Services - Types of Procedures

 

 

Trigger Point Injections

Trigger point injections are a specific type of local injection that your physician can use to treat local areas of muscle pain and spasm. Trigger points are commonly defined as areas of taut muscle bands or palpable knots of the muscle which are painful. Often these trigger points can cause localized pain and even referred pain patterns that can mimic the pain people feel from nerves being pinched in their neck or low back. Your physician may choose to give a trial of trigger point injections to see if they can help these areas of local muscle tenderness to relieve pain.

Common medications used in trigger point injections can include local anesthetic, normal saline and small doses of steroid medications. Many studies have been done on trigger point injections and their efficacy utilizing these different types of medications. Research has demonstrated that just the local placement of the needle can help with muscle spasms, similar to acupuncture. The volume of the solution can affect the muscle spasm as well, and often times the injections of normal saline can be helpful for pain.

Utilizing a local anesthetic to numb the region of pain can help break the cycle of pain. A small dose of steroid medication at the site can help decrease inflammation of muscles as well.

Your physician may choose a combination of the above medications, depending on your symptoms and response. Trigger point injections are sometimes repeated in a series, depending on the results of the injections and the relief of pain that they provide. Often times, more than one injection is performed on various sites, depending on the physician's examination findings of trigger points.

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What is Botulinum Toxin Type A?

Botulinum toxin is a chemical from the organism that causes botulism. This sounds alarming but, in actuality, we would need to use 3,000 times as much as we do in order to give you botulism. Botulinum toxin forces muscles to relax by preventing the release of acetylcholine from nerve endings. It is this acetylcholine which activates the muscle, causing it to contract or tighten up. Without acetylcholine, the muscle cannot stay tight. Botulinum toxin injections are typically performed for muscle knots or "trigger points." The botulinum toxin does not actually begin to work for one to two weeks, but many patients feel better in a few days just from the needle breaking up the muscle knot. Trigger points are thought to be very tight bands in muscles. When other measures, such as trigger point injections, fail to produce relaxation in the muscle knot, we consider botulinum toxin injections.

When is it time to do botulinum toxin injection?

Naturally, before botulinum toxin injections are tried, we always try to find what is causing the muscle knots. This can be anything from inflammation inside the spinal column to a disc problem, or serious illness that might cause muscle knots or trigger points. This needs to be investigated and ruled out before botulinum trigger point injections are performed. Very frequently after various traumas or injuries, people develop painful muscle knots, often in their shoulders, neck or under their scapulae. Trigger points can also develop in the low back, buttocks and thighs. Trigger points can occur in the upper arms and forearms. When a patient gets good relief from their muscle knot pain with a simple trigger point injection of numbing medicine, but the pain returns, that is felt to be an indication for botulinum toxin injection.

How is the injection performed?

Botulinum toxin injections are usually done in the office, similar to trigger point injections. The area over the painful trigger point is sterilely cleaned and a small gauge needle is used to inject the medicine into the trigger point.

What are the risks of botulinum toxin injection?

Happily, the risks of botulinum toxin are few. Typically, there are no real side effects from the botulinum toxin. It tends to act locally where it is injected and usually does not cause body-wide side effects. One effect of the botulinum toxin is that it can produce weakness in the muscle into which it is injected. This is usually not a problem. If used frequently, a patient can develop antibodies to the botulinum toxin and it will begin to lose its effectiveness. We also warn patients about bleeding, infection, and drug reaction, but these problems are extremely rare.

How long does a botulinum toxin injection last?

Botulinum toxin injections are relatively new, and all of the studies to give precise answers to these questions have not been performed. The effect of botulinum toxin on the acetylcholine produced by the nerve ending typically wears off in three to four months. Interestingly, in many patients we have seen the effect of the injections last considerably longer; however, we do not have adequate information to predict how long the injection will last if it is effective. Trigger points, or muscle knots, treated with botulinum toxin injection may return and repeat injection may be required. It would probably not be worth repeating the injection if it does not last at least three to four months.

Is the injection painful?

Yes and no. Botulinum toxin injections usually are not as painful as injections with numbing medicine. The muscle knot, however, can be very sensitive. For patients who have benefited from botulinum toxin injection, they typically report the pain of injection is worth the relief.

What will happen during and after the procedure?

You will probably be put into a gown and seated or positioned lying down. The trigger point areas to be injected are marked with a pen and then carefully cleaned. At that point, a cold spray is used to numb the skin, and the botulinum toxin mixed with normal saline, with or without numbing medicine, is injected. The whole process takes a few minutes. The injection site is bandaged and the patient is instructed to take it easy for the rest of the day, and to place ice or a cold pack on the injected areas for a few minutes several times a day for a day or two. A return office visit appointment will be made in four to eight weeks for follow up. The patient is encouraged to call at any time if they have any problems.

Summary

Botulinum toxin injections have proven to be a valuable tool in the battle against pain from painful muscle knots or trigger points. Typically, botulinum toxin injections are not performed unless the patient has already responded favorably, but only temporarily, to regular trigger point injections with numbing medicine. Before botulinum toxin injections are performed, every effort should be made to understand the cause of the muscle knots or trigger points, and any serious illness should be dealt with first. The main side effects of botulinum toxin are weakness and the development of antibodies if used excessively.

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What is a Cervical Epidural Injection?

What is the epidural space?

The membrane that covers the spinal cord and nerve roots in your neck is called the dura membrane. The space surrounding the dura is epidural space in your neck. Inflammation of the nerve roots in the neck may cause pain in the arms and shoulders due to irritation from a damaged (protruding/herniated) disc or from contact with the bony structure of the spine (spinal stenosis) in some way.

What is an epidural and why is it helpful?

An epidural injection places anti-inflammatory medicine into the epidural space to decrease inflammation of the nerve roots, hopefully reducing the pain in your neck, shoulders and arms. The epidural injection may help the injury to heal by reducing inflammation. It may provide permanent relief or provide a period of pain relief for several months while the injury/cause of your pain is healing.

