Adam Sewell MD

Can Personality Affect Health?

“Researchers have found several negative health outcomes for those who have a Type D personality, including a risk of cardiovascular problems that are three times higher than average.”

Do you become irritated easily, especially when things don’t go your way? Do you have a more laid-back personality or are you prone to anxiety? Most of us are familiar with these personality qualities, whether they’re presented as options in an informal internet survey or as serious questions offered by a therapist. However, such characteristics aren’t solely beneficial to your personality. They can have a significant impact on your health as well. An increasing body of evidence suggests that our personality type has a significant impact on our physical and mental health. Take a peek at some of the results.

Type A

Type A personality traits include being competitive, controlling, hardworking, and meticulous. They can also be violent and domineering. According to specialists, Type A people may be viewed as workaholics who will go to any length to succeed. Studies have connected this personality type to a higher risk of hypertension, high cholesterol, cigarette, and alcohol use, poor food choices, job stress, and social isolation since it was originally characterized more than 60 years ago. The evidence for a link between a Type A personality and a higher risk of cardiovascular disease is equivocal; nonetheless, the anger and animosity that come with it appear to increase the risk of heart problems.

Type B

Type B persons are practically the polar opposite of Type A people, being more laid-back, easygoing, and relaxed than their colleagues. In general, these people are happier, less competitive, less stressed and they love the process more than the result. Type B people may benefit from a variety of factors.  According to research,  they’re less likely to suffer from stress, anxiety, or depression and they may have a higher quality of life as a result. Being excessively relaxed on the other hand can have unfavorable results. If you’re too laid-back, you can take a cavalier attitude toward your health, dismissing the importance of not seeing a doctor.

Type C   

According to psychologists, people with a Type C personality may appear to be as relaxed and laid-back as their Type B counterparts, but this is only a ruse. Type C people on the other hand are more prone to have difficulty expressing emotions, particularly negative ones. They may come across as extremely polite, patient, and eager to please while avoiding conflict in general. On the plus side, if you’re a Type C your drive to please others may motivate you to follow your doctor’s directions such as taking your prescriptions exactly as prescribed. The disadvantage of this personality type is a proclivity for feeling helpless and hopeless, especially when confronted with a significant health issue. This apathy may make you want to abandon treatment rather than take an active position in your treatment.

Type D

A “distressed” personality is another term for it. Consistent negative sensations, such as despair, anxiety, and loneliness as well as trouble expressing emotions characterize Type D. If you’re Type D, you’re likely to be critical of yourself and concentrate on negative thoughts, both of which have been linked to poor health. Type D people, for example, are more likely to suffer from excessive overeating and substance abuse. A variety of detrimental health consequences have been discovered in studies, including a three-fold increased risk of cardiovascular issues. Although roughly 20% of American citizens have a Type D personality, Type D personality traits are found in about half of heart disease patients. According to other studies, those with Type D personality with coronary artery disease have a four-fold increased risk of death compared to people with other personality types.

My Take

Many personality qualities, such as optimism, pessimism, introversion, and extroversion, might have an impact on one’s health. While research reveals that your personality type can have an impact on your well-being, this does not mean that you are doomed to suffer bad consequences. Understanding your overall personality traits can help you get on the road to better health. Once you’ve figured out how you think and respond you may attempt to counteract any negative consequences your personality traits may have on your health. Type A persons, for example, may benefit from relaxing practices such as breathwork, meditation, and yoga whereas Type D people may benefit from focusing on creating a social support network. A therapist or other clinician may be able to assist you if you believe your personality type is negatively affecting your health.

Adam Sewell MD

Eat Globally For Your Health

It’s no secret that the typical American diet is unhealthy: red meat, dairy products, and processed and junk foods are all rich in saturated fat and sugar. To be honest, we’d be better off looking to other civilizations for dietary advice. Traditional Mediterranean, Japanese, and Nordic diets, in particular, have strong links to health and lifespan.

The Mediterranean Diet

The Mediterranean diet has long been hailed as a healthy eating plan by doctors and nutritionists alike. It appeals to me for various reasons: it’s simple to follow, it’s flavorful, and it provides a wide variety of health advantages validated by clinical studies. In reality, I follow many of the general dietary guidelines myself.

