Category: Adam Sewell MD

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:

1. Evaluation of lumbar facet joint nerve blocks in the management of chronic low back pain: preliminary report of a randomized, double-blind controlled trial: clinical trial NCT00355914. Manchikanti L, Manchikanti KN, Manchukonda R, Cash KA, Damron KS, Pampati V, McManus CD. Pain Physician. 2007 May;10(3):425-40 PMID: 17525777
2. Increases in lumbosacral injections in the Medicare population: 1994 to 2001 Friedly J, Chan L, Deyo R. Spine. 2007 Jul 15;32(16):1754-60 PMID: 17632396
3. Patients’ response to facet joint injection. Anand S, Butt MS. Acta Orthop Belg. 2007 Apr;73(2):230-3 PMID: 17515236
4. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Boswell MV,Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB,Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L; American Society of Interventional Pain Physicians. Pain Physician. 2007 Jan;10(1):7-111 PMID: 17256025

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.

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.

Journal Articles

• Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L; American Society of Interventional Pain Physicians. Pain Physician. 2007 Jan;10(1):7-111 PMID: 17256025
• Percutaneous lysis of epidural adhesions. Manchikanti L, Bakhit CE. Pain Physician. 2000 Jan;3(1):46-64 PMID: 16906207
• Systematic review of effectiveness and complications of adhesiolysis in the management of chronic spinal pain: an update. Trescot AM, Chopra P, Abdi S, Datta S, Schultz DM. Pain Physician. 2007 Jan;10(1):129-46 PMID: 17256027
• Role of one day epidural adhesiolysis in management of chronic low back pain: a randomized clinical trial. Manchikanti L, Pampati V, Fellows B, Rivera J, Beyer CD, Damron KS. Pain Physician. 2001 Apr;4(2):153-66 PMID: 16902688
• Transforaminal ventral epidural adhesiolysis. Hammer M, Doleys DM, Chung OY. Pain Physician. 2001 Jul;4(3):273-9 PMID: 16900254

Discography is a diagnostic tool used to determine whether certain discs of the spine are the source of a patient’s neck or back pain. Most of the population experiences low back pain, at least, sometime during their lifetime. It is the fifth leading cause of medical visits and the leading cause of workplace-related disability. Discography is used to pinpoint the cause of low back and neck pain, especially when non-invasive imaging, such as magnetic resonance imaging (MRI), has failed to reveal the source of pain (Wichman 2007). Discography is considered for patients with idiopathic (uknown), but disabling, neck and back pain.

Understanding the anatomy and function of the spine is important in evaluating back pain. The spine is made up of vertebrae (bones of the spine) that provide a flexible support for the back muscles and spinal cord. Certain conditions cause pain in, and around, the spine,  including Spinal stenosis, vertebral body fractures, Osteoporosis, Osteoarthritis, Spondylolisthesis (scar tissue), neoplasms (Primary vs. metastatic lesions), and infections. Separating each individual vertebrae are discs that act as cushions to minimize the impact that the spinal column receives. The softness of the discs give them a tendency to herniate posterior (backwards) through the outer disc segment and ligaments. Bulging and leaking discs often cause irritation to the adjacent nerves. This results in disc disease, which accounts for about 10% of all doctor visits for low back pain. It can be acute, resulting from herniation or trauma, and can become chronic. Degenerative disc disease is progressive, causing a thinning and degeneration of the discs over time.

Discography Procedure

After you skin is thoroughly cleaned, s small needle will numb the area with a local anesthetic. A larger needle will then be inserted and positioned near the outer layer of the disc. Fluoroscopy, real time X-ray, is used in order to assure proper placement of the needle. A contrast solution is injected into the disk and your response to the injection is observed at different locations. If pain is experienced, then it is possible that your doctor has located the source of your pain. This process is typically repeated twice for maximum relief. The procedure usually takes less than an hour. A CT scan may be ordered directly after the procedure to ensure that the contrast die has spread properly.

