Services
Diagnostic and Therapeutic Injections
- Epidural Steroid Blocks (Lumbar, Thoracic, Cervical, or Caudal)
- Stellate Ganglion Blocks
- Lumbar Sympathetic Blocks
- Vertebroplasty
- Facet Joint Injections
- Selective Nerve Root Blocks
- Intercostal Nerve Blocks
- Medial Branch Blocks for Facet Joint Injections
- Radiofrequency Lesioning
- Sacroiliac Joint Injections
- Peripheral Nerve Blocks
- Intravenous Regional Sympathetic Block
- Celiac Plexus Blocks/Splanchnic Nerve Blocks
- Brachial Plexus Blocks
- Trigger Point Injections
Other Procedures
- Spinal Cord Stimulators (SCS)
- Discography
- Epidural Blood Patch
- Long-term Intrathecal and Epidural Infusion Catheters
- Neurolytic Blocks
- Implanted Intrathecal Pumps
EPIDURAL STEROID BLOCKS(Lumbar, Thoracic, Cervical, or Caudal)
What is an epidural steroid injection?
An epidural steroid injection is an injection of an anti-inflammatory steroid (e.g., Kenalog) in the epidural space. The epidural space is not an injection into the spinal cord itself. The spinal cord and spinal nerves are in a “sack” containing clear fluid (cerebrospinal fluid). The area outside this “sack” is called the epidural space. An epidural steroid injection is not the same injection as a labor epidural, which is commonly given to women in labor.
Why is it done?
When the nerves in the epidural space are irritated or pinched by a bulging disk, narrowed “nerve canal” or bone spur, the resulting inflammation can cause pain, numbness, or tingling. The steroid injected can reduce inflammation of nerves in the epidural space and thus reduce pain and other symptoms.
How long does it take to do?
The actual injection takes only a few minutes. Please allow about an hour and a half for the procedure; this will include talking to your doctor before the procedure, signing the informed consent, positioning in the room, and observation by the recovery room nurse afterwards.
What medicines are injected?
The injection consists of a mixture of local anesthetics (e.g., bupivacaine) and the steroid medication (Kenalog).
Will it hurt?
All of our procedures begin by injecting a small amount of local anesthetic through a very small needle. It feels like a little pinch and then a slight burning as the local anesthetic starts numbing the skin. After the skin is numb, the procedure needle feels like a bit of pressure at the injection site. If you experience any pain during the procedure, your doctor will inject more local anesthetic as needed.
Will I be “put out” for this procedure?
No, we offer mild IV sedation to calm you and local anesthesia to numb the skin.
How is it done?
It is typically done with you lying on your stomach. Your blood pressure, heart rate, and oxygenation will be monitored. In addition to your doctor and the x-ray technician, there will be a nurse in the room at all times if you have any questions or discomfort during the procedure. The skin in the back is cleaned with antiseptic solution and then the procedure is done.
What should I expect after the injection?
Immediately after the injection, you may feel your legs becoming slightly heavy or numb. You may notice that your pain may be gone or considerably less. This is due to the effect of the local anesthetic and lasts only for a few hours. Your pain may return and you may have some soreness at the injection site for a day or so. You should start noticing pain relief starting about 2-3 days after the procedure.
What should I do after the procedure?
We advise the patients to take it easy for a day or so after the procedure. Perform the activities as tolerated by you. Your recovery room nurse will give you more instructions upon discharge.
Can I go back to work the same day or the next day?
Your doctor or recovery room nurse will discuss this with you.
How long does it last?
The long-term effect of the medication cannot be predicted. Usually, the immediate effect is from the local anesthetic injected. This wears off in a few hours. The steroid starts working in about 2-3 days and its effect can last for several days to a few months.
How many injections do I need to have?
The typical series of injections is for about three, spaced about a week apart. You should expect a gradual overall improvement in pain after each injection.
Can I have more than three injections?
It depends upon your response.
How will I know if it will help?
It is very difficult to predict how helpful injections will be. Generally, patients who have “radicular” symptoms (radiating outward or downward, like sciatica) respond better to the injections than patients who have only back pain. Patients with recent onset of pain may respond much better than ones with longstanding pain. Patients with back pain mainly from bony abnormalities (e.g., a bone spur pressing on a nerve root) may not respond as well.
What are the risks and side effects?
Overall, this procedure has very few risks. However, as with any procedure, there are some risks and side effects you should know about. Commonly encountered side effects are increased pain from the injection (usually temporary), inadvertent puncture of the “sack” containing spinal fluid (may cause headaches), infection, bleeding, nerve damage, or no relief from your usual pain. Side effects of the injected steroid may include weight gain, increase in blood sugar (mainly in diabetics), water retention, suppression of your own natural production of steroids, or temporary suppression of your immune system.
Who should not have this injection?
The following patients should not have this injection: if you are allergic to any of the medications to be injected or if you have an active infection going on. If you are on blood thinners, please talk with your doctor.
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STELLATE GANGLION BLOCK
What is a stellate ganglion block?
A stellate ganglion block is an injection in the front of the neck, toward the left or right side. The “stellate ganglion” is a small bundle of nerves that carries “sympathetic” nerve signals from the upper extremities. In some instances, certain injuries to the upper extremities can cause a burning, unusual pain called complex regional pain syndrome or reflex sympathetic dystrophy. Injecting a small amount of local anesthetic on the stellate ganglion can identify whether or not this pain is carried by the sympathetic nervous system.
How long does it take to do?
The actual injection takes only a few minutes. Please allow about an hour and a half for the procedure; this will include talking to your doctor before the procedure, signing the informed consent, positioning in the room, and observation by the recovery room nurse afterwards.
What medicines are injected?