The Mediterranean diet combines the traditional cuisine of Spain, Southern France, Italy, Greece, Crete, and portions of the Middle East. It includes everyday essentials like high-quality fresh fruits and vegetables, nuts, legumes, unrefined grains, olive oil, fermented dairy products like yogurt and natural cheese, and fresh seafood. The diet does not completely remove red meat, but it is limited to roughly one meal per month. Similarly, chicken, eggs, and sweets are included, but not regularly; instead, they are consumed once a month. There’s also a small quantity of wine in there.

Eating Globally at home 

You don’t have to completely change your diet. Instead, make a few little modifications to start reaping the health advantages.

  • Go fishing: Most Americans simply don’t eat enough fish high in important omega-3 fatty acids. Because of this, the omega-3 and omega-6 fatty acids ratio tend to be out of balance, which can lead to balance and which can lead to problems from depression to Dyslexia. Try to enjoy two to six servings of fish like wild Alaskan Salmon, herring, and sardines every week. If you don’t want to consume fish, get a fish oil or algae oil supplement with both EPA and DHA and take two to three grams each day.
  • Vegetables should be consumed in large quantities: An anti-inflammatory diet recommends eating four to five portions of veggies per day,  which these three worldwide diets easily do. Don’t be scared to try sea veggies, which can be found in many health-food stores and Asian markets at this time of year.
  • Mind Your Oil: Make extra-virgin olive oil (EVOO) your primary cooking oil; search for an organic EVOO that is of excellent quality. Also, foods like walnuts and freshly ground flaxseeds are high in additional healthful facts. 
  • Swap in soy and mushrooms: Try meals using tofu and sautéed Asian mushrooms as protein to cut down on meat consumption. I recommend eating one to two portions of whole soy meals every day, as well as an endless supply of Asian mushrooms like shiitake, maitake, and oyster mushrooms (just never eat them raw).

The traditional Mediterranean diet isn’t only about food. However, it is part of a whole cultural package that includes regular physical activity (more than most Americans get) as well as maintaining strong social and family bonds, often developed and enjoyed around shared meals.

Studies say: For decades, researchers have noted that some Mediterranean countries seem to have lower heart disease and cancer rates. Perhaps one of the most important studies to address the diet’s impact on heart health was the 2013  PREDIMED study.

It was shown that a Mediterranean diet can reduce the risk of heart attack and stroke by around 30% and mortality from cardiovascular disease, even in individuals at high risk. The report was initially published in the New England Journal of Medicine, but it was withdrawn last summer due to mistakes that compromised data regarding a quarter of the trial’s participants.

Although the retraction made headlines, it’s worth noting that the journal also released a corrected version of the study with reanalyzed data that came to the same results.  Older research backs up these findings. In 2003, researchers discovered that those who eat a Mediterranean-style diet have a 33 percent reduced risk of heart disease and  24 percent lower cancer death rate than those who follow more Western-style diets. According to research, there is a lower death rate from all causes.

Other studies have found that persons who eat a Mediterranean diet have improved cognitive function and a lower risk of dementia, including Alzheimer’s disease. In addition, the diet looks to be advantageous to postmenopausal women’s bones and muscles. Brazilian researchers found earlier this year that women who followed the Mediterranean diet most carefully had higher bone mineral density assessed at the lumbar spine and more muscle mass than women who followed the diet less strictly. Whether the subjects had previously used hormone replacement treatment, smoked, or were physically active had no bearing on the findings. Diabetes and Parkinson’s disease are also decreased in people who eat a Mediterranean diet.

The Traditional Japanese Diet

I’ve visited Japan several times and have a deep affection for the country’s culture and traditional cuisine and beverages. Although I eat a Mediterranean diet, I eat a lot of Japanese foods like shiitake mushrooms and tofu meals, and I drink green tea every day—either sencha, the traditional Japanese green tea, or matcha, the powdered form used in the Japanese tea ceremony, which is gaining popularity in the United States.

The Basics 

Fish, entire soy foods (edamame, soy milk, tofu), Asian mushrooms, rice, a wide variety of fresh vegetables (including sea vegetables), fruit, fermented foods like miso and pickles, and very little meat or dairy are all part of the traditional Japanese diet. It also has low sugar content. One disadvantage is the high sodium content. As previously said, green tea is a popular beverage. 