Discography Benefits

Although MRI is considered a very good method for showing disc abnormalities, it does not show direct causes of pain. A study in 2007 revealed that Discography is more accurate at locating disc pain and ruptures than is MRI. This is true for similar conditions as well (Montes Garcia 2007). Since discography is considered a minimally invasive procedure it is performed when your physician highly suspects the cause of your pain. Generally, when students undergo discography, they have tried a myriad of other ineffective treatments for isolating the precise area of their pain. An MRI and CT scan can show abnormalities, but a discography reveals the exact location of the pain. Sometimes, moderately effected discs can cause severe pain, and run the risk of being treated improperly if based solely on MRI and CT findings (MRI/CT scan).

Discography Risks

As with all treatments, there is risk. However, the risk with discography is usually small. Although very uncommon, discitis (infection of the disc) can be severe.  Other risks include bleeding, hematoma, headache, and increased pain.

Discography Outcome

Once your discography has been performed and your doctor has been able to isolate the source and location of your pain, you will be described an effective treatment plan. Discography is believed to be the best source of investigative protocol for disc disease   (Buenaventura 2007). If you are suffering from chronic back pain that has been refractory to other treatments contact Arkansas Pain Specialists today to see if you can benefit from discography, or any of their other innovative, pain-relieving services.

Journal Articles

1. Discography– PainDoctor.com
2. Evocative lumbar discography Montes García C, Nava Granados LF. Acta Ortop Mex. 2007 Mar-Apr;21(2):85 PMID: 17695763
3. Discography: over 50 years of controversy Wichman HJ. WMJ. 2007 Feb;106(1):27 PMID: 17393754
4. Systematic review of discography as a diagnostic test for spinal pain: an update Buenaventura RM, Shah RV, Patel V, Benyamin R, Singh V. Pain Physician. 2007 Jan;10(1):147- PMID: 17256028 www.spine.org

Disc pain is one of the most common forms of back pain across the world. Disc Denervation is a pain procedure used to treat chronic disc related pain. Pain occurs when discs compress or irritate local spinal nerves. Disc denervation, in a sense, deactivates the irritate nerves and blocks the affected nerves from sending anymore messages of pain. This is accomplished when the messages are heated and destroyed with radiofrequency. The heat generated from the radiofrequency modifies certain nerve fibers and blocks the perception of pain that is received by the brain.

Radiofrequency denervation is often more effective than other treatments, precisely, because of the temperature manipulation of irritated nerves (Ahmet 2006). Neuropeptides, or pain sensing chemicals along the periphery, or edges, of your nerves control both inflammation and the sense of pain. Nerves connected to the spinal cord eventually send a signal of pain to the brain. When the pain-sensing nerves are identified, successful pain relief can occur after they are denervated (Koscharskyy 2007).

Anatomy:

Spinal discs are designed to be soft and provide support, but they have a tendency to herniate backwards causing irritation to the adjacent nerves. Disc disease is one of the most common causes of chronic neck or back pain and accounts for approximately 10% of all lower back pain complaints. Disc disease can be acute, caused by herniation, trauma, or more commonly, degenerative disc disease. Degenerative disc disease causes as thinning and degeneration of the discs over time and can lead to spinal dysfunction, nerve impingement, or peripheral nerve irritation. Disc denervation is considered for most patients who have disabling chronic pain, especially when due to one of the aforementioned conditions and when conservative treatments have failed. Disc denervation is a common treatment for people with chronic neck and back pain.

Procedure:

Using a small thin needle, your physician will administer a local anesthetic to numb your skin and subcutaneous tissue (tissue just below the surface of your skin). A radiofrequency needle is advanced under fluoroscopy or real-time x-ray to the source of pain. Electrical stimulation is initiated through the needle and your disc pain is duplicated. When the correct nerves have been identified, the nerve supply to the disc is denervated with the radiofrequency. This procedure destroys pain-causing nerves and lessens the effects of pain on the surrounding area.  The entire procedure lasts about an hour, and the site receives a small bandage after the treatment is complete.

Benefits

Disc denervation is a minimally invasive procedure which may provide significant relief. No hospitalization is required and the procedure is performed with local anesthesia and, sometimes, sedation. There is, often, some post-procedure discomfort, but you will be able to quickly resume your normal activities. Disc denervation is that it can be controlled, minimizing the risk of damaging adjacent nerves. If pain reoccurs, the procedure can be repeated.