What will happen to me during the procedure?

An IV will be started so that relaxation medication can be given. You will be placed lying on your stomach and positioned in such a way that your doctor can best visualize your neck using X-ray guidance. The skin on the back of your neck will be scrubbed with a cleaning solution. Next, the physician will numb a small area of skin with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, your doctor will direct a small needle using X-ray guidance into the epidural space. A small amount of contrast (dye) is then injected to ensure proper needle position in the epidural space. Then, a small mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) will be injected.

What will happen after the procedure?

You will go back to the recovery area, where you will be monitored for 30 - 60 minutes. You will also be given a follow-up appointment for the Clinic or a repeat block if indicated. You will not be able to drive the day of your procedure. Your arm may feel weak or numb for a few hours.

General Pre/Post Instructions

You should have nothing to eat for seven hours prior to your procedure. Clear liquids can be taken up to four hours prior to your procedure. Please take your routine medications (i.e., high blood pressure and diabetic medications) with a sip of water at your usual time. If you are on Coumadin, Heparin, Plavix, or any other blood thinners you must notify the office so the timing of these medications can be explained. For your own safety, if you do not follow the above instructions your procedure may be cancelled. A driver must accompany you and be responsible for getting you home. No driving is allowed the day of the procedure. You may return to your normal activities the day after the procedure, including returning to work.

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What is a Thoracic Epidural Injection?

What is the epidural space?

The membrane that covers the spinal cord and nerve roots in your spine is called the dura membrane. The space surrounding the dura is the epidural space. Nerves travel through the epidural space to your mid back and along the ribs. Inflammation of these nerve roots may cause pain in these regions due to irritation from a damaged disc or from contact in some way with the bony structure of the spine.

What is an epidural and why is it helpful?

An epidural injection places anti-inflammatory medicine into the epidural space to decrease inflammation of the nerve roots, hopefully reducing the pain in your mid back or around your rib cage. The epidural injection may help the injury to heal by reducing inflammation. It may provide permanent relief or provide a period of pain relief for several months while the injury or cause of your pain is healing.

What will happen to me during the procedure?

An IV will be started so that relaxation medication can be given. You will be placed lying on your stomach and positioned in such a way that your doctor can best visualize your upper back using X-ray guidance. The skin on your upper back will be scrubbed with a cleaning solution. Next, the physician will numb a small area of skin with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, your doctor will direct a small needle using X-ray guidance into the epidural space. A small amount of contrast (dye) is then injected to ensure proper needle position in the epidural space. Then, a small mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) will be injected.

What will happen after the procedure?

You will go back to the recovery area, where you will be monitored for 30 - 60 minutes. You will then record the relief you experience during the next week on a post-injection evaluation sheet ("pain diary"). This will be given to you when you are released to go home. You will also be given a follow-up appointment for a repeat block if indicated. You will not be able to drive the day of your procedure. Your back may feel weak or numb for a few hours.

General Pre/Post Instructions

You should have nothing to eat for seven hours prior to your procedure. Clear liquids can be taken up to four hours prior to your procedure. Please take your routine medications (i.e. high blood pressure and diabetic medications) with a sip of water at your usual time. If you are on Coumadin, Heparin, Plavix, or any other blood thinners you must notify the office so the timing of these medications can be explained. For your own safety, if you do not follow the above instructions your procedure may be cancelled. A driver must accompany you and be responsible for getting you home. No driving is allowed the day of the procedure. You may return to your normal activities the day after the procedure, including returning to work.

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What is a Lumbar Epidural Injection?

What is the epidural space?

The membrane that covers the spinal cord and nerve roots in your spine is called the dura membrane. The space surrounding the dura is the epidural space. Nerves travel through the epidural space to your back and into your legs. Inflammation of these nerve roots may cause pain in these regions due to irritation from a damaged disc (disc protrusion/herniation) or from contact in some way with the bony structure of the spine (spinal stenosis).

What is an epidural and why is it helpful?

An epidural injection places anti-inflammatory medicine into the epidural space to decrease inflammation of the nerve roots, hopefully reducing the pain in your back or legs. The epidural injection may help the injury to heal by reducing inflammation. It may provide permanent relief, or provide a period of pain relief for several months while the injury or cause of your pain is healing.

What will happen to me during the procedure?

An IV will be started so that relaxation medication can be given. You will be placed lying on your stomach on the X-ray table and positioned in such a way that your doctor can best visualize your back using X-ray guidance. The skin on your back will be scrubbed using a cleaning solution. Next, the physician will numb a small area of skin on your low back with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, your doctor will direct a small needle using X-ray guidance into the epidural space. A small amount of contrast (dye) is then injected to ensure proper needle position in the epidural space. Then, a mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) will be injected.

What will happen after the procedure?

You will go back to the recovery area, where you will be monitored for 30-60 minutes. You will be given a follow-up appointment for the Clinic or a repeat block if indicated. You will not be able to drive the day of your procedure. Your legs may feel weak or numb for a few hours.

General Pre/Post Instructions

You should have nothing to eat for seven hours prior to your procedure. Clear liquids can be taken up to four hours prior to your procedure. Please take your routine medications (i.e., high blood pressure and diabetic medications) with a sip of water at your usual time. If you are on Coumadin, Heparin, Plavix, or any other blood thinners you must notify the office so the timing of these medications can be explained. For your own safety, if you do not follow the above instructions your procedure may be cancelled. A driver must accompany you and be responsible for getting you home. No driving is allowed the day of the procedure. You may return to your normal activities the day after the procedure, including returning to work.

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What is a Sacroiliac Joint Injection?