In comparison to the West, the Japanese consume smaller portions and eat more deliberately. The average Japanese individual consumes 25% fewer calories per day than the average American. As it is generally served tastefully on ornamental plates and platters, Japanese food is a superb example of “eating with your eyes.”

Studies say

Numerous studies have been conducted to demonstrate the health benefits of the various foods found in the Japanese diet. Compounds found in shiitake mushrooms, for example, have been shown to lower cholesterol, improve immunological function, and reduce the incidence of numerous types of cancer. Green tea’s primary antioxidant ingredient, EGCG, has been shown in test tubes to kill prostate cancer cells. Whole soy has also been demonstrated to lower cholesterol levels and may lessen the incidence of breast cancer.

However, studies have looked at the diet and found that it is heart-friendly. In one study, middle-aged Japanese men who ate a more Westernized Japanese diet were taught about traditional Japanese cuisine and told to follow traditional eating guidelines for six weeks. At the end of the study, 91 percent of patients had improved in more than one cardiovascular risk indicator. Bodyweight, LDL (“bad”) cholesterol, and triglyceride levels all considerably decreased. (April 1, 2017; Journal of Atherosclerosis and Thrombosis) The diet also appears to reduce the risk of cancer according to researchers. According to researchers, it could be due to the Japanese eating a lot of cruciferous vegetables which contain powerful anticancer chemicals.

Japanese women and men, on average, live longer and are healthier than individuals in any other country. They may expect to live to be 87 and 80 years old respectively compared to 81 and 76 for Americans; they can also expect to live an average of 75 years without handicap. Diet has a factor to play in this longevity. According to a recent study, people who followed Traditional Japanese dietary standards the most carefully had a 15% lower mortality risk than those who didn’t.

“Countless studies have highlighted the health benefits of the individual foods prominent in the Japanese diet. For example, compounds in shiitake mushrooms may lower cholesterol, enhance immune function and reduce the risk of several types of cancer.”

The Nordic Diet

Until recently, Nordic eating didn’t get nearly as much attention as the other two diets. This year, it was all over the news, with some even proclaiming it to be the healthiest country on the planet. While I wouldn’t go so far as to say it’s the healthiest of all diets, it does provide a variety of healthy options. 

The Basics 

The diet is influenced by Norwegian, Danish, Swedish, Finnish, and Icelandic cuisines and shares many similarities with the Mediterranean diet. Vegetables and fruits (particularly root vegetables and berries), legumes, nuts and seeds, whole grains including rye, barley, and oats, and fermented foods are all included. It emphasizes fatty seafood like salmon, mackerel, and herring while avoiding processed meals and high-fat red meats like sausage and bacon. When possible, many people in the Nordic countries choose organic and seasonal vegetables, consume more wild or foraged meals, and select high-quality meats that encourage animal welfare. 

The Nordic diet differs significantly from the Mediterranean diet in that it emphasizes canola oil over olive oil. Rapeseed, a cabbage family plant, is used to make canola oil. Even though it is mostly monounsaturated fat and hence healthier than saturated or polyunsaturated oils, I do not advocate it in place of olive oil. Canola oil, unlike extra-virgin olive oil, lacks the antioxidant polyphenols that protect against heart disease.

Studies say

The Nordic diet has been found to help reduce the risk of cardiovascular disease, despite its preference for canola oil over olive oil though not to the same amount as the Mediterranean diet. According to one study, eating a healthy diet protects against metabolic syndrome, a group of symptoms (such as elevated cholesterol, triglycerides, and blood pressure) that raises the risk of heart disease and diabetes. The diet, according to the World Health Organization, may also lower the risk of cancer.

Some of the diet’s broad health benefits may be related to its capacity to aid weight loss. It was discovered to help modulate the expression of genes linked to inflammation in a study conducted by the University of Eastern Finland. Obesity, like many chronic disorders, is linked to inflammation and the advantages extend far beyond physical well-being. Because of their concepts of hygge and lagom, Scandinavians routinely rank among the happiest people on the planet. The former inspires contentment, while the latter supports it by doing things in exactly the appropriate amount rather than restricting yourself or living in excess.

Coming Up In  Self Healing 

Health Trends: Help or Hoax?

Understanding Genetic Risk 

Healthy high-fat foods 

Adam Sewell MD

How to Win Back Your Health

I have been fortunate to have been able to treat thousands of patients in my career.  Looking back at my experiences of having a front row seat to watch and help so many people overcome their health challenges has been a real blessing.   I found three characteristics that are common among patients that have overcome health challenges.

  1. Positive Attitude (Focusing on Positive)

Probably the first and most misunderstood characteristic: Positive attitude.  This idea is commonly misunderstood to be unrealistic.  This is not the case. This is the most common characteristic I have seen in patients who have overcome almost any illness. The patients will acknowledge negative issues and results but they never dwell on the negative.  There is a large body of research from Carol Dweck, PhD on the importance of a “growth mindset” in the areas of education and learning.  Ms. Dweck set out to find why some children were able to learn faster than their peers.  What she found was that the children that were considered “gifted” and learned faster had one thing in common, they all had a certain set of beliefs.  These beliefs she called the “growth mindset.”  These beliefs were most evident when the children came across obstacles.  For example, when the student failed to solve a problem correctly those students with the growth mindset would almost immediately attempt to solve the problem again.  Often when faced with an incorrect answer they would say statements such as “it’s okay I will love to figure out this problem” and “I love challenges”.  The growth mindset students would also be forward thinking and anticipate success with beliefs such as “ I am going to really love it when I get this problem correct” and “I can figure this out, I love challenges”  This set of beliefs was the only thing that separated the “gifted” students from the average students.  How can you apply the “growth mindset” to your life? How will looking at the world through the growth mindset lens change your thoughts and therefore your actions?

  1. Taking Responsibility.

When we give away responsibility we give away our power.  Nearly all patients that heal and recover completely have always taken their healthcare as their responsibility.  While they consult physicians and other healthcare professionals they take responsibility for getting better.  When recommended a treatment they read about it and prepared themselves.  Often I could tell the success of a treatment prior to the treatment because the patients would often be so focused on getting better.  The patients would often come to a new patient appointment with many informed questions and would take notes.  If there was an obstacle to their care such as an insurance company they would work on their end to handle it.  If there was a problem with scheduling they would figure it out.  What was very interesting is that by taking responsibility it would empower the patient and in many cases this would correlate with a faster rate of recovery.  How often do we accidentally give our power to someone else?  How can we take our power back by taking responsibility?

  1. Willing to Try

The final characteristic common to patients who were able to win back their health was a willingness to try.  All too often, when we face a challenge we can default to blame or a “why me” attitude and give up.  Those patients that overcome a health challenge have a willingness to try different treatments and therapies.  Not all therapies worked and many did not work right away.  It is the ability to persist and keep trying until the correct solution is discovered that makes the difference between failure and success.  What I found most about patients who overcame illness was that by taking initiative and being willing to try new treatments this would produce results.  When these results were analyzed it would provide information that would often lead to a solution.  Without the initial attempt and failure, we would have never had the information to find the solution.  The willingness to try was directly linked to the solution the patient was seeking.  How willing are you to try new things?  How willing are you to think “outside of the box”.  I think this quote by Tobias Wolfe says it well — “We are made to persist .. That’s how we find out who we are”

Adam Sewell MD


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

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

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

Other Conditions commonly treated with Vertebroplasty include:

  • Osteoporosis
  • Bone cancer metastasis
  • Injury or Trauma


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

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


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

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


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

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

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

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


Fracture Prevention

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

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

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

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


  1. Vertebroplasty –
  2. Vertebroplasty and Kyphoplasty –
  3. Vertebral height restoration in osteoporotic compression fractures: kyphoplasty balloon tamp is superior to postural correction alone. Shindle MK, Gardner MJ, Koob J, Bukata S, Cabin JA, Lane JM. Osteoporosis Int. 2006 Dec;17(12):1815- 9. Epub 2006 Sep 16 PMID: 16983458.
  4. Balloon kyphoplasty in the therapy of vertebral fractures] DaFonseca K, Baier M, Grafe I, Libicher M, Noeldge G, Kasperk C, Meeder PJ. Orthopade. 2006 Oct;35(10):1101-9 PMID: 17195295.
  5. 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.
  6. American Society of Interventional Pain Physicians. Pain Physician. 2007 Jan;10(1):7-111 PMID: 17256025 Vertebroplasty for osteoporotic fractures with spinal canal compromise Hiwatashi A, Westesson PL. AJNR Am J Neuroradiol. 2007 Apr;28(4):690-2 PMID: 17416822
  7. Treatment of painful osteoporotic or traumatic vertebral compression fractures by percutaneous vertebral augmentation procedures: a nonrandomized comparison between vertebroplasty and kyphoplasty. De Negri P, Tirri T, Paternoster G, Modano P. Clin J Pain. 2007 Jun;23(5):425-30 PMID: 17515741.
  8. Vertebral Compression Fractures in the Elderly. Old, Jerry; Calvert, Michelle. American Family Physician. January 1, 2004
Adam Sewell MD


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

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

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


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


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

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


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


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

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

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


Adam Sewell MD


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

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

The Superior Hypogastric Plexus Block can Halt Pain originating from:

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

Pain secondary to:

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


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


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

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

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

A successful block is marked by profound pain relief.

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

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

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


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


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

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

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

Journal Articles:

  1. Cariati M, De Martini G, Pretolesi F, Roy MT. CT-guided superior hypogastric plexus block. J Comput Assist Tomogr. 2002 May-Jun;26(3):428-31.
  2. Chan WS, Peh WC, Ng KF, Tsui SL, Yang JC. Computed tomography scan-guided neurolytic superior hypogastric block complicated by somatic nerve damage in a severely kyphoscoliotic patient. Anesthesiology. 1997 Jun;86(6):1429-30.
  3. De Leon-Casasola O, Molloy RE, Lema M, Neurolytic visceral sympathetic blocks. In Benzon HT, Raja S, Molloy RE, et al (eds): Essentials of Pain Medicine and Regional Anesthesia, 2nd ed. New York, Elsevier-Churchill Livingston, 2005, pp 542-549.
  4. De Leon-Casasola OA, Kent E, Lema MJ. Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer. Pain. 1993 Aug;54(2):145-51.
  5. Dooley J, Beadles C, Ho KY, Sair F, Gray-Leithe L, Huh B. Computed tomography-guided bilateral transdiscal superior hypogastric plexus neurolysis. Pain Med. 2008 Apr;9(3):345-7.
  6. Erdine S, Yucel A, Celik M, Talu GK. Transdiscal approach for hypogastric plexus block. Reg Anesth Pain Med. 2003 Jul-Aug;28(4):304-8.
  7. Gamal G, Helaly M, Labib YM. Superior hypogastric block: transdiscal versus classic posterior approach in pelvic cancer pain. Clin J Pain. 2006 Jul-Aug;22(6):544-7.
  8. Kanazi GE, Perkins FM, Thakur R, Dotson E. New technique for superior hypogastric plexus block. Reg Anesth Pain Med. 1999 Sep-Oct;24(5):473-6.
  9. Michalek P, Dutka J. Computed tomography-guided anterior approach to the superior hypogastric plexus for noncancer pelvic pain: a report of two cases. Clin J Pain. 2005 Nov-Dec;21(6):553-6.
  10. Mishra S, Bhatnagar S, Gupta D, Thulkar S. Anterior ultrasound-guided superior hypogastric plexus neurolysis in pelvic cancer pain. Anaesth Intensive Care. 2008 Sep;36(5):732-5.
  11. Plancarte-Sanchez R, Guajardo-Rosas J, Guillen-Nuarez R. Superior hypogastric plexus block and ganglion impar. Techniques in Regional Anesthesia and Pain Management. 2005 April: 9(2):86-90.
  12. Plancarte R, de Leon-Casasola OA, El-Helaly M, Allende S, Lema MJ. Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer. Reg Anesth. 1997 Nov-Dec;22(6):562-8.
  13. Plancarte R, Amescua C, Patt RB, Aldrete JA. Superior hypogastric plexus block for pelvic cancer pain. Anesthesiology. 1990 Aug;73(2):236-9.
  14. Rosenberg SK, Tewari R, Boswell MV, Thompson GA, Seftel AD. Superior hypogastric plexus block successfully treats severe penile pain after transurethral resection of the prostate. Reg Anesth Pain Med. 1998 Nov-Dec;23(6):618-20.
  15. Turker G, Basagan-Mogol E, Gurbet A, Ozturk C, Uckunkaya N, Sahin S. A new technique for superior hypogastric plexus block: the posteromedian transdiscal approach. Tohoku J Exp Med. 2005 Jul;206(3):277-81.
  16. Waldman SD, Wilson WL, Kreps RD. Superior hypogastric plexus block using a single needle and computed tomography guidance: description of a modified technique. Reg Anesth. 1991 Sep-Oct;16(5):286-7.
  17. Wechsler RJ, Maurer PM, Halpern EJ, Frank ED. Superior hypogastric plexus block for chronic pelvic pain in the presence of endometriosis: CT techniques and results. July 1995 Radiology, 196, 103-106.
  18. Yeo SN, Chong JL. A case report on the treatment of intractable anal pain from metastatic carcinoma of the cervix. Ann Acad Med Singapore. 2001 Nov;30(6):632-5.
Adam Sewell MD