For diagnostic purposes, only local anesthetics are injected, usually bupivacaine. Sometimes, if the diagnostic injection is successful in blocking your pain, other medications may be used for longer-lasting relief (e.g. steroid).
Will it hurt?
All of our procedures begin by injecting a small amount of local anesthetic through a very small needle. It feels like a little pinch and then a slight burning as the local anesthetic starts numbing the skin. After the skin is numb, the procedure needle feels like a bit of pressure at the injection site. If you experience any pain during the procedure, your doctor will inject more local anesthetic as needed.
Will I be “put out” for this procedure?
No, we do offer mild IV sedation to calm you and local anesthesia to numb the skin.
How is it done?
It is typically done with you lying on your back. Your blood pressure, heart rate, and oxygenation will be monitored. In addition to your doctor and the x-ray technician, there will be a nurse in the room at all times if you have any questions or discomfort during the procedure. The skin on the side of the neck is cleaned with antiseptic solution and then the procedure is done.
What should I expect after the injection?
Shortly after the injection, you may feel your arm becoming warm. The pain may diminish considerably. Some patients develop temporary hoarseness or a slight droop around the eyelid on the side injected. The eye may also become slightly red. You can also get some nasal congestion on the side injected. This is normal and should last only for a few hours.
What should I do after the procedure?
We advise the patients to take it easy for a day or so after the procedure. Perform the activities as tolerated by you. Your recovery room nurse will give you instructions upon discharge.
Can I go back to work the same day or the next day?
Your doctor or recovery room nurse will discuss this with you.
How long does it last? How many injections do I need to have?
It is difficult to predict. Blockade of the sympathetic nerves can sometimes last permanently. For most patients, however, interruption of the sympathetic nerves provides temporary relief. Repeated injections can sometimes cause progressive lessening of symptoms. Your doctor will discuss this with you. You may be required to enroll In physical therapy for the full effect of the procedure.
What are the risks and side effects?
Overall, this procedure has very few risks. However, as with any procedure, there are some risks and side effects you should know about. Commonly encountered side effects are increased pain from the injection (usually temporary), inadvertent puncture of the “sack” containing spinal fluid, inadvertent injection into blood vessels in the neck, infection, bleeding, nerve damage, punctured lung or no relief from your usual pain.
Who should not have this injection?
The following patients should not have this injection: if you are allergic to any of the medications to be injected or if you have an active infection going on. If you are on blood thinners, please talk with your doctor.
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LUMBAR SYMPATHETIC BLOCK
What is a lumbar sympathetic block?
A lumbar sympathetic block is an injection in the middle of the lower back, toward the left or right side. The “lumbar sympathetic nerves” are a small bundle of nerves that carries “sympathetic” nerve signals from the lower extremities. In some instances, certain injuries to the lower extremities can cause a burning, unusual pain called complex regional pain syndrome or reflex sympathetic dystrophy. Injecting a small amount of local anesthetic on the lumbar sympathetic nerves can identify whether or not this pain is carried by the sympathetic nervous system.
How long does it take to do?
The actual injection takes only a few minutes. Please allow about an hour and a half for the procedure; this will include talking to your doctor before the procedure, signing the informed consent, positioning in the room, and observation by the recovery room nurse afterwards.
What medicines are injected?
For diagnostic purposes, only local anesthetics are injected, usually bupivacaine. Sometimes, if the diagnostic injection is successful in blocking your pain, other medications may be used for longer-lasting relief (e.g. steroid).
Will it hurt?
All of our procedures begin by injecting a small amount of local anesthetic through a very small needle. It feels like a little pinch and then a slight burning as the local anesthetic starts numbing the skin. After the skin is numb, the procedure needle feels like a bit of pressure at the injection site. If you experience any pain during the procedure, your doctor will inject more local anesthetic as needed.
Will I be “put out” for this procedure?
No, but we do offer mild IV sedation to calm you and local anesthesia to numb the skin.
How is it done?
It is typically done with you lying on your stomach. Your blood pressure, heart rate and oxygenation will be monitored. In addition to your doctor and the x-ray technician, there will be a nurse in the room at all times if you have any questions or discomfort during the procedure. The skin on the back is cleaned with antiseptic solution and then the procedure is done.
What should I expect after the injection?
Shortly after the injection, you may feel your leg becoming warm. The pain may diminish considerably. This is normal.
What should I do after the procedure?
We advise the patients to take it easy for a day or so after the procedure. Perform the activities as tolerated by you. Your recovery room nurse will give you instructions upon discharge.
Can I go back to work the same day or the next day?
Your doctor or recovery room nurse will discuss this with you.
How long does it last? How many injections do I need to have?
It is difficult to predict. Blockade of the sympathetic nerves can sometimes last permanently. For most patients, however, interruption of the sympathetic nerves provides temporary relief. Repeated injections can sometimes cause progressive lessening of symptoms. Your doctor will discuss this with you.
What are the risks and side effects?
Overall, this procedure has very few risks. However, as with any procedure, there are some risks and side effects you should know about. Commonly encountered side effects are increased pain from the injection (usually temporary), inadvertent puncture of the “sack” containing spinal fluid, inadvertent injection into blood vessels around the spine, infection, bleeding, nerve damage, or no relief from your usual pain.
Who should not have this injection?
The following patients should not have this injection: if you are allergic to any of the medications to be injected or if you have an active infection going on. If you are taking blood thinners, please talk with your doctor.
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VERTEBROPLASTY
What is a vertebroplasty? Why is it done?
