatinous inner layer of cartilage. These discs support the vertebrae and allow them to shift across one another. They facilitate the movement of the spine. Two vertebrae are connected to one another by two facet joints, or zygapophysials, located on either side of the bone. Facet joints connect the upward and create an opening at the side, between two connected vertebrae. These vertebrae are called the neural foramen. Through the neural formen, nerve roots exit the spine to peripheral tissues.

There are three ways to administer ESI. The interlaminar approach offers an injection into the back and directly between the thin laminar portions of two adjacent vertebrae. This is done to access the epidural space in the spinal cord. The transforaminal approach involves injection through the neural foramen at the side of two adjacent vertebrae, and this is done to directly target the epidural space near a nerve root. Finally, the caudal approach involves an injection through a structure known as the sacral hiatus. The sacral hiatus is located just above the tailbone. This approach is done to access the epidural space. Whatever the approach, during an ESI procedure, a radiologic technique known as fluoroscopy, a type of real-time x-ray, is used to assist the physician in guiding the needle to the proper site. Fluoroscopy makes ESI highly accurate.

Indications

ESI’s are guided toward the spot where the pain is believed to generate. Once appropriately positioned, a solution can be injected through the needle directly to the site to relieve pain and inflammation. This solution generally consists of an anesthetic, mixed with a long-acting steroid, and this has an anti-inflammatory effect on the irritated area. ESI’s are very effective in treating all manner of pain within the spine.

Herniated Disc

A herniated (slipped disc, as it is sometimes known), refers to the displacement of inter-vertebral disc material outside the borders of its joint. For reasons that are not completely understood, disc herniation may cause intense pain or very little pain. The pain results from the shifted disc material, or subsequent inflammation. This puts pressure on a nearby nerve or nerve root. This type of pain is termed radiculopathy. Depending on which level of the spinal cord is affected, pain can be felt in several areas: the back, neck, arms or legs, and compression can cause numbness and/or weakness in some circumstances.

Sciatica

ESI’s are most often performed when sciatica, or shooting leg pain, results from a herniated disk. A herniated disc compresses nearby nerve roots, causing systematic shooting pain along the path of the nerve. In the case of sciatica, the leg is specifically effected. Studies have shown that ESI’s provides effective short-term pain relief for up to 80% of patients and long-term pain relief for up to 75% of sufferers.

Discogenic Pain

Even if a disc is not herniated or compressing a nearby nerve root, it can still cause pain. Sometimes, because the discs are innervated, irritation to the disc can cause what is known as “disogenic pain”. ESIs may provide significant relief for this kind of pain.

Spinal stenosis

Spinal stenosis is a narrowing of the central vertebral channel through which the spinal cord passes. This causes compression of the spinal cord and limited movement of the spine. Stenosis can, also, cause a narrowing of the neural formen, which can lead to compression of specific nerve roots. Spinal stenosis is common with advancing age, and the compression of nerve tissue is a common cause of pain. Spinal stenosis if often associated with arthritis, disc herniation, spinal tumors and forms of spinal injury. ESIs are helpful in relieving pain from these conditions.

Adam Sewell MD

EPIDURAL LYSIS OF ADHESIONS

Post author By Jasmeet Singh
Post date April 13, 2020
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Epidural Lysis of Adhesions, Adhesiolysis, is also known as the Racz Procedure. The procedure’s name comes from “Adhesion” meaning scar tissue and “Lysis” meaning to dissolve or destroy. This 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. 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 low 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 the response to the epidural steroid injections may be limited. Once scar tissue is thought to be the cause of you pain you will be schedule for the Racz Procedure. Epidural Lysis of Adhesions 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 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 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

Epidural Lysis of Adhesions is considered safe and effective. The purpose of the procedure is to minimize the deleterious 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. Epidural Lysis of Adhesions is considered an appropriate treatment for many patients who suffer from back pain, but 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 epidural lysis of adhesions 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 Society of Interventional Pain Physicians developed a large evidence-based practice guideline for the management of chronic spinal pain with interventional techniques. In regards to Epidural Lysis of Adhesions, the guidelines state that there is strong evidence to indicate effectiveness of adhesiolysis with epidural steroids for short and long term pain control in refractory pain and radiculopathy. 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 results including the following: % of patients who achieved pain relief: < 3 months 3 months 6 months 12 months 100 90 72 52 Another study indicated that overall health status improved significantly in the patients treated with Epidural Lysis of Adhesions. Patients stated that their pain and pain medication use were decreased and their physical health, mental health, functional status, and psychological status 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.