Risks

As with all procedures, disc denervation carries some risk. However, that risk is quite rare. The complication rate per patient is 1.0% (Kornick 2004). There is a small risk of bleeding, infection, or nerve damage. The most common complaint is pain at the procedure site after the local anesthetic has worn off, but this tends to go away within 24 hours.

Outcomes

Disc denervation has been used as pain management for over two decades. In a 2007 study, it was revealed that more than half the patients treated with radiofrequency denervation had moderate to excellent pain relief lasting up to a year (Gofeld 2007). The best results were seen in patients with low back pain, who found that they were able to return to their normal daily activities very shortly after treatment (can Kleef 1999).  If you are suffering from chronic back or neck pain that has been resistant to other treatments, contact Arkansas Pain Specialists today to see if you can benefit from this innovative treatment.

Journal Articles

• Principles and Uses of Radiofrequency Nerve Lesioning in Chronic Pain Control Ahmet H. Ozturk, MD CHH Pain Management Clinic
  Complications of lumbar facet radiofrequency denervation. Kornick C; Kramarich SS; Lamer TJ; Todd Sitzman B Department of Anesthesiology, Division of Pain Management, Mayo Clinic, Jacksonville, Arkansas, USA. Spine. 2004; 29(12):1352-4 (ISSN: 1528-1159)
• Lumbar discogenic pain. Disk degeneration and minimally invasive interventional therapies Kosharskyy B, Rozen D. Anasthesiol Intensivmed Notfallmed Schmerzther. 2007 Apr;42(4):262-7
• Radiofrequency denervation of the lumbar zygapophysial joints: 10-year prospective clinical audit. Gofeld M, Jitendra J, Faclier G. Pain Physician. 2007 Mar;10(2):291-300
• A randomized controlled trial of radiofrequency denervation of the ramus communicans nerve for chronic discogenic low back pain. Oh WS, Shim JC. Clin J Pain. 2004 Jan-Feb;20(1):55-60
• Randomized trial of radiofrequency lumbar facet denervation for chronic low back pain. van Kleef M, Barendse GA, Kessels A, Voets HM, Weber WE, de Lange S. Spine. 1999 Sep 15;24(18):1937-42

Continuous peripheral nerve infusions involve inserting a small catheter under the skin, near a peripheral nerve in order to provide a continuous supply of an analgesic medication for pain relief (Ilfeld 2005). The conditions mostly likely to benefit from this treatment are post-operative surgical pain and Complex Regional Pain Syndrome or RSD (Dadure 2005). Our physicians are experienced in offering these techniques as an innovative means of pain management. Although most often used in treating post-operative surgical pain and RSD, the following conditions also benefit –

• Back and Neck Pain
• Traumatic Nerve Injuries
• Peripheral Vascular Disease Neuropathy
• Post-amputation Pain
• Herpetic Neuralgia
• Trigeminal Neuralgia
• Brachial Plexus Neuropathies

Procedure:

It, generally, takes less than 15 minutes to place the catheters. Your physician will first cleanse the skin and, under some circumstances, provide IV sedation. Then local anesthetic is applied, and a needle is placed through the anesthetized tissue. Using nerve stimulation with twitch-monitor or ultrasound guidance, your physician will place the needle next to the irritated nerve. The catheter is, then, manipulated in place and the needle withdrawn. The catheter remains, delivering much needed pain medication to the area.  The catheter will be secured with adhesive and a bandage, and the catheter is maintained in a carrying pouch, about the size of a softball. This pouch holds the medication, providing a constant stream of pain management for 5 to 7 days, after which time, it will be removed.

Benefits:

Patients who received continuous infusion local anesthetic were much less likely to experience breakthrough pain when compared those who managed pain through oral analgesics only (Ilfeld 2005). Oral opioids come with their own collection of side effects, some serious, so those who are able to utilize another pain management source, do not have the pharmacological side effects of oral pain medications as well. If the affected nerves are severely and regularly irritated, a continuous infusion may provide prolonged pain relief.