An vertebroplasty is an injection of bone cement into a fractured vertebra. Many people in their lifetime may sometimes experience a compression fracture of the vertebra, one of the many bones in the spine. These can be due to osteoporosis, traumatic injury, cancer involving the spine, or other causes. These fractures can be very painful and sometimes, progression of the fracture can affect other functions of the body, like good posture or proper breathing. A vertebroplasty, the injection of a small amount of cement through a needle into the fracture, can stabilize the fracture, significantly reduce pain, and prevent progression of the fracture in the future.
How long does it take to do?
The procedure takes about an hour to 2 hours. Please allow about 3-3 1/2 hours for the procedure; this will include talking to your doctor before the procedure, signing the informed consent, positioning in the room, and observation by the recovery room nurse afterwards.
What medicines are injected?
The injection consists of a mixture of local anesthetic in the skin and deep tissues, and the bone cement into the fracture.
Will it hurt?
All of our procedures begin by injecting a small amount of local anesthetic through a very small needle. It feels like a little pinch and then a slight burning as the local anesthetic starts numbing the skin. After the skin is numb, the procedure needle feels like a bit of pressure at the injection site. If you experience any pain during the procedure, your doctor will inject more local anesthetic as needed.
Will I be “put out” for this procedure?
You will not be completely “put out” but you will be mildly sedated with IV medication. It is important you are at least awake enough to communicate with your doctor. This procedure is done primarily under local anesthesia. It is typically done with you lying on your stomach. Your blood pressure, heart rate and oxygenation will be monitored. A small intravenous line will be started and you will receive antibiotics through it. In addition to your doctor and the x-ray technician, there will be a nurse in the room at all times if you have any questions or discomfort during the procedure. The skin in the back is cleaned with antiseptic solution and then the procedure is done.
During the procedure, you will feel the pressure of the needle being placed. If it becomes painful, let your doctor know at once and he/she can add more local anesthetic or more sedation. You may feel a slight tapping sensation. This is normal also. If any of these sensations make you feel uncomfortable, let your doctor know.
What should I expect after the injection?
After the procedure, you will be taken to the recovery room. For about an hour, your “vital signs” will be monitored. The recovery room nurse will also periodically ask you to wiggle your toes or move your legs. You may start to notice pain relief right away.
What should I do after the procedure?
We advise the patients to take it easy for a day or so after the procedure. Your recovery room nurse will give you instructions upon discharge.
Can I go back to work the same day or the next day?
No. Since sedation is used, you should go home and rest. Your doctor or recovery room nurse will discuss this with you.
How long does it last?
The placement of cement is permanent. Whether or not you obtain complete pain relief will depend on what other pain generators you have in the area. Your doctor will discuss this with you.
How many injections do I need to have?
For a typical vertebra, you need only one injection. You may need additional injections if fractures develop in other vertebrae.
How will I know if it will help?
It is very difficult to predict how helpful injections will be. Generally, patients who have severe back pain near the fracture site with minimal “radiating” pain from the site will do very well. However, there are other pain generators in the area. Sometimes, in addition to the compression fracture, the patient may have pain from inflamed facet joints, bulging disks, etc. Typically, your doctor will do this procedure only if the fracture is somewhat recent (usually occurring within the previous six months) and an MRI confirms the presence of an active inflammation at the fracture site.
What are the risks and side effects?
Overall, this procedure has few risks. However, as with any procedure, there are some risks and side effects you should know about. Commonly encountered side effects are increased pain from the injection (usually temporary), inadvertent puncture of the “sack” containing spinal fluid (may cause headaches), infection, bleeding, nerve damage, or no relief from your usual pain.
Who should not have this injection?
The following patients should not have this injection: if you are allergic to any of the medications to be injected or if you have an active infection going on. If you are on blood thinners, please talk with your doctor.
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FACET JOINT INJECTION
What is a facet joint injection?
A facet joint injection is an injection of an anti-inflammatory steroid (e.g., Kenalog) in the facet joints. The facet joints, also known as the zygapophysial joints, are part of the bony framework of the spine. They are small bony projections from one vertebra meeting with similar bony projections from the vertebra above or below. Sometimes, due to a variety of acute and chronic conditions, the facet joints can become inflamed. For lower back (lumbar) facet joints, the pattern of pain is usually an achiness in the low back, radiating across the lower back and slightly down the back of the buttocks and upper thighs. Usually, standing or bending backward worsens the pain. For neck (cervical) facet joints, the pattern of pain is an achiness in the neck, slight radiation across the neck and shoulders, may be associated with headaches, and worsening symptoms with turning the head from side to side or looking up.
How long does it take to do?
The actual injection takes only a few minutes. Please allow about an hour and a half for the procedure; this will include talking to your doctor before the procedure, signing the informed consent, positioning in the room, and observation by the recovery room nurse afterwards.
What medicines are injected?
The injection consists of a mixture of local anesthetics (e.g., bupivacaine) and the steroid medication (Kenalog).
Will it hurt?
All of our procedures begin by injecting a small amount of local anesthetic through a very small needle. It feels like a little pinch and then a slight burning as the local anesthetic starts numbing the skin. After the skin is numb, the procedure needle feels like a bit of pressure at the injection site. If you experience any pain during the procedure, your doctor will inject more local anesthetic as needed.
Will I be “put out” for this procedure?
No, we do offer mild IV sedation to calm you and local anesthesia to numb the skin.
How is it done?
It is typically done with you lying on your stomach for back injections and on your back for neck injections. Your blood pressure, heart rate, and oxygenation will be monitored. In addition to your doctor and the x-ray technician, there will be a nurse in the room at all times if you have any questions or discomfort during the procedure. The skin in the back is cleaned with antiseptic solution and then the procedure is done. Very small needles are placed within the joint capsule and a small volume (usually about 1 mL) is placed in each joint.
What should I expect after the injection?