The sacroiliac joint is a large joint in the region of the low back and buttocks where the pelvis actually joins with the spine. If the joints become painful they may cause pain in the low back, buttocks, abdomen, groin or legs. A sacroiliac joint injection serves several purposes. First, by placing numbing medicine into the joint, the amount of immediate relief experienced will help confirm or deny the joint as a source of pain. Additionally, the temporary relief of the numbing medicine may better allow a chiropractor or physical therapist to treat that joint. Also, time release cortisone (steroid) will help to reduce any inflammation that may exist within the joint(s).

What happens during the procedure?

You are placed on the X-ray table on your stomach in such a way that the physician can best visualize these joints in the back using X-ray guidance. The skin on the low back is scrubbed using two types of sterile scrub (soap). Next, the physician numbs a small area of skin with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, the physician directs a very small needle, using X-ray guidance into the joint. A small amount of contrast (dye) is injected to ensure proper needle position inside the joint space. Then, a small mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) is injected. One or several joints may be injected depending, on location of your usual pain.

What happens after the procedure?

Immediately after the procedure, you will walk around and try to imitate something that would normally bring about your usual pain. You are then asked to report the percentage of pain relief and record the relief experienced during the next week on a post-injection evaluation sheet ("pain diary"). This will be given to you when you are discharged to gohome. Your leg(s) may feel numb for a few hours. This is fairly uncommon, but does occasionally happen. You may be referred to a chiropractor or physical therapist immediately after the injection(s) while the numbing medicine is still working for manipulation or massage. If you get good relief but of short duration, you may be a candidate for radiofrequency lesioning (RFR).

General Pre/Post Instructions

You should have nothing to eat for seven hours prior to your procedure. Clear liquids can be taken up to four hours prior to your procedure. Please take your routine medications (i.e., high blood pressure and diabetic medications) with a sip of water at your usual time. If you are on Coumadin, Heparin, Plavix, or any other blood thinners you must notify the office so the timing of these medications can be explained. For your own safety, if you do not follow the above instructions your procedure may be cancelled. A driver must accompany you and be responsible for getting you home. No driving is allowed the day of the procedure. You may return to your normal activities the day after the procedure, including returning to work.

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What is a Facet Block?

What are the medial branch nerves and why are medial branch blocks helpful?

Medial branch nerves are the very small nerve branches that communicate pain caused by the facet joints in the spine. These nerves do not control any muscles or sensation in the arms or legs. They are located along a bony groove in the low back and neck and over a bone in the mid back. If this procedure has been scheduled, there is strong evidence to suspect that the facet joints are the source of your pain. Therefore, benefit may be obtained from having these medial branch nerves blocked with an anesthetic to see if a more permanent way of blocking these nerves would provide pain relief long term. Blocking these medial branch nerves temporarily stops the transmission of pain signals from the joints to the brain.

What happens during the procedure?

An IV may be started, to provide relaxation medication. You will be placed on the X-ray table and positioned in such a way that the physician can best visualize the bony areas where the medial branch nerves pass, using X-ray guidance. The skin is scrubbed with a cleaning solution. Next, the physician numbs a small area of skin with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, the physician directs a very small needle, using X-ray guidance near the specific nerve being tested. A small amount of contrast (dye) is injected to ensure proper needle position. Then, a small mixture of numbing medicine (anesthetic) is injected. This usually does not provoke your usual pain. The injection will be repeated at several (usually 3-4) levels.

What happens after the procedure?

You will be observed in the recovery room for 30 - 60 minutes. There is unlikely to be much discomfort. You should start feeling some relief in about 24 - 72 hours. Keep track of the amount of pain relief and duration. If successful you may be a candidate for radiofrequency lesioning (RFR). You will be scheduled to follow up with your physician in the Pain Clinic in 1 - 2 weeks to discuss results of the procedure. You will not be able to drive the day of your procedure. The arm(s), chest wall, or leg(s) may feel weak or numb for a few hours.

General Pre/Post Instructions

You should have nothing to eat for seven hours prior to your procedure. Clear liquids can be taken up to four hours prior to your procedure. Please take your routine medications (i.e. high blood pressure and diabetic medications) with a sip of water at your usual time. If you are on Coumadin, Heparin, Plavix, or any other blood thinners you must notify the office so the timing of these medications can be explained. For your own safety, if you do not follow the above instructions your procedure may be cancelled. A driver must accompany you and be responsible for getting you home. No driving is allowed the day of the procedure. You may return to your normal activities the day after the procedure, including returning to work.

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What is Biacuplasty?

This procedure is designed to reduce chronic back pain caused by the intervertebral discs. Disc biacuplasty is an alternative approach to managing discogenic back pain and for many people it may be an alternative to invasive spinal surgery.

How is the procedure performed?

Typically, a patient undergoing the disc biacuplasty procedure will lie in the prone position on a procedural table. Pillows may be used to flatten the lordosis of the lumbar spine, especially to facilitate access to the L5-S1 disc. Equipment will be used to monitor blood pressure, heart rate, heart rhythm, and blood oxygen levels.

A sedative is administered in order to relax the patient. This may include IV sedation or other methods depending on the physician or institutional preference. The patient must remain at a level of consciousness where they are able to verbally communicate with the physician. The site is prepared in the lumbar area with an appropriate sterile technique. A sterile field must be maintained throughout the procedure. A local anesthetic is injected subcutaneously to the two (2) areas where TransDiscal™ introducer needles will be inserted, and down the approximate path the introducers will take. The introducer needles are inserted percutaneously and navigated to the target intervertebral disc using fluoroscopic guidance. Physiologically-safe radiofrequency energy is passed between the two probes, lesioning the nociceptive fibers in the disc. The patient is held for observation and recovery from the effects of the sedative.

Who is eligible for this procedure?

The best candidate for disc biacuplasty will have a history of back pain lasting at least six months with minimal improvement from a comprehensive conservative program. People who have had prior back surgery on the symptomatic disc are not candidates.