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

Pain Syndromes

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

Vascular Insufficiency in Upper Extremities

  • Arterial insufficiency
  • Raynaud’s phenomenon
  • Scleroderma


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


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


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

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

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


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


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

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

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


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

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

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

Journal Articles:

  1. Stellate Ganglion Block – com
  2. Chester M, Hammond C, Leach A. Long-term benefits of stellate ganglion block in severe chronic refractory angina. Pain. 2000 Jul;87(1):103-5.
  3. Elias M. Continuous cervico-thoracic sympathetic ganglion block: therapeutic modality for arterial insufficiency of the arm of a neonate. Middle East J Anesthesiol. 2001 Oct;16(3):359-63.
  4. Gofeld M, Bhatia A, Abbas S, Ganapathy S, Johnson M. Development and validation of a new technique for ultrasound-guided stellate ganglion block. Reg Anesth Pain Med. 2009 Sep-Oct;34(5):475-9.
  5. Klyscz T, Jünger M, Meyer H, Rassner G. Improvement of acral circulation in a patient with systemic sclerosis with stellate blocks. Vasa. 1998 Feb;27(1):39-42.
  6. Lagade M, Poppers PJ: Stellate ganglion block: A therapeutic modality for arterial insufficiency of the arm in premature infants. Anesthesiology. 1984;61:203-204.
  7. Lipov EG, Joshi JR, Sanders S, Slavin KV. Lipov EG, Joshi JR, Sanders S, Slavin KV. A unifying theory linking the prolonged efficacy of the stellate ganglion block for the treatment of chronic regional pain syndrome (CRPS), hot flashes, and posttraumatic stress disorder (PTSD). Med Hypotheses. 2009 Jun;72(6):657-61. Epub 2009 Feb 23.
  8. Lipov EG, Joshi JR, Lipov S, Sanders SE, Siroko MK. Cervical sympathetic blockade in a patient with post-traumatic stress disorder: a case report. Ann Clin Psychiatry. 2008 Oct-Dec;20(4):227-8.
  9. Lipov EG, Joshi JR, Sanders S, Wilcox K, Lipov S, Xie H, Maganini R, Slavin K. Effectsof stellate-ganglion block on hot flushes and night awakenings in survivors of breast cancer: a pilot study. Lancet Oncol. 2008 Jun;9(6):523-32. Epub 2008 May 15.
  10. Marples, IL, Atkin RE. Stellate ganglion block. Pain Rev 2001; 8: 3-11.
  11. Moore R, Groves D, Hammond C, Leach A, Chester MR. Temporary sympathectomy in the treatment of chronic refractory angina. J Pain Symptom Manage. 2005 Aug;30(2):183-91.
  12. Narouze S, Vydyanathan A, Patel N. Pain Physician. Ultrasound-guided stellate ganglion block successfully prevented esophageal puncture. Pain Physician. 2007 Nov;10(6):747-52.
  13. Shibata Y, Fujiwara Y, Komatsu T. A new approach of ultrasound-guided stellate ganglion block. Anesth Analg. 2007 Aug;105(2):550-1.
  14. Stanik-Hutt JA. Management options for angina refractory to maximal medical and surgical interventions. AACN Clin Issues. 2005 Jul-Sep;16(3):320-32.
Adam Sewell MD


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

Conditions that are treated with SCS include:

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


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


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


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


Just as with any surgical procedure, possible risks include:

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


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

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

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


Adam Sewell MD


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

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


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


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


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


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


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


Adam Sewell MD


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


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

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

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

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

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

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

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

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

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


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


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


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

How We Can Help You

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

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