Shortly after the injection, you may notice that your pain may be gone or considerably less. This is due to the effect of the local anesthetic and lasts only for a few hours. Your pain may return and you may have some soreness at the injection site for a day or so. You should start noticing pain relief starting about 2-3 days after the procedure.
What should I do after the procedure?
We advise the patients to take it easy for a day or so after the procedure. Perform the activities as tolerated by you. Your recovery room nurse will give you instructions upon discharge.
Can I go back to work the same day or the next day?
Your doctor or recovery room nurse will discuss this with you.
How long does it last?
The long-term effect of the medication cannot be predicted. Usually, the immediate effect is from the local anesthetic injected. This wears off in a few hours. The steroid starts working in about 2-3 days and its effect can last for several days to a few months.
How many injections do I need to have?
This will vary with each patient; your doctor will discuss this with you.
Can I have more than one injection?
It depends upon the response of the first Injection.Your doctor will discuss this with you.
How will I know if it will help?
It is very difficult to predict how helpful injections will be. Generally, patients who have the symptoms described above will do well. Obviously, since there are several pain generators in the spine, the degree of response will vary widely. Patients with recent onset of pain may respond much better than ones with longstanding pain.
What are the risks and side effects?
Overall, this procedure has very few risks. However, as with any procedure, there are some risks and side effects you should know about. Commonly encountered side effects are increased pain from the injection (usually temporary), inadvertent puncture of the “sack” containing spinal fluid (may cause headaches), infection, bleeding, nerve damage, or no relief from your usual pain. Side effects of the injected steroid may include weight gain, increase in blood sugar (mainly in diabetics), water retention, suppression of your own natural production of steroids, or temporary suppression of your immune system.
Who should not have this injection?
The following patients should not have this injection: if you are allergic to any of the medications to be injected or if you have an active infection going on. If you are on blood thinners, please talk with your doctor.
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SELECTIVE NERVE ROOT BLOCK
What is a selective nerve root block?
A selective nerve root block is an injection of an anti-inflammatory steroid (e.g.,Kenalog) along a specific nerve root. Along the spine, there are several “holes” or “foramina” through which nerve roots emerge. If these foramina are partially closed from bulging disks, bone spurs, misalignment of vertebrae, etc., the nerve root can also be pinched. This typically causes a shooting or radiating pain along that nerve root. In a selective nerve root block, a small needle is placed in the foramen alongside the nerve root and the steroid dose is injected.
Why is it done?
When the nerves in the foramina are irritated or pinched by a bulging disk, narrowed “nerve canal” or bone spur, the resulting inflammation can cause pain, numbness, or tingling. The steroid injected can reduce inflammation of nerves in the specific foramen and thus reduce pain and other symptoms.
How long does it take to do?
The actual injection takes only a few minutes. Please allow about an hour and a half for the procedure; this will include talking to your doctor before the procedure, signing the informed consent, positioning in the room, and observation by the recovery room nurse afterwards.
What medicines are injected?
The injection consists of a mixture of local anesthetics (e.g., bupivacaine) and the steroid medication (Kenalog).
Will it hurt?
All of our procedures begin by injecting a small amount of local anesthetic through a very small needle. It feels like a little pinch and then a slight burning as the local anesthetic starts numbing the skin. After the skin is numb, the procedure needle feels like a bit of pressure at the injection site. If you experience any pain during the procedure, your doctor will inject more local anesthetic as needed. The actual placement of the needle is not painful. However, keep in mind the nerve root is pinched and irritated. If the needle tip brushes against the nerve during placement, you may feel a “zing” down the nerve root, similar to striking your “funny bone”. During the injection of the steroid and local anesthetic, there may be a temporary achiness along the nerve root until the local anesthetic sets in, usually in about 15 seconds. These sensations are normal.
Will I be “put out” for this procedure?
No, we do offer mild IV sedation to calm you and local anesthesia to numb the skin.
How is it done?
It is typically done with you lying on your stomach for back injections and on your back for neck injections. Your blood pressure, heart rate, and oxygenation will be monitored. In addition to your doctor and the x-ray technician, there will be a nurse in the room at all times if you have any questions or discomfort during the procedure. The skin in the back or neck is cleaned with antiseptic solution and then the procedure is done.
What should I expect after the injection?
Immediately after the injection, you may feel your legs or arms, along that specific nerve root, becoming slightly heavy or numb. You may notice that your pain may be gone or considerably less. This is due to the effect of the local anesthetic and lasts only for a few hours. Your pain may return and you may have some soreness at the injection site for a day or so. You should start noticing pain relief starting about 2-3 days after the procedure.
What should I do after the procedure?
We advise the patients to take it easy for a day or so after the procedure. Perform the activities as tolerated by you. Your recovery room nurse will give you instructions upon discharge.
Can I go back to work the same day or the next day?
Your doctor or recovery room nurse will discuss this with you.
How long does it last?
The long-term effect of the medication cannot be predicted. Usually, the immediate effect is from the local anesthetic injected. This wears off in a few hours. The steroid starts working in about 2-3 days and its effect can last for several days to a few months.
How many injections do I need to have?
The typical series of injections is for about two-three, spaced about a week apart. You should expect a gradual overall improvement in pain after each injection.
Can I have more than one injections?
Yes, the injection can be repeated. Your doctor will discuss this with you, based on your response to the first injection.
How will I know if it will help?
It is very difficult to predict how helpful injections will be. Generally, patients who have “radicular” symptoms (radiating outward or downward, like sciatica) respond well. Patients with recent onset of pain may respond much better than ones with longstanding pain.
What are the risks and side effects?
