Pain Management

Diagnosing spinal pain

Treating spinal pain

Depending on the cause of your chronic spinal pain, we will recommend some combination of:

• Physical therapy
• Surgery
• Pain management
• Therapeutic injections

The first treatment option is physical therapy, with an emphasis on activity and return to function, and it is often all that’s needed. If your pain persists, we may then recommend surgery. However, the most successful surgery depends on having the most accurate diagnosis regarding the source of pain. 

When surgery does not seem likely to succeed, we will recommend ways to make living with your pain more bearable. This could involve anything from traditional pain medication to alternative medicine techniques such as acupuncture.

Finally, if we know the exact source of your spinal pain, we may recommend therapeutic injections. These typically consist of local anesthetic and cortisone medication, and also may be accompanied by heat applications. Therapeutic injections not only have the potential to provide long-term pain relief, but even in the short-term will increase the effectiveness of other treatments.

Risks and side effects of therapeutic spinal injections

We use X-ray guidance to ensure the maximum safety and success of all our spinal injection procedures. As with any medical treatment though, there are possible risks. Those include bleeding, infection, allergic reaction, minor side effects, and more serious complications.

Bleeding

Minor bleeding from the needle placement is not uncommon. To minimize the risk of serious complications, we instruct you to:

• Stop taking anti-inflammatories for three days prior to your procedure
• Stop taking aspirin for seven days prior
• Notify us if you take blood-thinning medications

Infection

Needle procedures seldom result in a significant infection. However, minor infections can lead to serious complications with certain disc injection procedures. As a preventive measure in those cases, we’ll administer antibiotics both intravenously and directly into the disc at the time of the procedure.

Allergic reaction

You may also have a minor allergic reaction to the medications given during the procedure, including the contrast material or “dye” used for more accurate diagnosis and treatment. To avoid more serious complications, be sure to let us know in advance of any medication allergies. 

Since all procedures use local anesthesia and intravenous sedation, we’ll take the further safety precautions of administering oxygen while constantly monitoring your blood pressure, heart rate and oxygen levels.

Minor side effects

Common minor side effects after injection procedures include:

• Temporarily impaired coordination
• Numbness
• Weakness
• Soreness
• Increased pain

There may be lingering effects from the sedative medications. Therefore, for a day after the injection, we recommend you refrain from driving and limit any activities requiring coordination. You may also experience localized numbness or weakness for up to six hours until the local anesthetic injected into the spine wears off.

Some soreness at the site of the injection for a day or two is also not uncommon, and may be eased by applying ice packs.

Especially if you’ve had a discogram, don’t be surprised if you experience a higher level of pain for up to 10 days after the injection. Simply rest and take your usual pain medication. But let us know if the pain continues.

If your injection contained cortisone, note that it may take up to 14 days for the full effect, although you may find some pain improvement in just two to three days. Side effects are rare, but have been known to include:

• Sweating
• Flushing
• Palpitations
• Increased heart rate
• Insomnia
• Anxiety
• Hiccups
• Headache
• Menstrual changes
• Upset stomach
• Frequent urination
• Slight fever with flu-like symptoms

Be sure to let us know if any of these side effects bother you intensely or for more than three days.

Serious complications

Keep in mind that serious complications are rare, but may include: 

• Increased pain
• Headache
• Temporary or permanent nerve damage
• Hip (bone) damage caused by steroids
• Seizures
• Difficulty breathing
• Collapsed lung
• Death
• Paralysis

Serious complications related to bleeding and infection in particular can occur after you’re back home recovering. With that in mind, be sure to let us know immediately if you develop fever, progressive weakness or numbness, loss of bowel or bladder control, or any other symptoms that concern you.

Pain management treatment options

• Caudal steroid injection
• Cervical epidural steroid injection series
• Epidural steroid injections 
• Facet injections
• Geniculate nerve blocks and radiofrequency ablation
• Medial branch blocks (MBB) and radiofrequency ablation
• Spinal cord stimulation
• Sympathetic nerve blocks
• Transforaminal epidural steroid injection (TFESI) series

Caudal steroid injection

This injection procedure is performed to relieve low back and radiating pain. The steroid medication can reduce the swelling and inflammation caused by spinal conditions, such as spinal stenosis, radiculopathy, sciatica and herniated discs.

Cervical epidural steroid injection series

Conditions such as herniated discs, spinal stenosis or radiculopathy can compress nerves, causing inflammation and pain. 

A cervical epidural steroid injection decreases the inflammation, irritation and swelling of nerves, thereby relieving associated pain in the neck, shoulders and arms. The medication also spreads to other portions of the spine, further reducing inflammation and irritation.

Usually an interlaminar approach is performed, due to less risk when injecting the cervical spine. This injection uses a long-lasting steroid and saline. 

Epidural steroid injections

An epidural steroid injection (ESI) is an interventional procedure done to reduce pain and inflammation in the spine. Many different spinal issues can cause pain, including vertebral disc disease, nerve impingement, joint arthritis and spinal stenosis. 

Epidural injections can help relieve pain caused by these types of issues. It is important to know that you may not receive significant relief from the first or even second ESI. The local anesthetic is short-acting. However, the steroid is a long-lasting medication, and its effect on the inflammation happens over the course of several weeks.

Facet injections

A facet injection is both a diagnostic and therapeutic injection. It is designed to identify and treat the source of spinal pain. There are many components to the spine that could be injured and causing pain. One of the most common causes of pain is facet joints. 

This treatment’s goal is to determine if the patient’s pain is from arthritic facet joints. A facet injection is a diagnostic tool, and pain relief may vary from minimal ​​to complete elimination of pain. This relief may only last a few hours. 

The purpose of this procedure is not to provide long-lasting pain relief, but to identify whether arthritic facet joints are the source of a patient’s pain. Facet arthritis means the joints of the spine are inflamed. Nerves in the spinal cord transmit pain impulses when this occurs. A facet injection will block these impulses, reducing pain.

Geniculate nerve blocks and radiofrequency ablation

A geniculate nerve block is an outpatient procedure that is performed to reduce knee pain. This procedure can be performed before or after a knee replacement as part of your outpatient pain management therapeutic plan. This procedure may be performed in conjunction with other procedures to aid in the reduction of your pain.  

There are many tiny nerves in and around the knee that control pain. These are called geniculate nerves. By isolating some of the geniculate nerves, we can block their pain signal. Since these tiny nerves only control pain, you will not lose any function. Because there are multiple geniculate nerves, the protective defense signal to the knee is also preserved. 

By performing a diagnostic block, our goal is to find out if your knee pain can be reduced, similar to a dentist blocking the nerve to your tooth during a procedure. If a positive response is achieved, you are a candidate for a radiofrequency ablation. This is a procedure that provides long-term pain relief. 

A geniculate nerve ablation is an outpatient procedure designed to relieve knee pain for months and even years. Although it is not permanent, it is long-term. By using radiofrequency heat, the ablation can destroy part of the geniculate nerves and eliminate the pain signal to the brain. Similar to the diagnostic block, no function is lost and the protective defense system remains in place.  

Medial branch blocks (MBB) and radiofrequency ablation

A medial branch nerve block or MBB is a diagnostic injection used to confirm that the source of your pain is the facet joint. The medial branch nerve sends a pain signal from the facet joint (the connection point between two vertebrae in the spine). 

During this procedure, a needle is placed over this nerve and a local anesthetic is injected (at times with a steroid). The anesthetic works to interrupt the pain signal transmission. If the source of your pain is indeed coming from the facet, you should experience fairly rapid pain relief after the procedure. If this diagnostic test is successful at relieving your pain, a more long-term treatment option can be employed – radiofrequency ablation (RFA) of the nerve.

An RFA is a procedure that can provide longer-lasting pain relief for patients who have successfully completed the MBB series (i.e., received pain relief). During an RFA, a needle is placed over the identified nerve. An electrode is then threaded through the needle. The electrode is heated and remains at this temperature for a specified time. The heat creates a lesion over the nerve, and this lesion interrupts the pain signal generated by the nerve, thus decreasing the pain perception by the brain. 

Spinal cord stimulation

Spinal cord stimulation (SCS) uses groundbreaking technology that works by introducing an electrical current into the epidural space near the source of chronic pain impulses. 

Under a local anesthetic and minimal sedation, a doctor will first place the trial SCS leads into the epidural space. The SCS lead, a soft thin wire with electrical leads on its tip, is inserted into the epidural space through a needle in your back. 

The trial stimulator is typically worn for five to seven days as the lead is taped to the back and connected to a stimulating device. If the trial successfully relieves the pain, you may have the option to use the device on a permanent basis.

Sympathetic nerve blocks

A sympathetic nerve block is an outpatient procedure. This is a diagnostic and therapeutic nerve block performed for the diagnosis of Complex Regional Pain Syndrome, a pain syndrome that occurs after surgery or an injury. This block can be performed for upper and lower extremity pain syndromes that may involve the sympathetic nervous system.

Transforaminal epidural steroid injection (TFESI) series

A TFESI involves injecting medications into the epidural space, where irritated nerve roots are located. This injection uses a long-lasting steroid and may also include a local anesthetic (usually lidocaine). The steroid reduces the inflammation/irritation of the nerves, and the anesthetic works to interrupt the pain signal transmission. 

The medications also spread to other levels and portions of the spine, further reducing inflammation and irritation. TFESIs can be performed in the cervical, thoracic, lumbar or sacral portion of the spine. 

It is important to know that you may not receive significant relief from the first or even second TFESI.  The local anesthetic is short-acting. However, the steroid is a long-lasting medication, and its effect on the inflammation happens over the course of several weeks.