Risks:

Most continuous catheter placements are performed on an outpatient basis with minimal risks. However, as expected with any procedure, there are associated risks. With continuous catheters the risks are bleeding, infection, inadequate pain surface area coverage, and nerve injury (Ilfeld 2007). The catheter site must be kept dry and clean while healing in order to avoid infection. While the catheter site 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, you’ll need to contact your doctor immediately.

Outcome:

A 2006 study revealed that a group of patients recovering from knee surgery, receiving continuous catheter infusion, healed faster than those using oral or intravenous opiates after surgery. Their recovery time was shorter and rehabilitation time more effective. (Ruyter 2006).  In several other large studies, involving both adults and pediatric patients, continuous catheter infusion resulted in excellent pain management solutions for a myriad of chronic pain issues (Singelyn 2005).

Journal Articles:

• Ambulatory Perineural Local Anesthetic Infusion. Ilfeld, Brian; University of Arkansas, Gainesville. 4th Regional Anesthesia Int’l Symposium Oct. 11, 2002 Continuous Peripheral Nerve Blocks for Patients at Home Brian M. Ilfeld, M.D. F. Kayser Enneking, M.D. American Society of Anesthesiologists May 2005
• A pilot study on continuous femoral perineural catheter for analgesia after total knee arthroplasty: the effect on physical rehabilitation and outcomes. De Ruyter ML, Brueilly KE, Harrison BA, Greengrass RA, Putzke JD, Brodersen MP. J Arthroplasty. 2006 Dec;21(8):1111- 7. Epub 2006 Jun 21
• Continuous peripheral nerve blocks at home for treatment of recurrent complex regional pain syndrome I in children. Dadure C, Motais F, Ricard C, Raux O, Troncin R, Capdevila X. Anesthesiology. 2005 Feb;102(2):252-5.
• Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous femoral nerve sheath block on rehabilitation after unilateral total-hip arthroplasty. Singelyn FJ, Ferrant T, Malisse MF, Joris D. Reg Anesth Pain Med. 2005 Sep-Oct;30(5):452-

Cervical epidural steroid injections (CESIs) are one of the most commonly used treatments for chronic neck pain and cervical radiculitis (radiating spinal pain). Headaches and cervical spinal stenosis may also benefit from this treatment.

Cervical radiculitis is a result of nerve compression in the neck, also known as the “cervical spine”, and it radiates down the length of the arm or into some other location. The pain center actually stems from the cervical nerves in the spine and cause irritating and inflammation. This can results in pain, numbness, or weakness, especially, when a cervical disk is bulging. Cervical radiculitis can be caused by spondylitis and arthritis of the facet joints. Both issues can be effectively resolved with CESIs (cervical epidural steroid injections).

Procedure:

With CESIs, a steroid is injected into the epidural space in the cervical canal. This is where the irritated and inflamed nerve roots reside. The injection includes a long-lasting steroid and a local anesthetic (usually, Lidocaine or Bupivacaine). The steroid reduces the inflammation, while the other medication numbs the area and prohibits some of the pain spasm cycle. The entire procedure usually takes less than 15 minutes.

Benefits:

Cervical steroid injections are simple and relatively painless. Most people, more than 70%, experience immediate pain relief from the procedure. If pain relief is only moderate after the first injection, up to two more can be administered at later dates. Subsequent injections are usually needed to experience complete relief.

For many people, cervical steroid injections cause rapid relief of symptoms, which allow them to become active again. The pain relief achieved from this treatment often allows patients to resume their normal daily activities within a short time, even in more treatments are needed to maintain the relief.

Risks:

As with all procedures, there are risks with cervical epidural steroid injections. However, they are low. It is a non-surgical pain effective pain treatment, but it can cause Cervical epidural steroid injections do have risks, but they are typically low. This pain treatment is considered an appropriate non-surgical treatment for many patients who suffer from neck pain and headaches. Complications of the injection can include bleeding, infection, headaches, and nerve damage. The medications used can also cause pharmacological complications, like anaphylaxis, in the rare case that an individual has an allergy to them or an ingredient. Additional pharmacological risks are – high blood sugars, decreased immune response, and the potential for weight gain, as with all steroids.