Overall, this procedure has very few risks. However, as with any procedure, there are some risks and side effects you should know about. Commonly encountered side effects are increased pain from the injection (usually temporary), inadvertent puncture of the “sack” containing spinal fluid (may cause headaches), infection, bleeding, nerve damage, or no relief from your usual pain. Side effects of the injected steroid may include weight gain, increase in blood sugar (mainly in diabetics), water retention, suppression of your own natural production of steroids, or temporary suppression of your immune system.
Who should not have this injection?
The following patients should not have this injection: if you are allergic to any of the medications to be injected or if you have an active infection going on. If you are on blood thinners, please talk with your doctor.
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INTERCOSTAL NERVE BLOCKS
What is an intercostal nerve block?
An intercostal nerve block is a block of nerves that lie underneath the lower edge of each rib. For certain types of injuries, e.g., rib fractures, nerve injuries to the chest wall, postoperative pain along the rib nerves (“intercostal nerves”), injection of a small amount of local anesthetic can significantly diminish pain.
How long does it take to do?
The actual injection takes only a few minutes. Please allow about an hour and a half for the procedure; this will include talking to your doctor before the procedure, signing the informed consent, positioning in the room, and observation by the recovery room nurse afterwards.
What medicines are injected?
The diagnostic injection consists of local anesthetic only. If the diagnostic injection is successful, your doctor may discuss with you the option of injecting other medications that could last for several weeks, months, or even permanently.
Will it hurt?
All of our procedures begin by injecting a small amount of local anesthetic through a very small needle. It feels like a little pinch and then a slight burning as the local anesthetic starts numbing the skin. After the skin is numb, the procedure needle feels like a bit of pressure at the injection site. If you experience any pain during the procedure, your doctor will inject more local anesthetic as needed.
Will I be “put out” for this procedure?
No, we do offer mild IV sedation to calm you and local anesthesia to numb the skin.
How is it done?
It is typically done with you lying on your stomach or on the back depending upon the location of the pain. Your blood pressure, heart rate, and oxygenation will be monitored. In addition to your doctor and the x-ray technician, there will be a nurse or medical assistant in the room at all times if you have any questions or discomfort during the procedure. The skin over the affected rib(s) is cleaned with antiseptic solution and then the procedure is done. A very small, slightly blunt needle is carefully placed under the rib, contrast agent is injected and its path is verified by x-ray. Then, the medicine is injected.
What should I expect after the injection?
Shortly after the injection, you may notice that your pain may be gone or considerably less. You will be kept in the recovery room for a short period for observation. Very rarely, this injection can result in a complication called a pneumothorax (collapsed lung) so a chest x-ray may be obtained.
What should I do after the procedure?
We advise the patients to take it easy for a day or so after the procedure. Perform the activities as tolerated by you. Your recovery room nurse will give you instructions upon discharge.
Can I go back to work the same day or the next day?
Your doctor or recovery room nurse will discuss this with you.
How long does it last?
The long-term effect of the medication cannot be predicted. For the diagnostic injection, the duration is only for the effectiveness of the local anesthetic. If other agents are used, the block may last for weeks, months, or even permanently.
How many injections do I need to have?
This will vary with each patient; your doctor will discuss this with you.
Can I have more than one injection?
If the first injection is successful but the pain returns, you may be eligible for another injection, if you had relief from pain for a reasonable period of time. Your doctor will discuss this with you.
How will I know if it will help?
It is very difficult to predict how helpful injections will be. Generally, patients who have the symptoms described above will do well. Obviously, since there are several pain generators for back and chest wall pain, the degree of response will vary widely. Patients with recent onset of pain may respond much better than ones with longstanding pain.
What are the risks and side effects?
Overall, this procedure has very few risks. However, as with any procedure, there are some risks and side effects you should know about. Commonly encountered side effects are increased pain from the injection (usually temporary), inadvertent puncture of the “sack” containing spinal fluid (may cause headaches), infection, bleeding, nerve damage, or no relief from your usual pain. One complication that is very rare but can occur with this block is a “pneumothorax” (a collapsed lung). If you develop symptoms of shortness of breath a few hours after the procedure, you should call 911 immediately.
Who should not have this injection?
The following patients should not have this injection: if you are allergic to any of the medications to be injected or if you have an active infection going on. If you are on blood thinners, please talk with your doctor.
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MEDIAL BRANCH BLOCKS
What is a medial branch block?
A medial branch block is an injection of an anti-inflammatory steroid (e.g., Kenalog) on the medial branch nerves that supply the facet joints. The facet joints, also known as the zygapophysial joints, are part of the bony framework of the spine. They are small bony projections from one vertebra meeting with similar bony projections from the vertebra above or below. Sometimes, due to a variety of acute and chronic conditions, the facet joints can become inflamed. For lower back (lumbar) facet joints, the pattern of pain is usually an achiness in the low back, radiating across the lower back and slightly down the back of the buttocks and upper thighs. Usually, standing or bending backward worsens the pain. For neck (cervical) facet joints, the pattern of pain is an achiness in the neck, slight radiation across the neck and shoulders, and worsening symptoms with turning the head from side to side or looking up, headaches and whiplash.
How long does it take to do?
The actual injection takes only a few minutes. Please allow about an hour and a half for the procedure; this will include talking to your doctor before the procedure, signing the informed consent, positioning in the room, and observation by the recovery room nurse afterwards.
What medicines are injected?
The injection consists of a mixture of local anesthetic (e.g., bupivacaine) and a small dose of the steroid medication (Kenalog).
Will it hurt?
All of our procedures begin by injecting a small amount of local anesthetic through a very small needle. It feels like a little pinch and then a slight burning as the local anesthetic starts numbing the skin. After the skin is numb, the procedure needle feels like a bit of pressure at the injection site. If you experience any pain during the procedure, your doctor will inject more local anesthetic as needed.