Post-procedure care

After the procedure, biacuplasty patients may experience tenderness and inflammation of the treatment area. This is due to the insertion of the introducers and the generation of heat in the disc. This tenderness should subside within 2 weeks from the procedure date. The patient will be discharged from the clinic and instructed to avoid strenuous activity for a period of six weeks. A brace is necessary for 6-8 weeks and physical activity must be increased gradually.

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What is Balloon Kyphoplasty?

This is a minimally invasive treatment that can repair VCF (Vertebral Compression Fractures) caused by primary or secondary (steroid-induced) osteoporosis, cancer, or benign lesions. Orthopedic balloons are used as an attempt to elevate the bone fragments of the fractured vertebra and return them to the correct position. Balloon kyphoplasty has been shown to benefit patients with osteoporotic or cancer-induced VCF. Balloon kyphoplasty can be done under local or general anesthesia; your doctor will decide which option is appropriate for you. Typically, the procedure takes less than one hour per fracture treated and may require an overnight hospital stay.

How is the procedure performed?

With a hollow instrument, the surgeon creates a small pathway into the fractured bone. A small, orthopaedic balloon is guided through the instrument into the vertebra. Next, the balloon is carefully inflated in an attempt to raise the collapsed vertebra and return it to its normal position. Once the vertebra is in the correct position, the balloon is deflated and removed. This process creates a void (cavity) within the vertebral body. The cavity is filled with a special cement to support the surrounding bone and prevent further collapse. Generally, the procedure is done on both sides of the vertebral body.

Post-Procedure Care

After the procedure, you will most likely be transferred to the Recovery Room for about an hour. Generally, patients are discharged from the hospital within 24 hours. Your doctor will have you schedule a follow-up visit and explain limitations, if any, on your physical activity. After treatment with balloon kyphoplasty, mobility is often quickly improved. Most patients are very satisfied with the procedure and are able to gradually resume activity once discharged from the hospital.

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What is Radiofrequency Lesioning (Rhizotomy)?

What is a Rhizotomy (RFR) and why is it helpful?

This procedure is done to treat pain caused by the facet joints by creating a lesion or burn in the pain fibers to the facet joint, also known as the medial branch of the posterior primary ramus. The purpose of RFR of the medial branch is to decrease pain and improve function. This is done only if pain is relieved temporarily by medial branch nerve blocks.

How is it done?

It is accomplished by placing a special needle alongside the facet joint under X-ray control. Following this, a controlled heat lesion is made to decrease the sensation of the facet joints. Nerve testing is performed to verify the proper position of the needle. An intravenous solution will be started so that medications or a short-acting sedative, if necessary, can be given during the procedure. The procedure will take approximately 20 - 60 minutes. You will then be monitored for an additional 30 - 60 minutes. All measures will be taken to ensure your comfort and safety. After you return home, you may use ice packs to relieve any discomfort.

General Pre/Post Instructions

You should have nothing to eat for seven hours prior to your procedure. Clear liquids can be taken up to four hours prior to your procedure. Please take your routine medications (i.e. high blood pressure and diabetic medications) with a sip of water at your usual time. If you are on Coumadin, Heparin, Plavix, or any other blood thinners you must notify the office so the timing of these medications can be explained. For your own safety, if you do not follow the above instructions your procedure may be cancelled. A driver must accompany you and be responsible for getting you home. No driving is allowed the day of the procedure. You may return to your normal activities the day after the procedure, including returning to work.

Potential Risks

Prior to this procedure, a written consent will be obtained that will include the possible risks and hazards. Certain effects are to be expected: bruising at the injection sites, soreness and swelling. Possible side effects include burning sensation at the injection site, numbness, itching, and occasionally 2 - 3 weeks of increased pain. This is only temporary.

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What is a Sympathetic Nerve Block?

What are the sympathetic nerves?

The sympathetic nerves run on the front surface of the spinal column (not in the spinal canal with the nerves from your central nervous system). The sympathetic nerves are part of the autonomic nervous system, which basically controls functions like blood flow to the extremities, sweating, heart rate, digestion, blood pressure, goose bumps and many other functions. In other words, the autonomic nervous system is responsible for controlling things you do not think about or have direct control over. However, there is a connection between the central and autonomic nervous systems. Sometimes arm or leg pain is caused by a malfunction of the autonomic system secondary to an injury.

What is a sympathetic nerve block and why is it helpful?

A sympathetic nerve block involves injecting medicine around the sympathetic nerves in the lumbar or cervical area. By doing this, the system is temporarily blocked in hopes of reducing or eliminating your pain. If the initial block is successful, then additional blocks are generally repeated in 7 - 10 days and repeated again until your pain diminishes.

What will happen to me during the procedure?

An IV will be started so that relaxation medication can be given. You will be placed on the X-ray table on your back for a cervical block and on your stomach for a lumbar block. The skin on your neck or the skin on your low back will be scrubbed using two types of sterile scrub (soap). Next, the physician will numb a small area of skin with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, your doctor will direct a very small needle, using X-ray guidance, to the area of the sympathetic nerves. A small amount of contrast (dye) is then injected to ensure proper needle position. Then, a small mixture of numbing medicine (anesthetic), normal saline and anti-inflammatory (cortisone/steroid) will be injected.

What will happen after the procedure?

Immediately after the procedure, you will go back to the recovery area where you will be monitored for 30 - 60 minutes. The recovery room nurse will be checking you periodically to see if you get good arm/hand or good leg/foot warming. If a good block is accomplished with good pain relief, a repeat block will be scheduled for you in 7 - 10 days. You will not be able to drive the day of your procedure. Your arm or leg may feel weak or numb for a few hours.

General Pre/Post Instructions

You should have nothing to eat for seven hours prior to your procedure. Clear liquids can be taken up to four hours prior to your procedure. Please take your routine medications (i.e. high blood pressure and diabetic medications) with a sip of water at your usual time. If you are on Coumadin, Heparin, Plavix, or any other blood thinners you must notify the office so the timing of these medications can be explained. For your own safety, if you do not follow the above instructions your procedure may be cancelled. A driver must accompany you and be responsible for getting you home. No driving is allowed the day of the procedure. You may return to your normal activities the day after the procedure, including returning to work.