Along with proper technique, the procedural risks are reduced by using fluoroscopic guidance (x-ray) for proper positioning and administration.

Outcome:

Cervical epidural steroid injections have proven to be highly effective in relieving neck pain. A 2007 study revealed a 72% effectiveness with the procedure (Kwon 2007).

The amount and duration of pain relief vary from person to person. Some find immediate relief from just one injection, but most require all three for maximum effectiveness.

If you are experiencing chronic neck pain that has lasted longer than four weeks or is severe you should contact Arkansas Pain Specialists about this highly effective treatment. Early intervention may decrease the chances of developing a worsening chronic pain syndrome.

Articles:

• Epidural Local Anesthetic Plus Corticosteroid for the Treatment of Cervical Brachial Radicular Pain: Single Injection Versus Continuous Infusion. Pasqualucci A, Varrassi G, Braschi A, Peduto VA, Brunelli A, Marinangeli F, Gori F, Colò F,Paladini A, Mojoli F. PMID: 17710003
• Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L; American Society of Interventional Pain Physicians. Pain Physician. 2007 Jan;10(1):7-111 PMID: 17256025
• Cervical interlaminar epidural steroid injection for neck pain and cervical radiculopathy: effect and prognostic factors. Skeletal Radiol. 2007 May;36(5):431-6. Epub 2007 Mar 6 Kwon JW, Lee JW, Kim SH, Choi JY, Yeom JS, Kim HJ, Kwack KS, Moon SG, Jun WS, Kang HS

This treatment is a combination of a steroid and a local anesthetic that is delivered to your lower back to treat chronic back and lower extremity pain.

Most Common Conditions Treated Are:

Sciatica/Lumbar Radiculitis –This is a condition that is characterized by pain, weakness, or sensory changes along the sciatic nerve pathway in the lower extremity. Pain typically radiates down the back of the buttock into the lower leg and foot. Some people describe the sensory changes as “pins and needles” and “sharp shooting pain”.

Herniated/Bulging Disc (most common cause of sciatica) – Disk disease is one of the most common causes of chronic lower back pain and accounts for approximately 10% of all low back pain complaints. Between the vertebrae (spine bones), are discs that cushion impact received by the spinal column. Since the discs are designed to be pliable and supportive, they have a tendency to herniate (or bend/squeeze) backwards through the outer ligaments, causing irritation to adjacent nerves.

Degenerative Lumbar Spinal Stenosis (DLSS) – DLSS is a narrowing of the spinal canal, causing nerve impingement or encroachment. Spinal stenosis can result in persistent pain in the lower back and lower extremities, like the legs and feet. Those affected often complain of difficulty walking, chronic back and leg pain, and decreased sensation in the lower extremities. All of this results in diminished physical activity. Many people with spinal stenosis present with bilateral (both left and right) lower extremity pain radiation.

Procedure:

Caudal epidural steroid injections involve injecting a steroid into the epidural space, where the irritated nerve roots are located. The caudal injection is performed through the sacral opening. The combination treats low back pain. It has, both, a long-lasting steroid and an anesthetic (Lidocaine, Bupivacaine). The steroid reduces inflammation and irritation, while the anesthetic interrupts the pain-spasm cycle and nociceptor transmission (Boswell 2007). The medicines spread to the most painful levels of the spine, reducing inflammation and irritation. The entire procedure usually takes less than 15 minutes.

Epidural steroid injections often result in a rapid relief of symptoms. This allows patients to experience enough relief to become active and resume their normal daily activities.

A large study in 2005, included two hundred and twenty-eight patients with a clinical diagnosis of unilateral sciatica, who experienced a 75% improvement in pain over a placebo group in a three week period, when they received a caudal steroidal injection.  (Arden 2005).

This technique can be combined with other medications as well and a small catheter. Additionally, an Epidural Lysis or Racz Procedure can be performed to remove any pain-causing scar tissue. Scar tissue often results from prolonged irritation, inflammation, or previous surgery in the area and should be removed for effective pain management to continue.