Will I be “put out” for this procedure?
No, but we do offer mild IV sedation to calm you and local anesthesia to numb the skin.
How is it done?
It is typically done with you lying on your stomach for back injections and on your back for neck injections. Your blood pressure, heart rate, and oxygenation will be monitored. In addition to your doctor and the x-ray technician, there will be a nurse in the room at all times if you have any questions or discomfort during the procedure. The skin in the back is cleaned with antiseptic solution and then the procedure is done. Very small needles are placed along the bony landmarks that mark the location of the medial branch nerves. A small volume, usually about 1 mL, is injected along each nerve.
What should I expect after the injection?
Shortly after the injection, you may notice that your pain may be gone or considerably less. This is due to the effect of the local anesthetic and lasts only for a few hours to a few days.
What should I do after the procedure?
We advise the patients to take it easy for a day or so after the procedure. Perform the activities as tolerated by you. This is a diagnostic test and it is important to maintain reasonably normal activities so the block’s efficacy can be evaluated. You will be given instructions upon discharge.
Can I go back to work the same day or the next day?
Your doctor or recovery room nurse will discuss this with you.
How long does it last?
This is a diagnostic test and the injection seldom lasts more than a few hours or a couple of days, at the most. This is normal. This injection is performed as a predictor of the efficacy of radiofrequency lesioning of these medial branch nerves.
How many injections do I need to have?
Usually just one in any region (lumbar, cervical, thoracic, etc.) Multiple levels are blocked simultaneously, usually on one side only. If relief is experienced on the injected side but not on the opposite side, the diagnostic block is a success. The next step is radiofrequency lesioning of the medial branch nerve.
How will I know if it will help?
It is very difficult to predict how helpful injections will be. Generally, patients who have the symptoms described above will do well. Obviously, since there are several pain generators in the spine, the degree of response will vary widely. If you do not obtain reasonable relief from this diagnostic injection, it is unlikely you will obtain relief from radiofrequency lesioning. Your doctor will discuss this with you.
What are the risks and side effects?
Overall, this procedure has very few risks. However, as with any procedure, there are some risks and side effects you should know about. Commonly encountered side effects are increased pain from the injection (usually temporary), infection, bleeding, nerve damage, or no relief from your usual pain. Side effects of the injected steroid may include weight gain, increase in blood sugar (mainly in diabetics), water retention, suppression of your own natural production of steroids, or temporary suppression of your immune system.
Who should not have this injection?
The following patients should not have this injection: if you are allergic to any of the medications to be injected or if you have an active infection going on. If you are on blood thinners, please talk with your doctor.
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RADIOFREQUENCY (RF) LESIONING
What is Radiofrequency (RF) lesioning?
Radiofrequency lesioning is a procedure in which special needles are used to create lesions along selected nerves. The needles heat the nerve to 80 deg C (about the temperature of hot, not boiling, water). When this heat is applied to the nerve for about 2-3 minutes, the nerve stops carrying pain signals. The body tends to try to re-grow nerves that are blocked in this manner but that process can take up to a year or longer.
Am I a candidate for Radiofrequency lesioning?
Radiofrequency lesioning is offered to patients with certain types of low back or neck pain (predominantly pain from the facet joints), patients with RSD (reflex sympathetic dystrophy, also known as Complex Regional Pain Syndrome, types I or II), or abdominal pain responsive to splanchnic nerve blocks. You must have responded well to diagnostic local anesthetic blocks to be a candidate for RF lesioning. How effective RF lesioning will be to you depends on how well you respond to the “temporary” or diagnostic block.
What are the benefits of Radiofrequency lesioning?
The procedure disrupts nerve conduction (such as conduction of pain signals), and it may in turn reduce pain, and other related symptoms. Approximately 70-80% of patients will get a good block of the intended nerve. This should help relieve that part of the pain that the blocked nerve controls. Sometimes after a nerve is blocked, it becomes clear that there is pain from the other areas as well.
How long does the procedure take?
Depending upon the areas to be treated, the procedure can take from about 90 minutes to 2 hours.
How is it actually performed?
Since nerves cannot be seen on x-ray, the needles are positioned using bony landmarks that indicate where the nerves usually are. Fluoroscopy (x-ray) is used to identify those bony landmarks. After needle placement, extremely low voltages are applied to the needle to test for proper placement. You will report feeling a pressure, tingling, buzzing, twitching, or tapping sensation. After confirmation of the needle tip position, a small amount of local anesthetic is injected. After the nerve is sufficiently numbed, higher radiofrequency voltages are applied and the nerve heats to the desired temperature.
How painful is it?
All of our procedures begin by injecting a small amount of local anesthetic through a very small needle. It feels like a little pinch and then a slight burning as the local anesthetic starts numbing the skin. After the skin is numb, the procedure needle feels like a bit of pressure at the injection site. If you experience any pain during the procedure, your doctor will inject more local anesthetic as needed.
Will I be “put out” for this procedure?
No. This procedure is done under local anesthesia along with mild IVsedation. The amount of sedation given generally depends upon the patient tolerance. It is necessary for you to be awake enough to communicate easily during the procedure.
What should I expect after the procedure?
After recovery from the sedation, you should have someone drive you home. There will be some muscle soreness that may persist for up to a week. Application of ice packs will help. Your doctor will also discuss with you any medications you can take to help with the post-procedure discomfort. Although most patients experience significant relief within a week, it can sometimes take up to 3-4 weeks. You will be given instructions upon discharge.
Can I go to work to work the next day?
You should be able to return to your work the next day. Sometimes soreness at the injection site causes you to be off work for a day or two.
How long will the effects of the procedure last?
If successful, the effects of the procedure can last from 9-18 months.
How many procedures do I need to have?
Your doctor will evaluate this on subsequent visits. Keep in mind that although this is a “permanent” procedure, the body tends to re-grow these nerves over time. You may need to have it repeated in the future.
What are the risks and side effects?
Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and the possibility of complications. The risks and complications are dependent upon the sites that are lesioned. Any time there is an injection through the skin, there is a risk of infection. This is why sterile conditions are used for these blocks. The needles have to go through skin and soft tissues, which will cause soreness. The nerves to be lesioned may be near blood vessels or other nerves, which can be potentially damaged. Great care is taken when placing the radio frequency needles, but sometimes complications occur. Your doctor will discuss all of the risks and benefits when you meet with him/her prior to the procedure.
Who should not have this procedure?
If you are on a blood thinning medication (e.g. Coumadin®, Plavix®), or if you have an active infection going on, you should not have the procedure. If you have not responded to local anesthetic blocks, you may not be a candidate for this procedure.
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SPINAL CORD STIMULATION
What is a spinal cord stimulator (SCS)?
A spinal cord stimulator, also called a dorsal column stimulator is a device which stimulates pain-carrying nerves via small electrical wires placed in the “epidural space” just outside the spinal cord.
Am I a candidate for spinal cord stimulation?
Spinal cord stimulation is offered to patients with chronic and severe neuropathic (pain from damaged nerve tissue) pain. Some patients may have neuropathic pain in their extremities and some may have severe chronic low-back pain after spine surgery. It is for patients who have not responded to other treatment modalities.
What is the purpose of the device?
A spinal cord stimulator interrupts nerve conduction along certain types of nerves that predominantly carry pain signals to the brain.
How long does the procedure take?
This is a two-stage procedure. The first stage is the trial stage and does not involve any surgery. Through a specialized needle, one or two wires are placed in the epidural space. These wires are attached to an external generator which the patient controls. The wires may be left in place for up to 5-7 days. During this phase, the patient engages in relatively normal activity and gauges the effectiveness of the device. If it is successful and the patient is satisfied by the degree of pain relief, the second stage involves placing the wires under the skin, tunneling the wires to the location of the battery, and placement of the battery just under the skin. Each procedure can take up to 90 minutes-2 hours.
Will the procedure hurt?
All of our procedures begin by injecting a small amount of local anesthetic through a very small needle. It feels like a little pinch and then a slight burning as the local anesthetic starts numbing the skin. After the skin is numb, the procedure needle feels like a bit of pressure at the injection site. If you experience any pain during the procedure, your doctor will inject more local anesthetic as needed.
Will I be “put out” for this procedure?
The placement of the wires is done under local anesthesia with mild IV sedation. This is necessary to ensure proper placement of the wires. The amount of sedation given generally depends upon the patient tolerance. For the generator placement, patients are given stronger intravenous sedation.
How is the procedure performed?
It is done with the patient lying on the stomach when placing the wires. For the insertion of the generator, patients are placed on their back or on the side. The patients are monitored with EKG, blood pressure cuff and blood oxygen-monitoring device. The skin is cleaned with antiseptic solution and then the procedure is carried out. X-ray (fluoroscopy) is used to guide the needle for wire placement.
Where are the wires inserted? Where is the generator placed?
For the pain involving lower back and lower extremities, the wires are inserted in the midline at the lower back. The generator is then placed on the side of the abdomen. For the pain involving upper extremities, the wires are inserted in the midline at the upper back. The generator is then placed on the side of the chest.
What should I expect after the procedure?
If the procedure is successful, you may feel that your pain may be gone or quite less. You will experience a fairly constant sensation of stimulation. You may have soreness due to the needles used for a day or two.
What should I do after the procedure?
This procedure is normally a day-procedure. Some patients may be kept overnight for observation. You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. Perform the activities as tolerated by you. You will be given instructions upon discharge.
How long will the generators last?
The implanted generators are rechargeable and the charging interval depends on the amount of power required by you to feel comfortable. Recharge intervals are typically every 2-4 weeks. The generator can last for 5-8 years.
What are the risks and side effects?
Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. Please discuss your concerns with your physician.
Who should not have this procedure?
If you are on a blood-thinning medication (e.g. Coumadin®), or if you have an active infection going on, you should not have the procedure.
Where can I get additional information?
Give us a call and we can assist you in getting more information.
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DISCOGRAPHY
What is Discography?
Discography is a diagnostic procedure in which x-ray dye is injected under gentle pressure into the discs of the spine. Based on the presence or absence of pain during the injection of dye, your doctor may be able to determine if the disc is responsible for your pain symptoms. After the x-ray dye is injected, an x-ray picture is taken of the discs. This image, called a “discogram” may be normal or may show tears (fissures) in the lining of the disc. Typically, a surgeon will request discography to determine which specific disc is the pain generator and to plan subsequent treatment.
How do I know if my pain is from a damaged disc?
During the procedure, your doctor will place a needle in the disk and under gentle pressure, inject x-ray contrast into the disc. This may cause pain and if the pain is the same as your baseline pain (called “concordant pain”), this will determine if the disc is responsible for your pain.
How is discography performed?
The procedure is done with you lying on your stomach. Your vital signs will be monitored with an EKG, blood pressure cuff, and oxygen monitor. The skin over the injection site(s) is cleaned with an antiseptic solution and then the injections are carried out. An x-ray machine is used to identify the specific levels. After the procedure, you will be placed on you back in the recovery room.
What will I feel during the injection? Will it hurt?
All of our procedures begin by injecting a small amount of local anesthetic through a very small needle. It feels like a little pinch and then a slight burning as the local anesthetic starts numbing the skin. After the skin is numb, the procedure needle feels like a bit of pressure at the injection site. If you experience any pain during the procedure, your doctor will inject more local anesthetic as needed. When a normal disc is injected, you will feel a sense of pressure, but not pain. When an abnormal disc is injected, you will feel pain. It is important to try to tell if the pain you are feeling is your usual pain (“concordant pain”) or different (“discordant pain”). With each disc injected, you will be asked if it is painful, where you feel the pain and whether it is in the same area as your usual pain.
How many discs will be injected?
Based on your symptoms and your MRI, we will identify which discs we suspect are your pain generators. These discs will be injected. In addition, a normal disc is injected to serve as a reference point.
How long does discography take?
Discography takes about 60-90 minutes, depending on how many levels are injected.
What is actually injected?
The injection consists of x-ray dye. It is usually mixed with some antibiotics to prevent infection.
Will I be “put out” for this procedure?
You will not be completely “put out” but you will be mildly sedated with IV medications. It is important you are at least awake enough to communicate with your doctor. This procedure is done primarily under local anesthesia.
Will my pain be better after the injection?
No. Discography is a diagnostic procedure that is meant to identify the source of pain. Definitive treatment to treat the pain will be planned with your doctor and referring surgeon.
What should I do after the procedure?
We advise the patients to take it easy for a day or so after the procedure. Your recovery room nurse will give you instructions upon discharge.
Can I go to work to work the next day?
We usually recommend taking 2-3 days off work after the injection.
What are the risks and side effects of discography?
Overall, this procedure has few risks. However, as with any procedure, there are some risks and side effects you should know about. Commonly encountered side effects are increased pain from the injection (usually temporary), inadvertent puncture of the “sack” containing spinal fluid (may cause headaches), infection, bleeding, nerve damage, or no relief from your usual pain.
Who should not have this injection?
The following patients should not have this injection: if you are allergic to any of the medications to be injected or if you have an active infection going on. If you are on blood thinners, please talk with your doctor.
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EPIDURAL BLOOD PATCH
What is an epidural blood patch?
An epidural blood patch is an injection of your blood into the epidural space. The epidural space is not an injection into the spinal cord itself. The spinal cord and spinal nerves are in a “sack” containing clear fluid (cerebrospinal fluid). The area outside this “sack” is called the epidural space.
Why is it done?
There are certain conditions under which patients will have had injections in the spinal column. Examples include an epidural during labor, a diagnostic spinal tap, a therapeutic spinal injection, etc. A small number of patients will experience a severe headache after the procedure, usually worse with standing and better when lying down. This is due to a persistent leak of spinal fluid into the epidural space. Although the headache itself is harmless, it can be very severe and very debilitating. Your doctor may ask you to come to our clinic for an “epidural blood patch”. The injection of a freshly drawn sample of your own blood into the epidural space “plugs the leak” and the headache goes away.
How long does it take to do?
The actual injection takes only a few minutes. Please allow about 90minutes to 2 hours for the procedure; this will include talking to your doctor before the procedure, signing the informed consent, positioning in the room, and observation by the recovery room nurse afterwards.
What medicines are injected?
Except for the local anesthetic to numb your skin, no other medications are injected.
Will it hurt?
All of our procedures begin by injecting a small amount of local anesthetic through a very small needle. It feels like a little pinch and then a slight burning as the local anesthetic starts numbing the skin. After the skin is numb, the procedure needle feels like a bit of pressure at the injection site. If you experience any pain during the procedure, your doctor will inject more local anesthetic as needed.
Will I be “put out” for this procedure?
No, we do offer mild IV sedation to calm you and local anesthesia to numb the skin.
How is it done?
It is typically done with you lying on your stomach. Your blood pressure, heart rate, and oxygen levels will be monitored. In addition to your doctor and the x-ray technician, there will be a nurse in the room at all times if you have any questions or discomfort during the procedure. The skin in the back is cleaned with antiseptic solution. A separate area where a good vein is available is also cleaned with antiseptic solution. A small intravenous catheter is placed in the vein. After your doctor has placed the epidural needle near the affected area, your nurse will draw about 25 cc of blood from your vein and give it to the doctor. The doctor will then gradually inject the blood until you feel severe pressure in the back. Typically, about 15-25 cc are injected.
What should I expect after the injection?
Immediately after the injection, you may feel pressure in the back. This is due to the effect of the blood in the epidural space. After resting for about 30 minutes, you will be asked to stand up. Typically, most patients experience significant relief immediately. After a few hours, your body will have had a chance to replenish the lost spinal fluid and your headache should continue to get better.
What should I do after the procedure?
We advise patients to take it easy for a day or so after the procedure. You should stay flat in bed for the first day although bathroom visits are permitted. Your recovery room nurse will advise you about your activities at home upon discharge.
Can I go back to work the same day or the next day?
You should not go back to work the same day. By the next day, most patients will be able to although you might need an extra day to recover.
How long does it last?
The epidural blood patch is permanent. After the injection of your blood, the body’s own healing system should take over and finish repairing the spinal fluid leak. A small number of patients (usually less then 10%) may need to have a second blood patch.
What are the risks and side effects?
Overall, this procedure has very few risks. However, as with any procedure, there are some risks and side effects you should know about. Commonly encountered side effects are increased pain from the injection (usually temporary), inadvertent puncture of the “sack” containing spinal fluid (may not relieve your headaches), infection, bleeding, nerve damage, or no relief from your headache.
Who should not have this injection?
The following patients should not have this injection: if you are allergic to any of the medications to be injected or if you have an active infection going on. If you are on blood thinners, please talk with your doctor.
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