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What are Cervical, Thoracic and Lumbar Discography?

What are the discs?

The discs are cushion-like pads that separate the hard vertebral bones of your spine. A disc may be painful when it presses on nerves or the spinal cord, herniates, tears or degenerates and may cause pain in your neck, mid-back, low back and arms, chest wall, abdomen and legs. Other structures in your spine may also cause similar pain, such as the muscles, joints, and nerves. Usually, we have first determined that these other structures are not the sole pain source (through history and physical examination, review of X-rays, CTs, MRIs, myelograms, and/or other diagnostic injection procedures such as facet and sacroiliac joint injections and nerve root blocks) before performing discography.

What is discography and why is it helpful?

Discography helps confirm or rule out the disc(s) as a source of your pain. This procedure utilizes the placement of a needle into the discs themselves and injecting contrast (dye). CT and MRI scans only demonstrate anatomy and cannot absolutely prove your pain source. In many instances, the discs may be abnormal on MRI or CT scans but not be a source of pain. Only discography can tell if the disc itself is probably a source of your pain. Therefore, discography is done to identify painful disc(s) and help the surgeon plan the correct surgery, or avoid surgery that may not be beneficial. Discography is usually done only if you think your pain is significant enough for you to consider surgery.

What will happen to me during the procedure?

An IV will be started so that antibiotics (to prevent infection) and relaxation medication can be given. The skin will be scrubbed with a cleaning solution. Next, the physician will numb a small area of skin with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, your doctor will direct a small needle using X-ray guidance into the disc space. You may feel temporary discomfort as the needle passes through the muscle or near a nerve root. Your doctor may perform this at more than one disc level. After the needles are in their proper locations, a small amount of contrast (dye) is injected into each disc. Your doctor will ask you about your experience as the dye is being injected. It is important that you describe what you feel as accurately as you can. You need to be alert enough to be aware of and describe the sensations you experience.

What will happen after the procedure?

Immediately afterwards you will be taken to a recovery room or to a CT scan, where additional pictures will be taken. You will be monitored for 30 - 60 minutes. You may be given a prescription for pain medication over the next 2 - 3 days for muscle discomfort that may exist after this procedure. You will not be able to drive the day of your procedure. You will follow up with your physician in the Pain Clinic in 1-2 weeks to discuss the results of the procedure, or be scheduled immediately for another procedure or referral.

General Pre/Post Instructions

You should have nothing to eat for seven hours prior to your procedure. Clear liquids can be taken up to four hours prior to your procedure. Please take your routine medications (i.e., high blood pressure and diabetic medications) with a sip of water at your usual time. If you are on Coumadin, Heparin, Plavix, or any other blood thinners you must notify the office so the timing of these medications can be explained. For your own safety, if you do not follow the above instructions your procedure may be cancelled. A driver must accompany you and be responsible for getting you home. No driving is allowed the day of the procedure. You may return to your normal activities the day after the procedure, including returning to work.

What is IDET (Intradiscal Electrothermal Therapy)?

The Procedure

Certain lumbar disc problems can be treated with IDET (Intradiscal Electrothermal Therapy). The thermal treatment with the Intradiscal Catheter is intended to treat the protein wall of your disc and reduce the volume of disc material that causes nerve irritation. Your physician feels this procedure could improve your symptoms. This is a minimally invasive procedure and you will most likely go home the same day. The procedure involves a wire (the catheter) which is guided into your disc through a needle and is heated for about 15 minutes. Then the catheter and needle are removed completely and you will be sent back to recovery.

Pre-operative Preparation

You should not eat the day of your procedure. Clear liquids are permitted. Bring your brace with you to the hospital. Rest well the night before the procedure. Arrange to have someone drive you to and from the medical facility. You may not drive until one week after your treatment.

What will happen to me during the procedure?

An I.V. will be placed in your arm and you will be given sedation. After you are in position on the table, X-ray equipment will identify the area affected. Your lower back, skin, and muscle tissue will then be numbed with local anesthetic.

Electrothermal Therapy

Your physician will then place a needle into your disc under X-ray guidance. Generally, you may experience mild discomfort during this part of the procedure. The next step is to insert the electrothermal treatment catheter through the needle. Patients typically do not feel any discomfort during this step. However, some patients have reported a mild discomfort in their back when the catheter moves through the disc. When the catheter position is confirmed by X-ray, the heating element is activated. The heat is slowly increased and will last for 14 to 17 minutes. As the heat increases into the treatment range, you might experience your disc-related symptoms. Your physician will monitor your responses during the procedure to ensure that any pain you feel is well controlled. At the end of the procedure, a small bandage will be placed on your back and you will rest in a recovery area until you are ready to go home.

Post-operative Management: Immediate

For the first 7 - 10 days after your procedure (the immediate post-operative period), you may experience a moderate increase in your normal back pain. Rest, ice, pain medication and anti-inflammatories will minimize possible discomfort during this time. Any unusual or new symptoms (for example, fever, rash or numbness) should be reported to your physician immediately by telephone. Do not expect your usual pain to disappear immediately after the procedure. If you experience a marked reduction in your pain, do not exert yourself during this time. Exertion may negatively affect the overall outcome. Housework, lifting, or bending should not be done.

Patient Information

Short walks (15 to 20 minutes) are permitted, but generally the first seven days should be spent resting. You should discuss with your physician your plan to return to work. If your work is sedentary, you can typically return seven days after the procedure. You will schedule follow-up visits with your physician for continuing assessment of your condition.