Benefits:

Low back pain (LBP) is one of the most difficult conditions for physicians to treat. Commonly LBP goes into remission with periods of decreased or absent symptoms, but the pain can return, causing a chronic pain syndrome.

Treatment for LBP is specific to the type of injury presented. There are several options available ranging from surgery to acupuncture to physical therapy. Surgical procedures are typically done when conservative options are exhausted and are not successful in reducing pain. Surgery is also indicated when the LBP is causing new weakness, bowel or bladder incontinence, spinal instability, or infection. Potential causes for these changes include severe lumbar disc herniation, vertebral body fracture or displacement, and progressive spinal stenosis.

Degenerative lumbar spinal stenosis (DLSS) is the most common reason adults over the age of sixty-five receive spinal surgery (Barre 2004). More recently, a large study has shown that fluoroscopically (x-ray) guided, caudal epidural injections represent a relatively safe option for the management of DLSS generated pain (Barre 2004).

Risks:

Many people are afraid to undergo spinal surgery because of the risks perceived to be associated with it. However, the risks associated with Caudal Steroid Injections are low. This pain treatment is considered an appropriate non-surgical treatment for many patients who suffer from unrelenting back pain. Rare complications of the injection can include bleeding, infection, headaches, and nerve damage. The medications used can also cause pharmacological complications. These risks include allergic reaction, high blood sugar, decreased immune response, and the potential for weight gain. Along with proper technique, the procedural risks are reduced by using fluoroscopic guidance (x-ray/camera) to position the needle and monitor the proper spread of medication.

Outcome:

Many patients who receive Caudal Steroidal Injections enjoy improved function and diminished pain for years and can benefit from additional procedures for prolonged relief (Barre 2004).

If your pain has lasted longer than four weeks or is severe in nature you should see a pain specialist about the most appropriate treatment options. Early intervention may decrease the chances of developing a worsening chronic pain syndrome.

Articles

• Fluroroscopically Guided Caudal Epidural Steroid Injections for Lumbar Spinal Stenosis: A Retrospective Evaluation of Long Term Efficacy. Barre, Lisha. Pain Physician 2004; 7:187-193. Rheumatology (Oxford). 2005 Nov; 44(11):1399-406. Epub 2005 Jul 19 Arden NK, Price C, Reading I, Stubbing J,
• Hazelgrove J, Dunne C, Michel M, Rogers P, Cooper C; WEST Study Group. Rheumatology (Oxford). 2005 Nov; 44(11): 1399-406. Epub 2005 Jul 19 PMID: 16030082
• Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L; American Society of Interventional Pain Physicians. Pain Physician. 2007 Jan; 10(1):7-111 PMID: 17256025

Adhesiolysis is the dissolution of epidural adhesions, or scar tissue. This minimally invasive surgery was developed in the mid-1980s by Dr. Gabor Racz (Boswell et all, 2007) and continues to be an effective way to eliminate the chronic, intense scar-tissue related pain that often radiates from the lower spine to the legs (Machikanti et all, 2000).

Scar tissue causes inflammation when nerve roots are compressed. This results in chronic injury and incredible pain for many patients. Typically, the scar tissue forms after spinal surgery or even injury and can block pain medications from reaching the area of pain. For this reason, adhesiolysis, is an excellent corrective treatment for this troublesome and painful issue. It directly dissolves the tissue that interferes with traditional pain management treatments.

Spinal scar tissue can result from:

Spinal Surgery

Most patients who undergo spinal surgery develop scar tissue that adheres to the nerve roots. This fixes the nerve into a certain position, often causing tension and nerve compression. In other cases, the scar tissue causes inflammation, which results in the same compression and pain (Belozer et al, 2004).

Annular Tears

An annular tear is a tear in the outer-most portion of the intervertebral discs, where cartilage cushions the joint and acts as a ligament to hold the joint in place.  A tear in this location will cause mechanical or chemical irritation (Cooper, 2011). Mechanical irritation caused by an annular tear occurs when the axial load of the center of the disc compresses the nerve endings. A chemical irritation happens when the glutamate from the intervertebral disc material causes inflammation around the nerve root, which results in swelling that can pin the nerve roots. This will cause the adhesions to remain after the inflammation disappears (Trescot et al, 2007). Annular tears are often caused by collagen genetics, trauma, or disc degeneration (Cooper 2011) and can be a continuous source of pain.

In addition to spinal surgery and annular tears, trauma is also a known cause of scar tissue along the spine (Hammer et al, 2007).

Procedure:

An MRI of the patient’s spine is the first step in step in determining if scar tissue is the cause of chronic pain. Once, the source and site of injury have been determined, the patient’s pain will be addressed with a series of epidural steroid injections. If these treatments fail, as they sometimes do when scar tissue blocks the medication from reaching the nerve roots-the source of the pain, an adhesiolysis procedure will be the best option.

The patient is first given an injection of local anesthetic, using a very small needle. Once the injection site is numb, a larger needle is inserted. This needle contains a catheter/guide wire and is fluoroscopically (with a camera) guided to prevent nerve damage (Boswell et al, 2007). Once the catheter is in the right place, a series of medications (omnipaque, hypertonic saline, hyaluronidase, local anesthetics and steroids) are injected near the nerve root. These medications help to eliminate the inflammation and dissolve scar tissue. Usually, an adhesiolysis treatment is completed in less than an hour. However, it can also be performed over a two-day period if a second immediate injection is needed. After a brief recovery period, the patient is allowed to return home. Patients who undergo this procedure may feel some discomfort as the numbing anesthetic wears off near the injection site, and even fewer, experience a heavy feeling in their legs which wears off within a couple of hours.

Benefits:

The scar tissue causes the nerve roots to be fixed into one position, often causing deep and relentless pain, and preventing pain medications from even reaching the site. This makes adhesiolysis the best possible treatment for this specific kind of pain. It dissolves the tissue, and therefore, often eliminates the problem and even further need for oral pain medications (Trescot et al, 2007). Adhesiolysis has been proven to be the best treatment after epidural steroid injections and other traditional pain-blocking attempts have failed (Boswellet et al, 2007).  In the short term, adhesiolysis, has shown great success and moderate success in long term pain magagement situations. In a recent study, it was revealed that 100% of patients experienced relief in the first three months after treatment (Bosewell et al, 2007). An additional study showed 93% pain relief in 14 patients who underwent adhesiolysis procedures, and 93%, experienced immediate relief. This number decreased to 71% within one month, and to 57% at the three month mark, 43% at six months and 21% at one year (Hammer et al, 2001). While the short term success rate is very high, more than one treatment is needed to sustain the positive pain management results long-term (Manchikanti et al, 2000).

Risks:

In general, adhesiolysis is considered a safe procedure, but all medical procedures have their risks and side effects. A patient scheduled for an adhesiolysis procedure should not be on blood thinning medications, pregnant, allergic to any of the anesthetics used or have an active infection (Hammer et al, 2001).

Some additional, but rare, risks are:

• Spinal cord compression.
• Mild pain at the injection site.
• Catheter shearing.
• Excessive intraspinal and intracranial pressures.
• Epidural hematoma.
• Bleeding at the injection site.
• Infection.
• Visual deficiencies and even blindness (Boswell et al, 2007).

Outcomes:

The most common form of spinal pain, low back pain, affects 15% to 39% of the population. Scar tissue is often the culprit. Adhesiolysis is the best option to treat scar tissue, as it is a safe and effective treatment and has a high success rate. Additionally, it is minimally invasive and requires only a short recovery period. And according to a recent study, patients that have undergone adhesiolysis treatment reported an improved emotional and physical state and were less dependent on pain medications (Manchikanti et al, 2000).