Post-operative Management: Mid Term

For the first month following the procedure, your disc continues to heal. You may begin to feel a reduction in pain. However, pain reduction usually occurs over 3 - 4 months. During the first month, you must treat your back carefully. Absolutely no bending, twisting or heavy lifting. No sport activities, including running, biking, golf, tennis, skiing, etc. You do not have to abstain from sexual activity, but be careful not to exert your back. You may resume back exercises under your physician's guidance. Anti-inflammatory medications and/or pain medication may be prescribed if needed to control discomfort associated with your normal back pain. Applying ice 1 - 2 times per day (10 - 15 minutes) is advisable to reduce any lower back discomfort.

Rehabilitation Exercises

Your physician will guide you regarding rehabilitation exercises after your procedure. If you have been performing strenuous rehabilitation exercises before the procedure, you will not immediately return to that level of exercise, but to a more moderate level that will be gradually increased as you improve. Be sure to ask your physician for a post-operative exercise program.

Post-operative Management: Long Term

In the second, third, and fourth months post-operatively, continue to maintain good body mechanics and do not bend improperly. Your physician and physical therapist will help you advance your strength and flexibility. If you plan to return to athletic pursuits, special advanced training will probably achieve your goal. Your physician may allow you to resume sporting activities 3 - 4 months after the procedure and may allow you to resume traveling for work or pleasure during this time as well.

In the end…

Your physician has selected this procedure because it offers you a less invasive option for your condition. It may be a promising step in trying to reduce your symptoms.

General Pre/Post Instructions

You should have nothing to eat for seven hours prior to your procedure. Clear liquids can be taken up to four hours prior to your procedure. Please take your routine medications (i.e., high blood pressure and diabetic medications) with a sip of water at your usual time. If you are on Coumadin, Heparin, Plavix, or any other blood thinners you must notify the office so the timing of these medications can be explained. For your own safety, if you do not follow the above instructions your procedure may be cancelled. A driver must accompany you and be responsible for getting you home. No driving is allowed the day of the procedure.

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What is DISC Nucleoplasty?

Disc decompression has been shown to treat symptoms caused by contained herniated discs. DISC Nucleoplasty is the latest scientific advance in performing disc decompression. The DISC Nucleoplasty procedure uses a minimally invasive catheter to create an accurate one-millimeter pathway into the disc.

Perc-DLE SpineWand
Figure 1 Perc-DLE™ SpineWand™
To perform the procedure, a micro-engineered alloy transmitter is introduced into the disc while the patient is awake, requiring only a topical anesthetic and light sedation. Radio wave signals are sent through the transmitter into the jelly-like nucleus of the herniated disc. The radio waves produce a low-temperature ionized gas that breaks up molecular bonds in the spongy nucleus, removing tissue volume.

Perc-DLE SpineWand removing tissue in nucleus of disc
Figure 2 - Perc-DLE™ SpineWand™ removing tissue in nucleus of disc
When the injection procedure is complete, the transmitter is withdrawn. The removal of nucleus tissue relieves pressure on the disc shell, typically allowing the bulge to recede so that the disc no longer irritates the adjacent nerve root.

Decompressed disc
Figure 3 - Decompressed disc with nerve root compression relieved
Normally, the entire procedure takes 20 to 30 minutes, and the patient is ready to walk out of the clinic in about an hour with no hospital stay required. DISC Nucleoplasty percutaneous disc decompression is designed to offer a fast-acting option to drug therapies and steroid injections, on the one hand, and a minimally invasive alternative to open surgery, on the other.

Clinically Proven Technology

The DISC Nucleoplasty procedure uses an FDA-cleared device, and is a clinically proven treatment with over 20,000 patients treated. The radio wave technology used in DISC Nucleoplasty was developed by ArthroCare, and has been used successfully for years in over two million procedures such as knee and shoulder surgery and tonsillectomy.
Using the same proven technology, DISC Nucleoplasty percutaneous disc decompression reduces the volume of the spongy nucleus within the herniated disc. The disc typically returns to a more natural shape, and the source of nerve root irritation is either minimized or eliminated in most cases, allowing the patient to resume their life.

General Pre/Post Instructions

You should have nothing to eat for seven hours prior to your procedure. Clear liquids can be taken up to four hours prior to your procedure. Please take your routine medications (i.e. high blood pressure and diabetic medications) with a sip of water at your usual time. If you are on Coumadin, Heparin, Plavix, or any other blood thinners you must notify the office so the timing of these medications can be explained. For your own safety, if you do not follow the above instructions your procedure may be cancelled. A driver must accompany you and be responsible for getting you home. No driving is allowed the day of the procedure.

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What is Intrathecal Pain (Pump) Therapy?

On-going pain can destroy your quality of life. Limitations imposed by living with chronic pain may mean that activities such as work and hobbies, even little things that once brought satisfaction, pleasure and self-esteem, may only be memories. Regaining quality of life is one of the goals of physicians who attempt to treat chronic pain. Pain signals go from the site of injury, through the spinal cord, to the brain where the signal is encoded as "pain." Then the brain sends the interpreted signal back through the spinal cord to the site of injury. When that signal is blocked or scrambled, the message is not received as "pain" at the injury site. Oral opiate medications as a treatment work for some people by altering the message sent to and from the brain. For others, doses enough to relieve pain may result in confusion, grogginess, over-sedation and other side effects. When attempts to increase quality of life and to manage pain with medications are unsatisfactory, your physician may recommend intrathecal pain therapy. This may be effective for pain that is caused by certain conditions, including failed back syndrome, arachnoiditis, osteoporosis and cancer.

What is Intrathecal Pain Therapy?

Intrathecal pain therapy works by delivering small doses of analgesic directly to the pain receptors in the spinal cord, blocking the message to the brain. Because the doses are small and applied directly at the site of pain receptors, the entire body is not flooded with medications, and therefore negative side effects such as grogginess, confusion and over-sedation are usually avoided. A surgically implanted pump delivers medication in small, regular doses. The medication goes through a catheter to the intrathecal space around the spinal cord where it most effectively blocks pain signals. Exact dosages and frequency of delivery are determined by the physician.

How will I know if it will work for me?

Once you and your doctor have decided that this is an option for long-term treatment, a trial will be arranged. A temporary catheter will be placed near your spinal cord and attached to an external pump. The trial usually lasts about 3 days and gives you a good idea of the degree of pain the pump will relieve. A successful trial will reduce your pain by at least 50%. During the trial, you should notice an improvement in your ability to perform daily activities.

What are the potential risks of intrathecal therapy and the surgery to implant the pump?

The potential risks of surgery to implant an intrathecal pump include any complication that can also occur with other types of surgery and anesthesia. These include:

There are some risks that are unique to the implantation of the infusion surgery and anesthesia. They include:

It is important that you discuss with your doctor the potential risks, complications and benefits regarding this therapy prior to giving your informed consent for treatment.

After Surgery

There will be some discomfort at the incision sites. Your doctor may prescribe something to help relieve post-surgery pain and an antibiotic to prevent infection. Infection is rare, but you do need to be aware of the signs of infection.

Signs of Infection

Other symptoms to report immediately

If you experience clear, watery fluid draining from your wound, or develop a headache when you are upright, you may have a spinal fluid leak. You should notify your doctor's nurse or the doctor on call right away. You will want to limit your activity for 6 to 8 weeks in order to prevent the catheter from moving before healing is complete. After the incision has healed, the pump site will require no special care. Oral medications will be reduced as the amount of medication released by the pump is increased. It will take several weeks to reach the optimal dosage.

Maintaining Your Pump

You will schedule regular appointments with your doctor for pump refills. At each visit your pump will be checked to be sure it is working properly. Work with your doctor to find the effective medication dosage for you. Call your doctor's nurse and report any unusual reactions to the medication. Call your doctor's nurse immediately if you hear beeping sounds from the pump. It will beep to signal that attention is needed: a refill is due, the battery needs to be changed, or there is a problem with the pump delivering medication. Do not participate in activities that could result in a blow to the pump site. Carry your pump identification card with you at all times. Consult with your doctor before scheduling any diagnostic tests such as MRI or other diagnostic imaging, or before engaging in treatments that could involve changes in atmospheric pressure (long flights, unpressurized flights, or hyperbaric chamber) or extreme changes in temperature (sauna or hot tub). Extreme temperature or pressure changes may result in the pump releasing too much medication or not enough. You can expect the battery to last 3 to 5 years, depending upon the amount of medication the pump delivers. At the end of battery life, the pump will need to be replaced. For more detailed information regarding living with an intrathecal pump, refer to the patient handbook.
Medtronic, Inc. - When Life Depends on Medical Technology

General Pre/Post Instructions

You should have nothing to eat for seven hours prior to your procedure. Clear liquids can be taken up to four hours prior to your procedure. Please take your routine medications (i.e. high blood pressure and diabetic medications) with a sip of water at your usual time. If you are on Coumadin, Heparin, Plavix, or any other blood thinners you must notify the office so the timing of these medications can be explained. For your own safety, if you do not follow the above instructions your procedure may be cancelled. A driver must accompany you and be responsible for getting you home. No driving is allowed the day of the procedure.

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What is Spinal Cord Stimulation?

It is a therapy that uses electrical impulses to block pain from being perceived in the brain. Instead of pain, the patient feels a more pleasant tingling sensation.

Who is a good candidate for a Spinal Cord Stimulator?

Intrathecal pain therapy works by delivering small doses of analgesic directly to the pain receptors in the spinal cord, blocking the message to the brain. Because the doses are small and applied directly at the site of pain receptors, the entire body is not flooded with medications, and therefore negative side effects such as grogginess, confusion and over-sedation are usually avoided.
Doctors will generally consider the following:

The Trial

After you and your physician discuss the SCS and determine that you would like to proceed, a trial will be arranged to learn if it will be effective in treating your pain. The trial involves a surgical procedure to implant a temporary stimulator to determine if the area of your pain will be covered by stimulation, and if the stimulation actually reduces your pain. The trial may last a minimum of 24 hours or as long as 10 days. You will want to be certain that you have satisfactory pain control and that you are comfortable with the sensations of stimulation. If the trial is successful, the permanent stimulator implantation will be scheduled.

Implantation: The Surgical Procedure

The procedure will take place in an operating room. You will be given a local anesthetic and sedation so that you can be awake during the procedure with minimal discomfort in order to give feedback to the physician regarding effective lead placement. After the local anesthetic has time to numb the area where the lead will be placed, the lead is inserted within the spinal column through a needle or through an incision. Once the lead is in place, your physician will activate the system. You will help the physician determine how well the stimulation pattern covers your pain pattern. You will also get a sense of how stimulation feels to help determine if it is right for you.

Risks of Surgery

Any time surgery is performed there are possible complications. For spinal procedures, these rare risks include:

After Implantation

After a trial, there is usually little discomfort other than that caused by the dressing and tape. You must sponge bathe until the lead is removed at your follow-up visit. As with any surgery, you will have some discomfort at the incision sites, and there will be some swelling which usually lasts for several days. There will be some discomfort over the area where the receiver is implanted. This is normal. Your doctor may prescribe an analgesic until this subsides. You must avoid showering (sponge bath only) until your follow-up visit, unless instructed otherwise. Immediately following implantation, you should avoid lifting, bending, stretching and twisting. Light exercise, such as walking is important to build strength and to help relieve pain.

Long-Term Care

Leads can remain permanently in place. However, if you engage in extreme bending, stretching, twisting, or strenuous activity such as jumping exercises and diving, etc., the leads may move or become damaged and require surgical repositioning or removal. This can occur especially within the first 8 weeks after implantation. Moving or lifting heavy objects can move or break the leads. Sometimes leads will move as a result of normal bending, stretching, or twisting, or due to your unique physical structure. Check with your doctor before performing any strenuous activity, and limit activity to no excessive bending/stretching or lifting > 10 lbs for the first 8 weeks.

Things to Keep in Mind

Do not drive a motor vehicle or heavy equipment while using the stimulator. You may use it if you are a passenger. The stimulator will set off metal detectors (such as at airports). You will want to be sure you have your SCS identification card in order to pass through. Department store theft detectors may cause an increase or decrease in stimulation as you pass through. This is temporary and will not harm you or the stimulator however, you may wish to turn the stimulator off before passing through. Anything with magnets can affect your stimulator in addition to theft detectors and metal detectors, be mindful of large stereo speakers with magnets, high voltage power lines, electric arc welding equipment, electric sub-stations and power generators. Magnets can turn an internally powered generator (IPG) on or off. You will want to avoid MRIs as they can damage the stimulator. Normal household equipment will not harm or interfere with the stimulator. This includes cellular or portable phones, microwaves, computers, TVs, appliances, electric blankets and heating pads. The stimulator control magnet may cause damage to certain items or erase information on items with magnetic strips (bank or credit cards), magnetic media (video cassette tapes, computer diskettes, cassette tapes), and home electronic items (computer, VCR, television, camera). The magnet will stop watches and clocks, so you will want to store the magnet at least two inches away. Life of batteries depends upon stimulation settings and usage. Ex ternal batteries last anywhere from several hours to several days. When the battery of an implanted pulse generator is depleted, you may need surgery to replace the IPG. Report to your doctor's nurse changes in stimulation patterns, increase in pain, or unexplained increased / decreased stimulation.

Will I be pain free?

There will be residual discomfort. Most patients report a 50%- 70% decrease in pain. The goal is to lower the level of pain and make it more manageable.

How will a spinal cord stimulator help me?

General Pre/Post Instructions

You should have nothing to eat for seven hours prior to your procedure. Clear liquids can be taken up to four hours prior to your procedure. Please take your routine medications (i.e. high blood pressure and diabetic medications) with a sip of water at your usual time. If you are on Coumadin, Heparin, Plavix, or any other blood thinners you must notify the office so the timing of these medications can be explained. For your own safety, if you do not follow the above instructions your procedure may be cancelled. A driver must accompany you and be responsible for getting you home. No driving is allowed the day of the procedure.

What is Vertebroplasty?

  Vertebroplasty is an image-guided, minimally invasive, nonsurgical therapy used to strengthen a broken vertebra (spinal bone) that has been weakened by osteoporosis or, less commonly, cancer. Vertebroplasty can increase the patient's functional abilities, allow a return to the previous level of activity, and prevent further vertebral collapse. It is usually successful at alleviating the pain caused by a compression fracture. Often performed on an outpatient basis, vertebroplasty is accomplished by injecting an orthopedic cement mixture through a needle into the fractured bone.

What are some common uses of the procedure?

  Vertebroplasty is used to treat pain caused by osteoporotic compression fractures. After menopause, women are especially vulnerable to bone loss. More than one-fourth of women over age 65 will develop a vertebral fracture due to osteoporosis. Older people suffering from compression fractures tend to become less mobile, and decreased mobility accelerates bone loss. High doses of pain medication, especially narcotic drugs, further limit functional ability.   Vertebroplasty is often performed on patients too elderly or frail to tolerate open spinal surgery, or with bones too weak for surgical spinal repair. Patients with vertebral damage due to a malignant tumor may sometimes benefit from vertebroplasty. In rare cases, it can be used in younger patients whose osteoporosis is caused by long-term steroid treatment or a metabolic disorder.   Typically, vertebroplasty is recommended after simpler treatments—such as bedrest, a back brace or pain medication—have been ineffective, or once medications have begun to cause other problems, such as stomach ulcers. Vertebroplasty can be performed right away in patients who have severe pain requiring hospitalization or conditions limiting bedrest and medications.

How is the procedure performed?

  Vertebroplasty is generally performed in the morning. The patient will be sedated and receive a local anesthetic to numb the skin and the muscles near the spinal fracture. Intravenous antibiotics may also be administered to prevent infection. Through a small incision and guided by a fluoroscope, a hollow needle is passed through the spinal muscles until its tip is precisely positioned within the fractured vertebra. Once the needle is shown to be in the proper location, the orthopedic cement is injected. Medical-grade cement hardens quickly, over the next 10 to 20 minutes. A CT scan may be performed at the end of the procedure to check the distribution of the cement. The longest part of vertebroplasty involves setting up the equipment and making sure the needle is perfectly positioned in the collapsed vertebra.

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What is Epidural Lysis of Adhesions?

This is a more aggressive approach to a typical Epidural Steroid Injection. An epidural lysis of adhesions is a procedure that was developed to help decrease chronic low back pain due to adhesions and scar tissue formation. This is a catheter injected procedure and is inserted into the epidural space in order to access the area of adhesions.

Epidural adhesions are most commonly observed following surgical intervention of the spine, leakage of disc material into the epidural space following annular tear or an inflammatory response. Scar tissue may restrict movement of nerves causing inflammation, therefore, creating pain.

How is the procedure performed?

The physician will inject local anesthetic to numb up the area prior to placing the catheter through the skin. Once the local anesthetic has set in, the epidural needle will then be introduced through the skin and into the sacral hiatus. Mild sedation will also be administered to ease any anxiety, however, general anesthesia is not an option since your participation in the procedure is critical to reduce the risk of any complication. Following placement of the epidural needle, the catheter is advanced into the injection site. The movement of the catheter is continuously monitored with the C-arm (X-ray) to assure safe and effective positioning. Contrast material (a metallic fluid that shows up on X-ray) will then be injected into the epidural space to outline the epidural space, this is called and epidurogram. Other fluids will then be injected to relieve pain, dissipate scar tissue, and reduce inflammation.

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