Resources:

• Belozer, M., Wang, G. (2004). Epidural Adhesiolysis for the Treatment of Back Pain. Retrieved from
• Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB, Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L. (2007). Interventional Techniques: Evidence-based Practice Guidelines in the Management of Chronic Spinal Pain. Pain Physician. Retrieved from
• Cooper, Ryan. (2011). Disc Tear (Annular Tear). Spine Doctor. Retrieved from
• Hammer
• Hammer, M. Doleys, D., Chung, O. (2001) Transforaminal Ventral Epidural Adhesiolysis. Pain Physician. Retrieved from
• Manchikanti, L., Bakhit, Cyrus. (2000). Percutaneous Lysis of Epidural Adhesions. Pain Physician. Retrieved from
• Trescot AM, Chopra P, Abdi S, Datta S, Schultz DM. (2007). Systematic Review of Effectiveness and Complications of Adhesiolysis in the Management of Chronic Spinal Pain: An Update. Pain Physician. Retrieved from

Whiplash pain is a term used to describe the soft tissue injuries of the neck that can occur when the neck moves in an abnormal way. It typically occurs following a motor vehicle accident, but may also occur following any activity which causes forceful movement of the neck, including falls, trauma, and sports-related injuries. The neck is forced to an extreme range of motion, which can cause significant injury to the muscles, ligaments, discs, and facet joints. This injury can lead to pain for many months, or even years.

Common symptoms associated with whiplash include neck pain, swelling along the back of the neck, muscle spasms, and difficulty turning the head from side-to-side or up and down. X-ray and MRIs can help to determine the extent of damage that has occurred. Common treatment following a whiplash injury includes anti-inflammatory medication, muscle relaxers, ice, heat, and rest. Chiropractic therapies, decompression, and massage therapy can also be very useful. Sometimes people experience symptoms following a whiplash injury that require immediate medical care.

Treatment

Most whiplash injuries resolve within six weeks of the initial injury. However, about 40% of people continue to have pain three months following the accident, and about 18% of people will continue to have pain after two years. Common treatment for whiplash injury includes chiropractic treatment, medication management, physical therapy, and injection therapy. Chiropractic adjustments and decompression therapies can help to relieve pain. Some medications used to treat whiplash pain include anti-inflammatories, anti-depressants, neuropathic medications, and occasionally short-term opioid use. Physical therapy helps to strengthen core muscles in the neck, thus reducing pain. Some injections used to treat whiplash injuries include trigger point injections (for muscle spasms), cervical epidural steroid injections (for discogenic pain with radicular symptoms), and medial branch blocks, for pain related to the cervical facet joints.

In a study by Manchicanti, Boswell, and Singh, et al (2004), it was estimated that 55% of all neck pain originates from the facet joints. For these patients, diagnostic and therapeutic facet injections, or medial branch blocks, have been very helpful. Facet injections involve injection of an anesthetic agent along the medial branch nerves of the facet joint. A positive response to this block is a 50% reduction in pain for the first several hours following injection.

Sometimes, a second block will be performed to confirm the diagnosis. If a person has a positive response to the medial branch block, they are considered candidates for radiofrequency ablation of the medial branch nerves. Radiofrequency is a procedure in which destruction of a nerve occurs.  A study by Lord, Barnsley, and Wallace, et al (1996) showed that radiofrequency ablation can provide significant, long-term relief for facetogenic neck pain.

For people who are experiencing chronic neck pain related to a whiplash injury, there are many treatments available. At Arkansas Pain, we offer comprehensive and complementary treatments for people in Ft. Smith, Arkansas. You don’t need to suffer. Contact one of our locations today to schedule an appointment!

References

• Whiplash Pain – PainDoctor.com
• Emedicinehealth (2010). Whiplash. Retrieved on February 24, 2010 from: Lord, S., Barnsley, L., Wallis, B., et al (1996).
• Percutaneous Radio-Frequency Neurotomy for Chronic Cervical Zygapophyseal-Joint Pain. The New England Journal of Medicine 335:1721-1726; 1996 Manchicanti, L., Boswell, M., and V. Singh, et al (2004)
• Prevalence of Facet Joint Pain in Chronic Spinal Pain of Cervical, Thoracic, and Lumbar Regions. BMC Musculoskelet Disorders, 5: 15; 2004.
• Spine Care Medical Group (2006). Whiplash. Retrieved February 24, 2010 from: