Treatments & Procedures

TREATMENTS & PROCEDURES

Randall Pain Management offers groundbreaking treatments along with traditional pain management procedures. By working closely with patients on personalized treatment plans, Dr. Randall achieves the highest compliance and effectiveness, while maintaining patient safety.

CERVICAL RADIOFREQUENCY DENERVATION

During this minimally-invasive procedure, the physician uses heat from radio waves to treat painful facet joints in your neck. This procedure is also called radiofrequency rhizotomy. It can treat pain that doesn’t respond to medications or to physical therapy.

Preparation

In preparation for the procedure, you lie on your stomach. You are given medicine to make you feel relaxed. The skin and tissue of your neck is numbed.

Inserting the Cannula

The physician inserts a tube called a “cannula.” A video x-ray device called a “fluoroscope” helps guide the cannula to the medial branch nerves in your spine. These tiny nerves carry pain signals from your facet joints to your brain.

Treating the Nerves

The physician inserts an electrode through the cannula. A weak electric jolt is used to test its position. If the jolt recreates the pain but does not cause any other muscular effects, it is positioned correctly. Then the physician uses the electrode to heat the nerve. This disrupts its ability to transmit pain signals. Several nerves may be treated if necessary.

End of Procedure

When the procedure is complete, the electrode and cannula are removed. A small bandage is placed on your skin. You will be monitored for a brief time before you are allowed to go home. Your injection site may feel sore after the procedure, and you may still have neck pain. If the correct nerves were treated, you will gradually experience pain relief as you heal. This may take several weeks. Your relief may last for several months.

CERVICAL EPIDURAL STEROID

This injection relieves pain in the neck, shoulders, and arms caused by a pinched nerve (or nerves) in the cervical spine. Conditions such as herniated discs and spinal stenosis can compress nerves, causing inflammation and pain. The medication injected helps decrease the swelling of nerves.

Patient Sedated

The procedure is performed with the patient lying down. Intravenous sedation may be administered, and a region of skin and tissue of the neck is numbed with a local anesthetic delivered through a small needle.

Needle Inserted

Using x-ray guidance (also called fluoroscopy), the physician guides a larger needle to the painful area of the neck. The needle is inserted into the epidural space, which is the region through which spinal nerves travel.

Contrast Dye Injected

Contrast dye is injected into the space to make sure the needle is properly positioned near the irritated nerve or nerves.

Steroid Injected –

A combination of an anesthetic and cortisone steroid solution is injected into the epidural space. The steroid is an anti-inflammatory medication. It is absorbed by the inflamed nerves to decrease swelling and relieve pressure. The needle is removed and a small bandage is applied.

End of Procedure

The patient goes to a recovery room and is given food and drink and discharged with post treatment instructions. Some patients may need only one injection, but it may take two or three injections (administered weeks apart) to provide significant pain relief.

CAUDAL EPIDURAL STEROID WITH CATHETER

This procedure is performed to diagnose and reduce abdominal pain caused by conditions such as cancer or pancreatitis. An injection is used to block the nerves serving the abdomen. An intravenous (IV) line may be used to administer medication to relax the patient.

Preparation

In preparation for the procedure, the patient lies face down. A cushion is placed under the abdomen to elevate the sacrum.

Anesthetic Injected

The physician administers a local anesthetic to numb the skin and the tissue above the small opening at the base of the sacrum. This opening is called the sacral hiatus.

Needle Inserted

When the area is numb, the physician guides a needle through the sacral hiatus and into the caudal epidural space. This is the open space in the sacrum where the irritated nerve roots are located.

Contrast Solution Injected

The physician injects contrast solution through the needle. The physician uses a fluoroscope (a type of x-ray device) to confirm that the tip of the needle is positioned correctly within the epidural space.

Medication Injected

After the needle’s position has been confirmed, the physician injects a steroid-anesthetic medication. This medication bathes the irritated nerve roots. It will help alleviate the patient’s pain.

End of Procedure

When the procedure is complete, the physician removes the needle and bandages the insertion site. The patient may feel significant relief after one injection. Some patients may need multiple injections before they feel the full benefit of the medication.

LUMBAR EPIDURAL STEROID

This injection procedure is performed to relieve low back and radiating leg pain. Steroid medication can reduce the swelling and inflammation caused by spinal conditions.

Patient Positioning

The patient lies face down. A cushion under the stomach area provides comfort and flexes the back. In this position, the spine opens and allows for easier access to the epidural space.

Tissue Anesthetized

A local anesthetic is used to numb the skin. All the tissue down to the surface of the lamina portion of the lumbar vertebra bone is anesthetized. The physician slides a thicker needle through the anesthetized track.

Fluoroscopic Guidance

Using a fluoroscope for guidance, the physician slides the needle toward the epidural space between the L-4 and L-5 vertebra. A contrast solution is injected. The physician uses the fluoroscope to confirm the correct location of the needle tip.

Steroids Injected

A steroid-anesthetics mix is injected into the epidural space, bathing the painful nerve root with soothing medication.

End of Procedure

The needle is removed, and a small bandage is applied to cover the tiny needle surface wound. In some cases it may be necessary to repeat the procedure as many as three times to get the full benefit of the medication. Many patients get significant relief from only one or two injections.

LUMBAR RADIOFREQUENCY DENERVATION

During this minimally-invasive procedure, the physician uses heat from radio waves to treat painful facet joints in your lower back. This procedure is also called radiofrequency rhizotomy. It can treat pain that doesn’t respond to medications or to physical therapy.

Preparation

In preparation for the procedure, you lie on your stomach. You are given medicine to make you feel relaxed. The skin and tissue of your back is numbed.

Inserting the Cannula

The physician inserts a tube called a “cannula.” A video x-ray device called a “fluoroscope” helps guide the cannula to the medial branch nerves in your spine. These tiny nerves carry pain signals from your facet joints to your brain.

Treating the Nerves

The physician inserts an electrode through the cannula. A weak electric jolt is used to test its position. If the jolt recreates the pain but does not cause any other muscular effects, it is positioned correctly. Then the physician uses the electrode to heat the nerve. This disrupts its ability to transmit pain signals. Several nerves may be treated if necessary.

End of Procedure

When the procedure is complete, the electrode and cannula are removed. A small bandage is placed on your skin. You will be monitored for a brief time before you are allowed to go home. Your injection site may feel sore after the procedure, and you may still have back pain. If the correct nerves were treated, you will gradually experience pain relief as you heal. This may take several weeks. Your relief may last for several months.

THORACIC RADIOFREQUENCY DENERVATION

During this minimally-invasive procedure, the physician uses heat from radio waves to treat painful facet joints in your upper back. This procedure is also called radiofrequency rhizotomy. It can treat pain that doesn’t respond to medications or to physical therapy.

Preparation

In preparation for the procedure, you lie on your stomach. You are given medicine to make you feel relaxed. The skin and tissue of your back is numbed.

Inserting the Cannula

The physician inserts a tube called a “cannula.” A video x-ray device called a “fluoroscope” helps guide the cannula to the medial branch nerves in your spine. These tiny nerves carry pain signals from your facet joints to your brain.

Treating the Nerves

The physician inserts an electrode through the cannula. A weak electric jolt is used to test its position. If the jolt recreates the pain but does not cause any other muscular effects, it is positioned correctly. Then the physician uses the electrode to heat the nerve. This disrupts its ability to transmit pain signals. Several nerves may be treated if necessary.

End of Procedure

When the procedure is complete, the electrode and cannula are removed. A small bandage is placed on your skin. You will be monitored for a brief time before you are allowed to go home. Your injection site may feel sore after the procedure, and you may still have back pain. If the correct nerves were treated, you will gradually experience pain relief as you heal. This may take several weeks. Your relief may last for several months.

SAROILIAC INJECTION

This injection procedure is performed to relieve pain caused by arthritis in the sacroiliac joint where the spine and hip bone meet. The steroid medication can reduce swelling and inflammation in the joint.

Sacroiliac Joint Located

The patient lies face down. A cushion is placed under the stomach for comfort and to arch the back. The physician uses touch and a fluoroscope to find the sacroiliac joint.

Anesthetic Injected

A local anesthetic numbs the skin and all the tissue down to the surface of the sacroiliac joint.

Needle Inserted

The physician advances a needle through the anesthetized track and into the sacroiliac joint.

Steroids Injected

A steroid-anesthetics mix is injected into the sacroiliac joint, bathing the painful area in medication.

End of Procedure

The needle is removed, and a small bandage is used to cover the tiny surface wound.

THORACIC EPIDURAL STEROID

This outpatient procedure is an injection performed to relieve pain in the upper back.

Preparation

The patient sits or lies down to expose the back. The back is cleaned and sterilized, and a local anesthetic is administered to numb the tissue of the injection site down to the spinal column.

Inserting the Needle

The physician uses an x-ray device called a fluoroscope to guide a needle down to the vertebra that is causing the pain. The needle is carefully pushed into the epidural space, which is the area surrounding the spinal cord. A contrast solution is injected to confirm the needle’s position.

Inserting the Medication

The physician injects a steroid-anesthetic mix into the epidural space, bathing the painful areas with soothing medication. The mixture will help reduce inflammation and reduce pain.

End of Procedure

The needle is removed, and the injection site may be covered with a small bandage. Extended pain relief usually begins within three to five days of the injection. In some cases it may be necessary to repeat the procedure as many as three times to get the full benefit of the medication. However, many patients get significant relief from only one or two injections.

Botox Injection for Migraine

Introduction

Botox® (onabotulinum toxin A) was licensed specifically for the treatment of chronic migraine in July 2010 by the Medicines and Healthcare products Regulatory Agency (MHRA). Botox® has not been shown to be effective for any other headache type (e.g. episodic migraine, tension-type headache, cluster headache) as yet. The information below outlines the evidence for the use of botulinum toxin in headache.

What is botulinum toxin?

Botulism – paralysis of muscles caused by high doses of botulinum toxin – was first described in 1817. The responsible bacterium, Clostridium botulinum, was not isolated until 1895. Seven different subtypes of botulinum toxin (A-G) are known. A highly dilute preparation of botulinum toxin type A (Botox®) was introduced in clinical practice in the 1970s and 1980s to treat squint and blepharospasm. Since then it has found uses in other areas of medicine including dystonia (including writer’s cramp), post-stroke spasticity, and hyperhidrosis. Other botulinum toxin preparations are available, both of type A (Dysport and Xeomin) and type B (Neurobloc or Myobloc), but these have never been tested in headache disorders.

Botulinum toxin and headache

In the mid-1990s a number of people reported improvement in headaches in patients receiving botulinum toxin for other reasons. Well-conducted clinical trials of botulinum toxin in various types of headache followed, but the results were disappointing, with no difference over placebo being found in tension-type headache, episodic migraine, and undifferentiated chronic headache. Detailed analysis of the results suggested, however, that there might be a subgroup of patients with chronic migraine who could benefit, and further trials were undertaken.

Botox® in chronic migraine: the PREEMPT trials

Two Phase 3 Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) trials recruited 1384 patients with chronic migraine, and randomised them to treatment with Botox® or placebo. These patients were suffering on average 20 days of headache each month, of which 18 were moderate or severe. Those randomised to Botox® received fixed-site, fixed dose injections every 12 weeks over 56 weeks. These injections covered seven specific areas of the head and neck, with a total dose of between 155-195 units. At six months, after two cycles of treatment, those treated with Botox® had on average eight less days of headache each month. After 12 months, 70% of those treated had ≤50% the number of headaches that they had done originally. Botox® was well-tolerated, the commonest side effects being neck pain (6.7%), muscular weakness (5.5%), and drooping of the eyelid (3.3%). No serious irreversible side effects have ever been reported in trials of Botox® in headache.

How does botulinum toxin work in chronic migraine?

The simple answer is that we don’t know fully. A recent US study by Rami Burstein et al using animal models suggested that botulinum toxin inhibits pain in chronic migraine by reducing the expression of certain pain pathways involving nerve cells in the trigeminovascular system. The trigeminovascular system is a sensory pathway thought to play a key role in the headache phase of a migraine attack.

Unlike many of the other conditions in which it is used, it is not thought to work by relaxing overactive muscles. Botulinum toxin has been shown to reduce pain in a number of disease states, including cervical dystonia, neuropathic pain, lower back pain, spasticity, myofascial pain, and bladder pain.

More research into the mechanism of action of botulinum toxin will hopefully shed light into all the pathways that it acts upon.

Is Botox® right for me?

Only patients with chronic migraine are eligible for treatment with Botox®. Chronic migraine is defined as headaches occurring on 15 or more days each month, at least half of which have migrainous features. There are, however, other treatments available to patients with chronic migraine, and it is important that patients have an informed discussion of their headaches and the options for treatment with a practitioner experienced in the diagnosis and management of headaches before a decision to use Botox® is taken.

Who can inject Botox® for chronic migraine?

At present the use of Botox® is restricted to a few specialist headache centres, but as time goes on there should be increasing numbers of trained injectors available. In all cases, however, you should ensure that the person injecting has received appropriate training, both in the diagnosis and management of chronic migraine, and in the delivery of Botox® according to the proven PREEMPT schedule.

Please note that the referral process differs for each location. In the first instance, patients who are struggling to manage their symptoms should discuss this with their general practitioner (GP) and if appropriate, seek referral to a specialist with an interest in headache disorders. Read more about seeking medical advice.

On visiting a migraine clinic a detailed history of the patient’s condition will be taken, including symptoms, frequency of attacks and any medication tried in the past or currently taking. Keeping a diary can help with this.

Availability of Botox® for treating chronic migraine on the NHS

The National Institute for Health and Clinical Excellence (NICE) issued guidance in June 2012 recommending Botox® is made available on the NHS as a preventive treatment option for adult patients with chronic migraine – this applies to NHS settings in England and Wales.

The Scottish Medicines Consortium (SMC) has advised NHS Scotland not to offer Botox® for the prophylaxis of headaches in adults with chronic migraine (2011 and reviewed in 2013 following resubmission). This guidance may be reviewed in future.

Following the NICE guidance, local NHS healthcare providers in England and Wales had three months to ensure the funding and resources were in place for suitable patients to access the treatment following recommendation by a suitably qualified health professional. This time frame has now elapsed and the treatment should be available locally on the NHS for those meeting the criteria. Access to treatments that have been recommended by NICE for use in the NHS, if your doctor says they are clinically appropriate for you, is a patient right enshrined in the NHS Constitution.

If your health professional has recommended that you are suitable for this treatment, but you or your health professional are having difficulty accessing the funding or resources for you to receive Botox® from your local NHS healthcare provider, then The Migraine Trust’s Advocacy Service may be able to provide further support.

NA

NA

Carpal Tunnel Injection

Carpal tunnel syndrome reflects a clinical diagnosis that involves one of the three main nerves in the arm. The median nerve passes through the carpal tunnel, which is located right here. The carpal tunnel itself houses the flexor tendons of the hand as well the fingers, the thumb, and the median nerve. Typically a patient will present with complaints of numbness and tingling, having to shake their hands in the morning. They might have complaints of numbness or tingling after typing at the keyboard or doing any repetitive motion that puts increased pressure on the wrist in either this direction or that direction.

Although the median nerve innervates the first 3.5 fingers of the hand, the patient usually does not have numbness and tingling just in that distribution. A lot of the times, they can have paresthesia within the whole hand and that sensation can vary from a frank falling asleep, to an itchiness, to feeling a need to stretch the hand, to do some type of motion, to shake the hand. A variety of those symptoms can occur.

What Causes Carpal Tunnel Syndrome?

There are about 5-6 main causes of carpal tunnel syndrome. Heredity plays an important role. Some people are born with congenitally small carpal tunnels. Any associated medical conditions, including rheumatoid arthritis, diabetes, and systemic conditions that may also increase the amount of fluid in the carpal tunnel may increase the likelihood of developing carpal tunnel syndrome.

What are the Symptoms of Carpal Tunnel Syndrome?

Patients often can present with difficulty buttoning their shirt, sometimes difficulty holding a pencil, quite often they’ll complain of dropping things inadvertently. When the symptoms are very bad, they’ll be able to see a visible atrophy of the muscles of their thumb.

How is Carpal Tunnel Syndrome Diagnosed?

In a physical examination for carpal tunnel syndrome, we’ll do a regular neurologic exam, testing the strength of all the muscles in their upper extremities, their sensation, and their reflexes. For carpal tunnel syndrome, there are a number of provocative tests that put pressure on the median nerve, which when a person does have carpal tunnel syndrome will be positive. Also during the physical examination, this is a chance to rule out when the numbness and tingling is not coming from carpal tunnel syndrome but also from other nerves, most often the neck.

In terms of diagnosis, the most objective way to diagnose carpal tunnel syndrome is to do an EMG and nerve conduction study, which provide a way to measure the degree of carpal tunnel syndrome (to classify as mild, moderate, severe) and also to rule out anything associated, number one, compressed nerves, or if there’s an associated and irritated nerve that’s coming from the neck.

The easiest way to look at carpal tunnel syndrome is to imagine that your hands are like light bulbs. When the light bulbs are going off in your house, that example can be related to the sensation of numbness and tingling in your hands. Sometimes that light bulb goes out when there’s something wrong with the light bulb itself, but sometimes it can go out because there’s something wrong with the power supply. So when evaluating for carpal tunnel syndrome, you want to see if it’s just the light bulbs, where the median nerves are specifically irritated, or if there is anything also going on with the power supply. The EMG and nerve conduction studies are good for telling that.

N/A

N/A

CERVICAL EPIDURAL STEROID WITH CATHETER

Epidural steroid injections (ESIs) are a frequently-used treatment for chronic pain syndromes.

A common characteristic among the syndromes treated with epidural steroid injections is a pain described as “radicular pain.”
The word radicular means root and typically refers to an irritated nerve root (radiculitis) or weakness associated with an affected nerve root (radiculopathy).

Radicular pain is pain that radiates from the spine down an irritated spinal nerve root. Irritation of a spinal nerve in the low back, called lumbar radiculopathy, causes pain that typically travels down a leg. Cervical radiculopathy describes pain that travels down an arm. Epidural injections are also used to treat nerve compression in the neck (cervical spine), as well as the low back (lumbar spine).
Conditions commonly treated with ESI:

Degenerative disc disease (Botwin 2007)
Spinal stenosis
Herniated discs (Lin 2006)
Spondylysis
Sciatica
Radiculitis
Radiculopathy
A study done at the Florida Spine Institute in 2007 confirmed that epidural steroid injections help reduce bilateral radicular pain and improve standing and walking in patients with degenerative lumbar spinal stenosis (Botwin 2007).

Procedure – Epidural Steroid Injection
The procedure involves injecting a medication into the epidural space, where irritated nerve roots are located. This injection includes both a long-lasting steroid and a local anesthetic (lidocaine, bupivacaine). The steroid reduces the inflammation and irritation, and the anesthetic works to interrupt the pain-spasm cycle and nociceptor (pain signal) transmission (Boswell 2007). The combination medicine then spreads to other levels and portions of the spine, reducing inflammation and irritation. The entire procedure usually takes less than 15 minutes.
The most important and greatest success achieved with the use of epidural steroid injections (ESI) is the rapid relief of symptoms that allows patients to experience enough relief to become active again. With this help, patients regain the ability to resume their normal daily activities.
There are several types of epidural steroid injections, and the specific type you receive depends on the cause of your pain syndrome. The trained pain specialist will decide which procedure is more beneficial to you after reviewing your history, performing a physical exam, and determining the cause of your pain. The main difference in the types of ESIs is the position where the needle is inserted as well as the amount of nerve roots treated.

Types of Epidural Steroid Injections

Intralaminar Injection: After your skin is anesthetized, the needle enters the mid-line of your back between your spinous processes (most prominent bones in the mid-line of your spine). The needle enters between the lamina of two vertebrae directly posterior to the vertebrae. The combination of steroid and anesthetic is delivered into the epidural space in the midline and spreads to the nerve roots on both sides of the spine. The evidence for interlaminar epidural steroid injections is strong for short-term relief and limited for long-term relief in managing radiculopathy.

Transforaminal Injection: After your skin is anesthetized, the needle enters through the side of the vertebra above the opening for the exiting nerve root. This approach treats one side at a time and is thought to be more specific. Pain specialists who are treating patients who have undergone previous spine surgery and have foreign bodies (surgical pins, surgical rods, or screws) as well as previous scarring prefer this method because they are able to avoid these structures. There is powerful evidence suggesting that transforaminal ESIs are effective for short-term and moderate for long-term improvement in managing lumbar back pain (Manchikanti 2007).
Caudal Injection: After your skin is anesthetized, a needle enters the epidural space by your tailbone. This technique allows for a catheter to be placed (Racz catheter) and larger volumes of steroid and anesthetic to be delivered. The additional medication can be used to affect more nerve roots distributing to the inflamed area at the same time. Often caudal ESIs are combined with another procedure called lysis of adhesions or the Racz Procedure, which is used to treat epidural scaring. The evidence for caudal ESIs is similar to that of the transformational ESIs.

Benefits of Epidural Steroid Injections

Epidural steroid injections are considered routine and relatively painless. Approximately 72% of patients experienced immediate pain relief in a 2007 research trial to evaluate the usefulness of a cervical interlaminar epidural steroid injection in patients with neck pain and cervical radiculopathy (Kwon 2007). If pain relief is only moderately achieved with the first injection, then another injection can be given in two weeks that may provide additional relief.
The use of multiple injections was studied by the Department of Anesthesiology and Intensive Care at the University of Pavia, Italy, and they concluded that therapy with multiple epidural steroid injections (ESIs) provide better control of chronic neck pain compared to that with a single injection (Pasqualucci 2007). Therefore likely your treating pain physician will recommend multiple ESIs. Often these procedures are done in sets of three.

The most important and greatest success achieved with the use of ESIs is the rapid relief of symptoms that allows patients to experience enough relief to become active again. With treatment, patients are often able to resume their normal daily activities.

Risks of Epidural Steroid Injection

Epidural steroid injections (ESIs) are considered an appropriate non-surgical treatment for many patients who suffer from back and neck pain. Although ESIs are considered safe and are one of the most commonly performed procedures in the world, there are risks associated with the procedure. The major risks associated with this procedure involve bleeding, infection, post-dural puncture headache, and nerve damage.

Another common complication of chronic pain is central sensitization. This is a development involving both the peripheral nervous system (PNS) and the central nervous system (CNS). Local tissue injury and inflammation activate the PNS, which sends signals through the spinal cord to the brain. Central sensitization occurs when there is an increase in the excitability of neurons within the CNS at the level of the spinal cord and higher. Eventually normal inputs from the PNS begin to produce abnormal responses. Low-threshold sensory fibers activated by very light touch of the skin activate neurons in the spinal cord that normally only respond to painful stimuli. As a result, an input that would normally produce a harmless sensation now produces significant pain.

The other risks of epidural steroid injections may be directly related to the medications injected. Some of the potential side effects of corticosteroids include elevated blood sugar, weight gain, arthritis, stomach ulcers, and transient decrease in immune system function. All patients before receiving an ESI should be assessed by their physician about risk assessment for the procedure.

Patients with an allergy to any anesthetic, are on blood thinning medications, have an active infection, or are pregnant should consult with their pain physician before receiving the procedure.

Outcomes of Epidural Steroid Injection

The amount and duration of pain relief vary from person to person and is dependent on many other factors, including underlying pathology and activity level. Some can have relief that lasts for years while others have short-term relief. It is important to discuss with your physician your response to epidural steroids in order to plan future treatment options.
The Department of Rehabilitation Medicine at the University of Washington conducted a study that compared the risks and efficacy between surgical alternatives versus lumbar epidural steroid injections (ESIs). In their conclusion, “when weighing the surgical alternatives and associated risk, cost, and outcomes, lumbar epidural steroid injections are a reasonable non-surgical option in select patients” (Young 2007).

N/A

N/A

CERVICAL MEDIAL BRANCH BLOCK

Role of a Medial Branch Block
A medial branch nerve block is a procedure in which an anesthetic is injected near small medial nerves connected to a specific facet joint. Typically several levels of the spine are injected in one procedure.

If the patient experiences marked pain relief immediately after the injection, then the facet joint is determined to be the source of the patient's pain.

See Facet Joint Disorders and Back Pain
The procedure is primarily diagnostic, meaning that if the patient has the appropriate duration of pain relief after the medial branch nerve block, then he or she may be a candidate for a subsequent procedure - called a medial branch radiofrequency neurotomy (or ablation) - for longer term pain relief.

Role of a Medial Branch Radiofrequency Neurotomy (Ablation)
In cases where a medial branch nerve block has confirmed that a patient's pain originates from a facet joint, a radiofrequency neurotomy can be considered for longer term pain relief.

A radiofrequency neurotomy is a type of injection procedure in which a heat lesion is created on the nerve that transmits the pain signal to the brain. The goal of a radiofrequency neurotomy is to interrupt the pain signal to the brain, while preserving other functions, such as normal sensation and muscle strength.

Facet Joint Injections

At times, a medial branch block is tried after the patient has already been treated with one or more facet joint injections, although this is not always the case.

Facet joint injections involve an injection of anti-inflammatory steroid solution directly into the joint. If such an injection confirms the facet joint as the likely source of the patient's pain, but this injection - along with other treatments (such as physical therapy, manual manipulation, and medications) have not resulted in long term pain relief, then a medial branch block may be recommended.

As evidence evolves on the efficacy of facet joint injections, a medial branch block may also be considered instead of a facet joint injection. A medial branch block might also be considered first if for any reason the patient cannot tolerate the steroid and/or an injection directly into the facet joint.

The medial nerves are uniquely located in each segment of the spine:

Cervical medial branch nerves are located in a bony groove in the neck
Thoracic medial branch nerves are located over a bone in the mid-back or upper back
Lumbosacral medial branch nerves are found in a bony groove in the low back.

N/A

N/A

CERVICAL SPINAL CORD STIMULATOR

Spinal cord stimulation (SCS). In spinal cord stimulation, soft, thin wires with electrical leads on their tips are placed through a needle in the back near to the spinal column. The leads are placed through a needle inserted in the back (no incision is required). A small incision is then made and a tiny, programmable generator is placed in the upper buttock or abdomen (under the skin) which emits electrical currents to the spinal column.

N/A

N/A

GLENOHUMERAL INJECTION WITH ARTHROGRAM

An arthrogram is a diagnostic test which examines the inside of a joint (e.g. shoulder, knee, wrist, ankle) to assess an injury or a symptom you may be experiencing.

The test is done by first injecting contrast medium (sometimes referred to as a contrast agent or “dye”) which outlines the soft tissue structures in the joint (e.g. ligaments and cartilage) and makes them clearer to see on the images or pictures that will be taken of the joint. This is usually done using fluoroscopy. Fluoroscopy uses X-rays to transmit moving images onto a screen to guide the placement of the needle containing the contrast medium. This may also be done using computed tomography (CT) or ultrasound for guidance.

The exact technique will vary from doctor to doctor and also depend on the joint being injected.

This is then followed by a magnetic resonance imaging (MRI) or CT scan. While an MRI or CT scan without the use of contrast medium can provide information on the soft tissue structures, using contrast medium with MRI or CT may provide more information about what is wrong with the joint.

How do I prepare for an arthrogram?
Generally no specific preparation is required.

Normally you should have already had at least a plain X-ray of the joint and often an ultrasound, CT scan or MRI to assess any pain or other symptom you may be experiencing. If so you should bring these scans with you to your arthrogram appointment.

It may be best to wear comfortable clothing with easy access to the joint being examined.

What happens during an arthrogram?
Generally you will be asked to lie down and the skin over the joint being examined will be cleaned with an antiseptic solution. Following this a local anaesthetic may be injected into the skin to numb the area where the contrast medium will be injected. You may feel a slight stinging sensation.

Then using X-ray, ultrasound, MRI or CT for guidance, a needle will be placed into the joint and after ensuring the needle is in the right place the contrast medium will be injected into the joint.

The injection may be accompanied by a feeling of fullness in the joint but should not be painful.

The contrast medium used depends on the exact nature of the arthrogram and the specialist doctor performing the arthrogram. This is generally iodinated contrast medium.

If you are having an MRI arthrogram, this will be followed by a very dilute mixture of MRI contrast (gadolinium chelates) together with sterile saline (mildly salty water). If you are having a CT arthrogram, occasionally air is injected either on its own, or with a small amount of X-ray contrast prior to the scan.

Following the injections you will be taken to either the MRI suite (for an MRI arthrogram), or the CT suite (for a CT arthrogram), where the scan of the joint will be performed.

Are there any after effects of an arthrogram?
Many people have a sore joint as the reason for the examination. Most patients feel some mild to moderate increase in soreness in the joint for 24-48 hours following the injection. The joint will then return to feeling the way it was before the examination.

How long does an arthrogram take?
The arthrogram itself usually takes about 15 minutes. You may then have to wait a short time before having the scan performed. A subsequent MRI scan may take 30-45 minutes and a CT scan may take 15 minutes, depending on the joint and the number of scans that have to be done. You should allow approximately 2 hours from arrival at the radiology department.

What are the risks of arthrography?
Arthrography is a very safe procedure and complications are unusual.

The most serious complication is an infection of the joint. This is usually caused by organisms from the patient’s skin being transferred into the joint and for this reason the procedure should not be carried out if there is broken or infected skin overlying the joint.

The risk of infection is not precisely known but the best available information suggests that it is in the order of 1 in 40,000 people having the test.

Occasionally people may be allergic to the contrast medium that is injected, and this most commonly results in a rash but may be more serious. The risk of minor reaction (e.g. hives) has been reported in 1 in 2,000 having the test. More serious reactions appear to be very rare.

Complications of gadolinium contrast medium used in an MRI have not been reported in the very small amounts used in orthography.

What are the benefits of an arthrogram?
The injection of contrast medium into the joint makes the subsequent scan more sensitive in detecting damage to the internal structure of the joint.

Some common reasons for an arthrogram in addition to the scan are:

In the shoulder – where the joint is unstable or if an ultrasound or plain MRI has not shown a suspected tendon tear.
In the hip – to show any tear of the cartilage labrum (or rim of the joint).
In the wrist – to show any tear of the small ligaments of the wrist.
There are many other individual situations where your referring doctor may feel that the additional information obtained by an arthrogram may help to determine the best course of treatment.

Who does the arthrogram?
A radiologist (specialist doctor) will perform the arthrogram, injecting the contrast medium into the joint. The radiologist is also responsible for ensuring that the appropriate scans are performed following the injection and for analysing the scans and preparing a formal report of the findings, which is sent to the doctor who referred you for the test.

Either a nurse or a radiographer may assist the radiologist in the arthrogram. The radiographer is responsible for taking the pictures in the arthrogram and the subsequent scan under the radiologist’s direction.

Where is an arthrogram done?
An arthrogram is performed in the diagnostic imaging department of most public and private hospitals and at private radiology practices.

When can I expect the results of my arthrogram?
The time that it takes your doctor to receive a written report on the test or procedure you have had will vary, depending on:

The urgency with which the result is needed
The complexity of the examination
Whether more information is needed from your doctor before the examination can be interpreted by the radiologist
Whether you have had previous X-rays or other medical imaging that needs to be compared with this new test or procedure (this is commonly the case if you have a disease or condition that is being followed to assess your progress)
How the report is conveyed from the practice or hospital to your doctor (i.e. phone, email, fax or mail)

N/A

N/A

OCCIPITAL NERVE BLOCK

The greater occipital nerve arises from between the first and second cervical vertebrae, along with the lesser occipital nerve. It supplies sensation to the skin along the back of the scalp to the top of the head.

Sometimes, when the occipital nerve is irritated, the pain of this irritation is felt near the eye of the same side of the head. This is known as referred pain.

These nerves may also contribute to headaches. Sometimes blocking (numbing) the occipital nerve will reduce headache in the front of the head.

What an Occipital Nerve Block Is
During a nerve block, pain-relieving medicine is injected to the region where the nerve crosses the skull. The patient is usually lying on his or her stomach. The needle is placed near the nerve and the anesthetic (or a combination of anesthetic and steroid) are injected. Pain relief may be immediate and usually lasts as long as the numbness, sometimes the relief may be long lasting.

An occipital nerve block is done to manage:

Pain that affects the back of the head or one side of the head. People who have sensations of shooting, zapping, stinging or burning pain usually have the best response to the procedure.
Some migraines or cluster headaches

Spondylosis of the cervical facet joints
A tender or painful scalp, which may be a sign of an inflamed nerve.

During an occipital nerve block, about a teaspoon of local anesthetic and steroids are injected into the scalp where the trunk of the nerve is. The injection is done at the back of the head, just above the neck. The skin is numbed before the injection is done. A very fine needle is used for the nerve block.

If the injection has been well located, the scalp on that side of the head will go numb quickly. Pain relief can be felt sometimes within minutes. The doctor may ask what the patient is feeling in terms of his or her symptoms.

If there is a lot of swelling in the nerve, the steroids will relieve the pain of that. The full effect of the steroids may not be felt for two or three days. Their effect is more long lasting -- sometimes weeks or months.

After an occipital nerve block, a patient can usually drive home and return to normal daily activities the following day. The effects of the local anesthetic may wear off in a few hours, but the effects of the steroid begin to increase over the next several days.

The best responses to an occipital nerve block usually come from patients whose pain is relatively recent rather than long-standing.

If the first occipital nerve block doesn't relieve the patient's symptoms in a week or two, it may be necessary to have a second injection. Additional nerve blocks may be done to keep the symptoms under control.

On the other hand, a lack of results may be a sign that the occipital nerves are not the source of the pain and further work should be done to diagnose the cause of the pain.

It is rare to do more than three occipital nerve blocks in a six-month period. The more injections of steroids that are given, the greater the chance of side effects. If more frequent injections are needed, another type of treatment will probably be considered.

These might include:

Cutting a nerve
Relieving pressure on the nerve
Killing nerve cells with small doses of a poison or radiofrequency energy
Inserting an occipital nerve stimulator. This works like a pacemaker in the heart.

N/A

N/A

GREATER TROCHANTERIC BURSA INJECTION

What is greater trochanteric bursitis?

Bursitis is the inflammation of a bursa, or fluid-filled space surrounding a bony prominence. After years of stressing the areas around your joints, these sacs or bursae may become inflamed. This inflammation can cause pain.

Greater trochanteric bursitis is the inflammation of the sac that lies over the outside part of your thigh bone (femur), where it joins the hip. You may notice a dull ache or stiffness in the area of your hip, pain with movement, or pressure over that area.

How is greater trochanteric bursitis treated?

In many cases, treatment is simple and includes resting and immobilizing the affected area, applying ice to reduce swelling, and taking non-steroidal anti-inflammatory drugs to relieve pain and reduce inflammation. With this self-care treatment, the bursitis usually disappears within a week or two. If there is no relief using this conservative treatment, your interventional pain doctor may inject a corticosteroid drug into the bursa to help relieve inflammation, after which relief is generally obtained within one to two weeks.

Please note: This procedure cannot be performed if you have an active infection, flu, fever, extremely high blood pressure, or if you are on blood thinners. For your safety, please inform us if any of these conditions exists.
What are the risks of the procedure?

As with most procedures, there is a remote risk of bleeding, infection, nerve injury or allergic reaction to the medications used. Some short-term side effects may occur, as well. You may have increased pain for a few days after the injection, including localized pain at the injection site. Diabetics may have a short-term elevation of blood sugars. People prone to fluid retention may have increased fluid retention for one to two weeks.

What happens during the procedure?

After you check in and sign a consent form, your vital signs will be taken. Then you will be taken to the procedure room. Please wear loose-fitting clothing. You may be asked to change into a hospital gown. Our nursing staff will position you on your side on a narrow table. The affected area will be cleaned with iodine and sterilely draped. Then, the doctor will numb your skin using a small needle, which will sting a bit. It is very important to hold still and let us know if we are causing you discomfort. Next, the doctor will use an X-ray machine (fluoroscope) to guide the needle into the correct spot. Local anesthetic and steroid are then injected through the needle, and the needle is removed. Your skin will be cleaned and a Band-Aid applied. The Band-Aid may be removed the next morning. The procedure will last approximately 10 to 15 minutes.

Your pain may improve immediately after the injection, due to the local anesthetic. The steroid usually takes two or three days to have an effect and peaks in about two weeks.

What happens after the procedure?

You will be taken back to the area from which you started, and you will remain there for approximately five minutes. If you experience local tenderness from the needles, ice may help relieve the discomfort. You can also resume taking your normal pain medications.

Will I have any restrictions after the procedure?

Following your procedure, you are not allowed to drive for the remainder of the day. An adult must be present to drive you home or to escort you on another form of transportation. This is for your own safety. Otherwise, you may do whatever you feel up to doing.

N/A

N/A

HARDWARE BLOCK

What Is A Hardware Blocks?

Spinal pain is one of the most common reasons why people seek treatment from their physicians. With the aging population, it is expected that the number of people suffering from spinal pain will increase dramatically throughout the coming years. When a patient’s spinal pain does not improve with conservative treatment options, including non-steroidal anti-inflammatory medication, physical therapy, massage therapy, acupuncture, spinal manipulation, and nerve blocks, among others, a patient’s physician may recommend spinal surgery.
In the United States, it is estimated that 300,000 spinal fusion surgeries are performed each year. Spinal fusion surgery involves permanently joining two or more vertebrae in the spine so that there is no movement between the joints. Most of these procedures are performed because of spinal pain due to degeneration of the spine. However, other conditions including spinal instability, scoliosis, spondylolysis, and spondylolithesis can result in chronic spinal pain that requires spinal fusion surgery.
During a spinal fusion surgery, hardware is usually placed to maintain alignment of the spine until biological fusion takes place. Hardware that is placed can include screws, metal plates, and metal rods. Oftentimes, however, patients can develop chronic pain from the hardware that was placed during their spinal fusion surgery.
Chronic pain is defined as pain that persists for longer than three months. According to the National Institute of Neurological Disorders and Stroke, approximately 20% of individuals affected by acute spinal pain will develop chronic spinal pain that persists beyond one year despite treatment. Not only does chronic pain affect the body, it can have serious implications for a patients’ mental health as well. Chronic pain is often associated with depression, anxiety, and other mood disorders. It is therefore important to discuss all of your symptoms with your physician to make an educated decision about your treatment options.

A hardware block procedure is a diagnostic procedure that is non-invasive and recommended for patients who suffer from chronic pain following spinal fusion surgery. A hardware block procedure allows the physician to determine if the hardware placed during spinal fusion surgery is actually the cause of a patient’s chronic pain. If it is determined that the hardware is the source of pain, patients are able to try a variety of pain management therapies.

How Is A Hardware Blocks Performed?

Patients are placed in either a prone or seated position to expose the area of the spine that is affected. A local anesthetic is then injected into the area where the hardware is located. Lidocaine is a commonly used anesthetic for hardware blocks, as it is effective and has a high potency rate. After the anesthetic is injected, patients are asked to perform some spinal movements.
Following a hardware block, if the patient reports a decrease in pain symptoms, it indicates that the hardware that was placed during the spinal fusion surgery is likely the source of their chronic pain. Conversely, if the patient reports no pain relief following a hardware block procedure, then it is unlikely that the hardware placed during their spinal fusion surgery is the source of their chronic pain. After the hardware block is completed, patients are moved to a recovery room to be monitored for any adverse reactions.

Hardware block procedures are performed in an outpatient setting as it is a non-surgical technique and requires less than an hour to perform. The pain associated with a hardware block is minimal because of the small needle size and short period of time it takes to complete the procedure. Patients are advised to minimize activities for 24 hours following a hardware injection block.
While hardware block procedures are minimally invasive and considered safe, there are risks associated with the procedure, including:

Dizziness
Nausea
Injection site tenderness
Headache
Infection
Hematoma
Allergic reaction
Local anesthetic toxicity

Conditions Related To Hardware Blocks

Hardware blocks have been shown to be beneficial for patients experiencing chronic pain following spinal fusion surgery. A hardware block allows the physician to determine if the hardware that was inserted into the patient is the source of pain. The diagnostic information obtained from hardware blocks has proven to be very useful for patients and physicians. The results obtained from this procedure allow physicians to determine the next course of treatment for pain relief, including the potential removal of hardware from a patient’s spine.

Conclusion

A hardware block procedure is a non-surgical, minimally invasive, diagnostic option for patients suffering from chronic pain following spinal fusion surgery. The nerve block can help a physician determine if a patient’s chronic pain is being caused by the hardware that was placed during their spinal fusion surgery or if the pain is originating from elsewhere. A hardware block is not a pain relief treatment; it helps to isolate the source of a patient’s chronic pain.
Once the source of pain is determined, the physician can discuss pain management options with the patient. Pain management options may include a multi-disciplinary approach to address both the physical and mental aspects of a patient’s health. Furthermore, the physician can determine if removal of the surgical hardware is warranted.

N/A

N/A

HIP GENICULATE NERVE BLOCK

The genicular nerve block and RFA are a proven and popular procedure to combat knee pain. The specialist interventional pain management physicians at Newbridge Spine & Pain Center perform this innovative new procedure for treating patients with knee pain without surgery. Genicular Nerve Block or Genicular Radiofrequency Nerve Ablation can be done before if the hopes of preventing surgery or after knee surgery to offer pain relief.

The procedure is performed in 2 stages:

1. Diagnostic Genicular Nerve Block – this procedure consists of placing a small amount of a local anesthetic, on the genicular nerves. This tests the patient’s response and determines if there is sufficient pain relief in the knee to justify performing a therapeutic neurotomy.

2. Genicular Nerve Ablation – during this therapeutic portion of treatment, your pain management physician will perform a radiofrequency ablation (RFA) of the genicular nerves, restoring function of the knee and alleviating pain.

N/A

N/A

HIP GENICULATE RADIOFREQUENCY DENERVATION

Chronic osteoarthritis pain of the knee is often not effectively managed with non-pharmacological or pharmacological treatments. Radiofrequency (RF) neurotomy, when applied to articular nerve branches (genicular nerves), provides a therapeutic alternative for effective management of chronic pain associated with osteoarthritis of the knee.
Although surgery is generally effective for patients with advanced disease, some older individuals with comorbidities may not be appropriate surgical candidates. In addition some patients do not wish to consider surgery and prefer non- surgical options. In these patients, radiofrequency (RF) neurotomy of the genicular nerves might be a successful alternative to surgery. This procedure is based on the theory that cutting the nerve supply to a painful structure may alleviate pain and restore function.

Anatomy
The knee joint is innervated by the articular branches of various nerves, including the femoral, common peroneal, saphenous, tibial and obturator nerves. These articular branches around the knee joint are known as genicular nerves. Genicular nerves can be easily approached percutaneously under fluoroscopic guidance.

Genicular branches of the knee joint
Genicular nerves consist of the superior lateral (SL), middle, superior medial (SM), inferior lateral (IL), inferior medial (IM), and recurrent tibial genicular nerve . The targets included the SL, SM and IM genicular nerves which pass periosteal areas connecting the shaft of the femur to bilateral epicondyles and the shaft of the tibia to the medial epicondyle.
Although genicular nerves are the main innervating articular branches for the knee joint, other articular branches may also be present. For this reason, pain of the knee joint may not be completely relieved, resulting in poor response to radiofrequency neurotomy.

Indications for genicular nerve blocks
Patients with chronic knee pain secondary to osteoarthritis
Patients with failed knee replacement
Patients unfit for knee replacement
Patients who want to avoid surgery

Diagnostic genicular nerve blocks
These injections are performed under fluoroscopy guidance. A small amount of local anaesthetic (1-2ml) of lidocaine or bupivacaine is injected around the superior lateral (SL), superior medial (SM) and the inferior medial (IM) branches. A response is considered positive if there is at least 50% reduction in pain in the 24hrs following injection.

Cooled radiofrequency of genicular nerves
Patients with a positive response are offered either cooled or conventional radiofrequency neurotomy for a more sustained response. The procedure is usually done on an outpatient basis. The procedure is performed under fluoroscopic guidance to ensure accuracy of needle placement. Patients need to be aware that the outcome of the procedure is variable and they may not receive the desired benefits. Similarly, they must be aware of the transient nature of the therapeutic benefits and that there may need repeated injections.
Radiofrequency treatment is a two-step procedure. The first step is diagnostic, involving injection of local anaesthetic around the genicular branches innervating the knee joint, as described above. Patients who experience good pain relief following diagnostic injections are offered radiofrequency denervation treatment. This involves creating a heat lesion around the genicular nerves carrying painful impulses from the knee joint. Successful treatment can result in pain relief lasting several months.
Either conventional radiofrequency treatment (70-80°c) or cooled radiofrequency treatment (60°c) can be used. Cooled radiofrequency allows creation of larger-volume, spherical lesions compared to conventional radiofrequency.
Treatment is performed under local anaesthetic and can take 4 to 6 weeks to work.

Complications
Complications are rare, particularly if injections are performed using a precise needle-positioning technique. Septic arthritis can be avoided with appropriate aseptic precautions. Severe allergic reactions to local anaesthetics are uncommon. Post-procedural pain flare-up is not uncommon, and may be treated with painkillers. Neurological complications including paraesthesias and numbness have been described but are extremely rare. Radiofrequency treatment can cause patchy numbness of the over lying skin. Incidence of infection is low as the procedure is performed under strict aseptic conditions and the injections are extra articular.

N/A

N/A

INTERCOSTAL NERVE BLOCK

What is an intercostal nerve block?
An intercostal nerve block is an injection of a steroid or other medication around the intercostal nerves that are located under each rib.

What is the purpose of an intercostal nerve block?
The steroid injected reduces the inflammation and/or swelling of tissue around the intercostal nerves, in between the ribs or in the chest wall. This may in turn reduce pain, and other symptoms caused by inflammation or irritation of the intercostal nerve and surrounding structures. Herpes zoster or shingles pain in the chest is commonly treated with intercostal blocks. Pain around a chest scar after a chest surgery may also respond well to intercostal blocks.

How long does the intercostal nerve block take?
The actual injection takes only a few minutes.

What is actually injected?
The injection consists of a local anesthetic and a steroid medication.

Will the intercostal nerve block hurt?
The procedure involves inserting a needle through skin and deeper tissues. So, there is some pain involved. However, the skin and deeper tissues are numbed with a local anesthetic using a very thin needle during the performance of the block.

Will I be "put out" for the intercostal nerve block?
No. This procedure is done with a small thin needle, usually without any sedation. There is local anesthetic within the injection.

How is the intercostal nerve block performed?
It is usually done with the patient lying down on one side of the chest. The side to be injected is facing up. The skin of the chest is cleaned with antiseptic solution and then the injection is carried out.

What should I expect after the Intercostal nerve block?
Immediately after the injection, you may feel that your pain may be gone or quite less. This is due to the local anesthetic injected. This will last only for a few hours. Your pain may return and you may have a sore spot for a day or two. This is due to the mechanical process of needle insertion as well as initial irritation from the steroid itself. You should start noticing a more lasting pain relief starting the third day or so.

What should I do after the intercostal nerve block?
You will rest for a while in the office. Most patients can drive themselves home. We advise the patient to take it easy for several hours after the procedure. You may want to apply ice to the injected area. You can perform any activity you can tolerate.

Can I go to work to work the next day?
Unless there are complications, you should be able to return to work the next day. The most common thing you may feel is a sore spot at the injection site.

How long does the effect of the medication last?
The immediate effect is usually from the local anesthetic injected. This wears off in a few hours. The steroid starts working in about 3 to 5 days and its effect can last for several days to a few months.

How many intercostal nerve blocks do I need to have?
It varies. The injections are done about one week apart and only if needed. If the first injection does not relieve your symptoms in about a week to two weeks, you may be recommended to have a second injection. If you respond to the injections, you may be recommended for additional injections when the symptoms return.

How many intercostal nerves can be blocked at once?
Many times only one nerve is blocked, especially if the symptoms appear to be related to an easily identified nerve. Other times, several nerves are blocked, often three levels. In this case, the worst nerve is blocked and then one nerve is done above and one nerve is done below.

Will the intercostal nerve blocks help me?
It is difficult to predict if the injection will help you or not. The patients who have recent onset of pain may respond much better than the ones with a longstanding pain. Usually the first injection is as much a test as it is a treatment. The first block will confirm that the intercostal nerves are involved in the pain and be helpful. Or the blocks will not help and the intercostal nerves will not be suspected as part of the pain.

What are the risks and side effects of intercostal nerve blocks?
Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects and possibility of complications. The most common side effect is temporary pain at the injection site. Other uncommon risks involve infection, bruising, bleeding, worsening of symptoms etc. Fortunately, serious side effects and complications are uncommon. One serious side effect is a collapsed lung. This is rare, but since the needles are in close proximity to the lung, such a side effect is possible.

How would I know if I had a collapsed lung?
Because of the size of the needle used, a lung usually does not collapse quickly. It may take several hours or the better part of the day. Id, after the block, a patient feels winded or cannot seem to catch their breath or gasps for air, a collapsed lung should be suspected. Prompt transportation to the nearest Emergency Room and a chest x-ray can confirm the suspicion of a collapsed lung.

Who should not have an intercostal nerve block?
If you are allergic to any of the medications to be injected, if you are on a blood thinning medication, if you have an active infection going on, or if you have poorly controlled diabetes or heart disease, you should not have an intercostal nerve block or at least consider postponing it if postponing would improve your overall medical condition. Likewise, if you have very poor lung function and would have great difficulty with a collapsed lung, an intercostal block may not be the treatment of choice.

N/A

N/A

KNEE GENICULATE RADIOFREQUENCY DENERVATION

Genicular Neurotomy (aka Genicular Nerve Ablation)
If you suffer from osteoarthritis of the knees and want to do everything possible to avoid surgery, or you have already had knee surgery that has failed to relieve the pain, this cutting-edge treatment option may be for you.

What is Genicular Neurotomy?
Genicular Neurotomy (aka ablation) is a brand new, innovative option for treating knee pain without surgery. This highly advanced procedure is on the absolute cutting edge of medicine. By selectively applying a sophisticated type of radio wave to the nerves surrounding the knee (the genicular nerves), one can effectively relieve pain in the knee from any number of causes.

Indications
Perhaps the greatest advantage of genicular neurotomy is the fact that the entire procedure is performed OUTSIDE the knee capsule. This is what allows it to succeed where other procedures like cortisone injections, hyaluronic acid injections, and even surgery fail. In fact, this procedure can be done up to one month before knee surgery and even after surgery.

Genicular neurotomy is indicated for a variety of conditions:
Osteoarthritis (OA)
Chronic Knee Pain
Degenerative Joint Disease
Total Knee Replacement (before or after)
Partial Knee Replacement (before or after)
Patients unfit for knee replacement
Patients who want to avoid a knee replacement

While surgery is considered to be the accepted treatment option for patients with advanced joint disease, many individuals have comorbidities that may prevent them from being an appropriate surgical candidate. Others may simply want to avoid surgery, as they may be unable to take off the necessary time from work for the procedure and post-operative recovery period. In these cases, radiofrequency neurotomy of the genicular nerves is a safe, potential alternative to joint replacement for pain.

Despite the general efficacy of knee replacements, many patients complain the pain persists after surgery. In these unfortunate cases, patients have traditionally had few options, if any, that did not involve additional surgery. With the advent of genicular nerve neurtomy, patients can look forward to pain relief without any potential further surgeries.

N/A

N/A

KYPHOPLASTY

Performing Kyphoplasty Surgery

During kyphoplasty surgery, a small incision is made in the back through which the doctor places a narrow tube. Using fluoroscopy to guide it to the correct position, the tube creates a path through the back into the fractured area through the pedicle of the involved vertebrae.
Using X-ray images, the doctor inserts a special balloon through the tube and into the vertebrae, then gently and carefully inflates it. As the balloon inflates, it elevates the fracture, returning the pieces to a more normal position. It also compacts the soft inner bone to create a cavity inside the vertebrae.
The balloon is removed and the doctor uses specially designed instruments under low pressure to fill the cavity with a cement-like material called polymethylmethacrylate (PMMA). After being injected, the pasty material hardens quickly, stabilizing the bone.
Kyphoplasty surgery to treat a fracture from osteoporosis is performed at a hospital under local or general anesthesia. Other logistics for a typical kyphoplasty procedure are:
The kyphoplasty procedure takes about one hour for each vertebra involved
Patients will be observed closely in the recovery room immediately following the kyphoplasty procedure
Patients may spend one day in the hospital after the kyphoplasty procedure
Patients should not drive until they are given approval by their doctor. If they are released the day of the kyphoplasty surgery, they will need to arrange for transportation home from the hospital.
Recovery from Kyphoplasty

Pain relief will be immediate for some patients. In others, elimination or reduction of pain is reported within two days. At home, patients can return to their normal daily activities, although strenuous exertion, such as heavy lifting, should be avoided for at least six weeks.

Patients should see their physician to begin or review their treatment plan for osteoporosis, including medications to prevent further bone loss.

Candidates for Kyphoplasty

Kyphoplasty cannot correct an established deformity of the spine, and certain patients with osteoporosis are not candidates for this treatment. Patients experiencing painful symptoms or spinal deformities from recent osteoporotic compression fractures are likely candidates for kyphoplasty. The procedure should be completed within 8 weeks of when the fracture occurs for the highest probability of restoring height.

Risks and Complications of Kyphoplasty

Some general surgical risks apply to kyphoplasty, including a reaction to anesthesia and infection. Other risks that are specific to the kyphoplasty procedure and vertebroplasty include:

Nerve damage or a spinal cord injury from malpositioned instruments placed in the back
Nerve injury or spinal cord compression from leaking of the PMMA into veins or epidural space
Allergic reaction to the solution used to see the balloon on the X-ray image as it inflates.

It is not known whether kyphoplasty or vertebroplasty will increase the number of fractures at adjacent levels of the spine. Bench studies on treated bone have shown that inserting PMMA does not change the stiffness of the bone, but human studies have not been done. Osteoporosis is a chronic, progressive disease. As stated earlier, patients who have sustained fractures from osteoporosis are at an increased risk for additional fractures due to the loss of bone strength caused by osteoporosis.

N/A

N/A

LUMBAR MEDIAL BRANCH BLOCK

The medial branch block is often used as part of a 2-step diagnostic and treatment approach:

Role of a Medial Branch Block
A medial branch nerve block is a procedure in which an anesthetic is injected near small medial nerves connected to a specific facet joint. Typically several levels of the spine are injected in one procedure.

If the patient experiences marked pain relief immediately after the injection, then the facet joint is determined to be the source of the patient's pain.

See Facet Joint Disorders and Back Pain
The procedure is primarily diagnostic, meaning that if the patient has the appropriate duration of pain relief after the medial branch nerve block, then he or she may be a candidate for a subsequent procedure - called a medial branch radiofrequency neurotomy (or ablation) - for longer term pain relief.

Role of a Medial Branch Radiofrequency Neurotomy (Ablation)
In cases where a medial branch nerve block has confirmed that a patient's pain originates from a facet joint, a radiofrequency neurotomy can be considered for longer term pain relief.

A radiofrequency neurotomy is a type of injection procedure in which a heat lesion is created on the nerve that transmits the pain signal to the brain. The goal of a radiofrequency neurotomy is to interrupt the pain signal to the brain, while preserving other functions, such as normal sensation and muscle strength.

Lumbosacral medial branch nerves are found in a bony groove in the low back.

N/A

N/A

LUMBAR SPINAL CORD STIMULATOR

Approved by the FDA in 1989, spinal cord stimulation (SCS) has become a standard treatment for patients with chronic pain in their back and or limbs who have not found pain relief from other treatments. While the treatment does not work for everyone, most patients who qualify for neurostimulation therapy report a 50 to 70% reduction in overall pain, as well as an increased ability to participate in normal family and work activities. Many patients find that they can decrease or stop taking painkillers or other pain medications after undergoing spinal cord stimulation. Given these benefits, there has been ongoing investment and advances in spinal cord stimulation technology, and many individuals suffering from chronic pain find that neurostimulation positively impacts the quality of their lives.

Electrical Stimulation Blocks the Pain Signals

In general, neurostimulation works by applying an electrical current to the source of chronic pain. This creates a pleasant sensation that blocks the brain's ability to sense the previously perceived pain. There are two related forms of electrical stimulation commonly used to treat chronic pain:

Spinal cord stimulation (SCS). In spinal cord stimulation, soft, thin wires with electrical leads on their tips are placed through a needle in the back near to the spinal column. The leads are placed through a needle inserted in the back (no incision is required). A small incision is then made and a tiny, programmable generator is placed in the upper buttock or abdomen (under the skin) which emits electrical currents to the spinal column.

Peripheral Nerve Field Stimulation (PNFS). Very similar to spinal cord stimulation, peripheral nerve field stimulation involves placing the leads just under the skin in an area near to the nerves involved in pain.
In both approaches, the generator can be programmed in a way similar to using a remote control to adjust the television. The area or intensity of electrical stimulation can be changed, and the system can be turned on and off or adjusted as necessary to provide optimal pain relief. Although programming is initially done at the physician's office, patients can learn how to control the stimulation on their own and adjust it to their pain levels.

N/A

N/A

LUMBAR SYMPATHETIC NERVE BLOCK

What is a lumbar sympathetic block?
A lumbar sympathetic block is an injection of local anesthetic into or around the sympathetic nerves. These sympathetic nerves are a part of the sympathetic nervous system. The nerves are located on the either side of spine, in the lower back. Normally these nerves control basic functions like regulating blood flow. In certain conditions, these sympathetic nerves can carry pain information from the peripheral tissues back to the spinal cord.

What is the purpose of a lumbar sympathetic block?
A lumbar sympathetic block is performed to block the sympathetic nerves that go to the leg on the same side as the injection. This may in turn reduce pain, swelling, color, sweating and other unusual changes in the lower extremity and may improve mobility. It is done as a part of the treatment of Reflex Sympathetic Dystrophy (RSD), Sympathetic Maintained Pain, Complex Regional Pain Syndrome and Herpes Zoster (shingles) involving the legs. Certain patients with neuropathy or peripheral vascular disease may also benefit from lumbar sympathetic blocks.

How long does the lumbar sympathetic block take?
The actual injection takes from ten to thirty minutes.

What is actually injected?
The injection consists of a local anesthetic. On occasion, epinephrine, clonidine or a steroid medication may be added to prolong the effects of the lumbar sympathetic block.

Will the lumbar sympathetic block hurt?
The procedure involves inserting a needle through skin and deeper tissues. So, there is some pain involved. However, we may numb the skin and deeper tissues with a local anesthetic using a very thin needle before inserting the actual block needle. Most of the patients also receive intravenous sedation that makes the procedure easier to tolerate.

Will I be "put out" for the lumbar sympathetic block?
No. This procedure is done under local anesthesia. Most of the patients also receive some sedation, which makes the procedure easy to tolerate. The amount of sedation given generally depends upon the patient tolerance. Some patients may have enough sedation that they have amnesia and may not remember all or parts of the procedure.

How is the lumbar sympathetic block performed?
It is done with the patient lying on stomach. The patients are monitored with EKG, blood pressure cuff and an oxygen-monitoring device. Temperature sensing probes may also be placed on your feet. The lumbar sympathetic block is performed under sterile conditions. The skin on back is cleaned with antiseptic solution and the skin is then numbed with a local anesthetic. Then X-ray is used to guide the needle or needles into the proper position along the outside of the spine. Once in place, a test dose of dye is used to confirm that the injected medication will spread in an appropriate area. If this is okay, the injection takes place gradually over several minutes. The physician will use the X-ray to evaluate the spread of the injected medication. When a sufficient area is covered, the injection will be over. When done, the needle is removed and a Band Aid is applied.

What should I expect after the lumbar sympathetic block?
Immediately after the injection, you may feel your lower extremity getting warm. In addition, you may notice that your pain may be gone or quite less. You may also notice some temporary weakness or numbness in the leg, although this is actually not a desired effect of a lumbar sympathetic block.

What should I do after the lumbar sympathetic block?
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 that you can tolerate. Some of the patients may go for immediate physical therapy.

Can I go to work to work the next day?
Unless there are complications, you should be able to return to your work the next day. The most common thing you may feel is soreness in the back at the injection site.

How long does the effect of the medication last?
The local anesthetic wears off in a few hours. However, the blockade of sympathetic nerves may last for many more hours. Usually, the duration of relief gets longer after each injection.

How many lumbar sympathetic blocks do I need to have?
If you respond to the first injection, you will be recommended for repeat injections. Usually, a series of such injections is needed to treat the problem. Some may need only 2 to 4 and some may need more than 10. The response to such injections varies from patient to patient.

Will the lumbar sympathetic block help me?
It is sometimes difficult to predict if the injection will indeed help you or not. The patients who present early during their illness tend to respond better than those who have had symptoms for a long time. Patients in the advanced stages of disease may not respond adequately.

What are the risks and side effects of a lumbar sympathetic block?
This procedure is safe. However, with any procedure there are risks, side effects and possibility of complications. The most common side effect is temporary pain or soreness at the injection site. Uncommon risks involve bleeding, infection, spinal block, epidural block and injection into blood vessels and surrounding organs. Fortunately, the serious side effects and complications are uncommon.

Who should not have a lumbar sympathetic block?
If you are allergic to any of the medications to be injected, if you are on blood thinning medications, if you have an active infection going on, or if you have poorly controlled diabetes or heart disease, you should not have the injection or at least consider postponing it if postponing would improve your overall medical condition.

N/A

N/A

LUMBAR TRANSFORAMINAL EPIDURAL STEROID

Patients will find that the benefits of an epidural steroid injection include a reduction in pain, primarily in leg pain (also called sciatica or radicular pain). Patients seem to have a better response when the epidural steroid injections are coupled with an organized therapeutic exercise program.

Epidural Steroid Injection Success Rates

While the effects of an epidural steroid injection tend to be temporary (lasting from a week to up to a year) an epidural steroid injection can deliver substantial benefits for many patients experiencing low back pain.

When proper placement is made using fluoroscopic guidance and radiographic confirmation through the use of contrast, > 50% of patients receive some pain relief as a result of lumbar epidural steroid injections.
Pain relief is more often felt for primary radicular (leg) pain and, less prominently, low back pain.
The pain relief and control brought on by injections can improve a patient's mental health and quality of life, minimize the need for painkiller use, and potentially delay or avoid surgery.

Recent research reports that lumbar epidural steroid injections are successful in patients with persistent sciatica from lumbar disc herniation, with more than 80% of the injected group with disc herniation experiencing relief (in contrast to 48% of the group that received a saline placebo injection)1.
Similarly, in a study focused on a group of patients with lumbar spinal stenosis and related sciatica symptoms, 75% of patients receiving injections had more than 50% of pain reduction one year following the injections. The majority also increased their walking duration and tolerance for standing.

Nonetheless, there is still some skepticism about the efficacy of injections and the appropriateness of injections for most patients. As noted previously, much of the controversy is generated by studies that analyze injection outcomes where fluoroscopy and radiographic contrast were not used to ensure accurate placement of the steroid solution at the level of pathology, or do not confirm that the injection was in fact made directly into the epidural space, which would diminish its effectiveness considerably.

N/A

N/A

LYSIS OF ADHESION

Definition
Adhesions are scars that form within the body. They usually form in the abdomen or pelvis. Adhesions develop naturally after surgery as part of the healing process. They can also develop after infection or any other inflammatory process, such as:
Endometriosis
Diverticulitis
Appendicitis
Crohn's disease
Lysis of adhesions is the process of cutting scar tissue within the body. This is done to restore normal function and reduce pain.

Reasons for Procedure
Adhesions can cause:
Pain
Obstruction of the bowel
Infertility
This surgery can fix intestinal blockage and treat infertility caused by adhesions. It also reduces chronic abdominal pain in some individuals.
Possible Complications
Problems from the procedure are rare, but all procedures have some risk. Your doctor will review potential problems, like:
Injury to organs
Worse adhesions
Bleeding
Infection
Hernia
Before your procedure, talk to your doctor about ways to manage factors that may increase your risk of complications such as:
Smoking
Drinking
Chronic diseases, such as diabetes and obesity
What to Expect
Prior to Procedure
Your doctor will perform a physical exam and may order some of these tests:
Blood and urine tests
Imaging tests will be used to look for adhesions and complications from them:
Ultrasound
CT scan
MRI scan
Leading up to the surgery:
Talk to your doctor about your medications. You may be asked to stop taking some medications up to 1 week before the procedure.
Arrange for a ride home from the hospital. Also, arrange for someone to help you at home.
Eat a light meal the night before the surgery. Do not eat or drink anything after midnight.
Anesthesia
General anesthesia —blocks pain and keeps you asleep through the surgery
Description of the Procedure
This surgery is usually done laparoscopically. When you are asleep, a needle will be inserted to inject a gas into the abdomen. The gas will make the abdomen expand. This will make it easier to see the organs. The laparoscope will then be inserted through a small hole that is cut in the skin. The laparoscope lights, magnifies, and projects an image onto a screen. The area will be inspected. Several small incisions will be made in the wall of the abdomen. Using small instruments that are put through these holes, the adhesions will be cut out. Doing so will free the organs that were caught in the adhesions.
In some cases, the doctor may need to switch to or do open abdominal surgery (called laparotomy). A larger incision will be made in the abdomen. This will allow direct access to all of the organs. The adhesions will be cut out.
How Long Will It Take?
1-3 hours
How Much Will It Hurt?
Anesthesia will prevent pain during surgery. Pain and discomfort after the procedure can be managed with medications.
Average Hospital Stay
This surgery is done in a hospital setting. If you have laparoscopic surgery, you will be able to leave that day or the next. If you have open surgery, you will need to stay in the hospital for a few days. You may need to stay longer if you have complications.
Post-procedure Care
Preventing Infection
During your stay, the hospital staff will take steps to reduce your chance of infection, such as:
Washing their hands
Wearing gloves or masks
Keeping your incisions covered
There are also steps you can take to reduce your chance of infection, such as:
Washing your hands often and reminding your healthcare providers to do the same
Reminding your healthcare providers to wear gloves or masks
Not allowing others to touch your incision.

N/A

N/A

SELECTIVE NERVE ROOT BLOCK

Another common injection, a selective nerve root block (SNRB), is primarily used to diagnose the specific source of nerve root pain and, secondarily, for therapeutic relief of low back pain and/or leg pain (see Figure 1).

When a nerve root becomes compressed and inflamed, it can produce back and/or leg pain. Occasionally, an imaging study (e.g. MRI) may not clearly show which nerve is causing the pain and an SNRB injection is performed to assist in isolating the source of pain. In addition to its diagnostic function, this type of injection for pain management can also be used as a treatment for a far lateral disc herniation (a disc that ruptures outside the spinal canal).

Selective Nerve Root Block (SNRB) for Diagnosis and Back Pain Management

In an SNRB, the nerve is approached at the level where it exits the foramen (the hole between the vertebral bodies). The injection is done both with a steroid (an anti-inflammatory medication) and lidocaine (a numbing agent). Fluoroscopy (live X-ray) is used to ensure the medication is delivered to the correct location. If the patient’s pain goes away after the injection, it can be inferred that the back pain generator is the specific nerve root that has just been injected. Following the injection, the steroid also helps reduce inflammation around the nerve root.

Success rates vary depending on the primary diagnosis and whether or not the injections are being used primarily for diagnosis. While there is no definitive research to dictate the frequency of SNRBs, it is generally considered reasonable to limit SNRBs to three times per year.

Technically, SNRB injections are more difficult to perform than epidural steroid injections and should be performed by experienced physicians. Since the injection is outside the spine, there is no risk of a wet tap (cerebrospinal fluid leak). However, since the injection is right next to the nerve root, sometimes an SNRB will temporarily worsen the patient's leg pain.

N/A

N/A

SHOULDER DILITATION FOR ADHESIVE CAPSULITIS

The term 'arthrographic' refers to the use of radiological imaging to watch and guide the procedure. A small amount of contrast material is injected into the joint which allows the procedure to show up on an imaging device. The injected fluid can be seen to expand the joint and sometimes flow out of the joint in a particular direction. Distension of the glenohumeral joint with fluid is thought to disrupt adhesions (scar tissue), thereby opening or freeing up the joint allowing improved range of movement.

The procedure is performed under local anaesthetic, takes about 15 minutes to complete and the patient goes home immediately afterwards. The procedure appears to be safe with transient pain during and after the procedure being the most common complaint. Most have included corticosteroid as part of the procedure but it is not known if this is necessary. It is also not known whether arthrographic distension using steroid and saline is better than intra-articular steroid injection alone [1.

There have been descriptions of distension of the joint being performed in the clinic or under radiological guidance (radiographic techniques to visualise the joint and guide injection into the correct site) with distension being achieved using various substances including combinations of saline, local anaesthetic, steroid, contrast and air.

There is some evidence that arthrographic distension provides benefits in pain, range of movement and function in Frozen Shoulder (1-7). Most studies are small and low powered, but distension with steroid appears to be more effective than a steroid injection alone.

Why have I been offered this treatment?
Your specialist has diagnosed a frozen shoulder which is a painful condition which causes reduced movement of the shoulder joint.

What is involved?
Hydodilatation involves stretching the capsule of the joint by injecting a mixture of sterile saline, local anaesthetic and steroid. This opens up the joint and releases sticky adhesions within the joint. The Radiologist performs the procedure in the Xray department using Xray guidance to ensure the injection is accurately placed.

You will be asked to lie on your back with your hand by your side. The skin will be cleaned and local anaesthetic will be given to numb up the area. A fine needle will be introduced onto the surface of the shoulder joint under Xray guidance and a small volume of Xray dye (iodine contrast) will be injected to ensure safe positioning.

Is it safe?
It is a safe procedure. There is a very small risk of infection, as with any joint injection. There is a risk that it may not work (in about 30%). There is a small risk of bleeding. You must inform the department if you are taking anti-coagulants eg Warfarin.

What can I expect to feel during and after the procedure?
Once the area is numbed up you should feel very little. There may be some pushing and pressure sensation. If you feel discomfort you must tell the doctor. Occasionally people have described a feeling of excess fluid in the shoulder. These symptoms should resolve quickly.

What happens after the procedure?
Some people do have moderate discomfort, which can last for thirty minutes after the procedure, due to the joint distension.
It is advised that you bring along someone to drive you home after the procedure, as we would advise that you do not to drive or "operate heavy machinery" for at least 6 hours after the procedure.
You can continue physiotherapy after the procedure and we would recommend you see your therapist approximately 3-5 days afterwards.

Does it work?
We have a success rate of over 70% in improving the movement of the shoulder and over 90% in improving pain. Many people feel immediate relief, but for some it can take a couple of weeks to achieve full benefit.

What if it fails?
Your specialist will discuss the option of a keyhole surgical release (arthroscopic arthrolysis) or MUA (Manipulation Under Anaesthetic).

N/A

N/A

THORACIC EPIDURAL STEROID WITH CATHETER

Epidural steroid injections can be performed in almost any area of the spine, from the neck (cervical) to the mid back (thoracic), all the way to the lower back (lumbar), and even as low as just above the tailbone (caudal). The specific location is chosen based on the area of injury or damage. Epidural injections can be used to treat many conditions including nerve compression, nerve injury, disc related pain, Complex Regional Pain Syndromes, and a variety of other indications. The specific type of epidural will be based on the underlying condition that is being treated and the patient’s injury. There are four basic types of epidural injections:

A Midline or interlaminar approach in which the needle is inserted into the center of the spine through a small window between bones of adjacent spinal levels. This can be done in the neck, mid-back, or low back regions. This is typically used for central disc herniations or central canal stenosis and is also used when catheters or spinal cord stimulators are inserted into the epidural space.
In a Transforaminal approach, a needle is inserted into an opening on the side of the spine, between the spinal bones, in the area where the nerve exits the spine. This bony opening between spinal levels is also called the foramen. In this case the injection is placed in close proximity to the nerve; injection in this location will typically cause reproduction of arm or leg symptoms. When the area of compression is within the foramen, a transforaminal approach tends to provide greater relief than an interlaminar approach.
Caudal epidural injections are performed through a small opening in the spine called the sacral hiatus, which is located just above the tailbone at the base of the spine. Caudal injections can be used for the treatment of a variety of conditions including peripheral neuropathy and pathology or injury at the lowest lumbar levels. This approach is also commonly used with epidural lysis of adhesions procedures.
Catheter guided – In this situation a needle is inserted via a mid-line or interlaminar approach into the epidural space. Through the needle, a catheter is guided into the area of damage. Once the catheter tip is properly positioned, and verified by contrast injection (to demonstrate that the medication will go to the intended location), medication is injected through the catheter. .

N/A

N/A

THORACIC MEDIAL BRANCH BLOCK

Thoracic medial branch nerves are located over a bone in the mid-back or upper back.

Role of a Medial Branch Block

A medial branch nerve block is a procedure in which an anesthetic is injected near small medial nerves connected to a specific facet joint. Typically several levels of the spine are injected in one procedure.

If the patient experiences marked pain relief immediately after the injection, then the facet joint is determined to be the source of the patient's pain.

See Facet Joint Disorders and Back Pain
The procedure is primarily diagnostic, meaning that if the patient has the appropriate duration of pain relief after the medial branch nerve block, then he or she may be a candidate for a subsequent procedure - called a medial branch radiofrequency neurotomy (or ablation) - for longer term pain relief.

Role of a Medial Branch Radiofrequency Neurotomy (Ablation)
In cases where a medial branch nerve block has confirmed that a patient's pain originates from a facet joint, a radiofrequency neurotomy can be considered for longer term pain relief.

A radiofrequency neurotomy is a type of injection procedure in which a heat lesion is created on the nerve that transmits the pain signal to the brain. The goal of a radiofrequency neurotomy is to interrupt the pain signal to the brain, while preserving other functions, such as normal sensation and muscle strength.

N/A

N/A

TRIGGER FINGER INJECTION

What is trigger finger?

Trigger finger is a "snapping" or "locking" condition of any of the digits of the hand when opened or closed. Trigger finger is medically termed stenosing tenosynovitis.

What are symptoms of trigger finger?

Symptoms of trigger finger may occur when any of the four fingers of the hand attempts to flex closed while gripping. Instead of a smooth, continual closure, the digit hesitates, then snaps closed. When attempting to extend the digit, a similar hesitation may occur before it "snaps" into full extension. In severe cases, the digits must be manually brought into full extension or flexion. The closure is frequently associated with pain at the base of the digit on the palm of the hand. Triggering can also affect the thumb.

What causes trigger finger?

Trigger finger is caused by local swelling from inflammation or scarring of the tendon sheath around the flexor tendons. These are tendons that normally pull the affected digit inward toward the palm (flexion). Usually, trigger finger occurs as an isolated condition because of repetitive trauma. Sometimes, trigger finger is an associated condition resulting from an underlying illness that causes inflammation of tissues of the hand, such as rheumatoid arthritis. In fact, data presented at the 2005 American College of Rheumatology national meeting suggested that a majority of patients with rheumatoid arthritis have inflammation around the tendons of the palm of the hand that could develop into trigger finger.

Surgical and other procedures

If your symptoms are severe or if conservative treatments haven't helped, your doctor might suggest:

Steroid injection. An injection of a steroid medication near or into the tendon sheath may reduce inflammation and allow the tendon to glide freely again. This is the most common treatment, and in people who do not have diabetes, it is effective in up to 90 percent of patients. In people with diabetes, it is effective about half the time. Sometimes to obtain these results, a second injection is needed.
Percutaneous release. After numbing your palm, your doctor inserts a sturdy needle into the tissue around your affected tendon. Moving the needle and your finger helps break apart the constriction that's blocking the smooth motion of the tendon. This treatment may be done under ultrasound control, so the doctor can see where the tip of the needle is under the skin to be sure it opens the tendon sheath without damaging the tendon or nearby nerves. This procedure is usually done in the doctor's office or procedure room.
Surgery. Working through a small incision near the base of your affected finger, a surgeon can cut open the constricted section of tendon sheath. This procedure is usually done in an operating room.

N/A

N/A

TRIGGER POINT INJECTION

Trigger point injection is used to treat extremely painful areas of a muscle, which are characterized by the presence of the trigger points. A trigger point is a traumatized area in the muscle, feels like a knot or a tight, taut band of the muscle, and it is tender to deep pressure or palpation.

These trigger points may occur in any area of the body but most commonly they develop in the neck, shoulders and low back.

The trigger point can trap and irritate surrounding nerves and causes a referred pain i.e. pain felt in another part but with close proximity to the original site. Multiple trigger points may have overlapping areas of referred pain.

PROCEDURE
The trigger point injections are a simple procedure performed in the office. The physician examines the patient and the painful involved area to identify the trigger points. After cleansing the skin, a small needle is entered into the trigger point. The injection may cause a twitch or mild pain that lasts from a few seconds to a few minutes.

AFTERCARE
Soreness from multiple needle sticks may respond well to an ice pack or massage. Numbness from local anesthetic may last about an hour. We strongly recommend ice, massage and stretching exercises for several days following the procedure.

COMPLICATIONS
They are remote, but may include but not limited to infection, bleeding, puncture the lung or the pleura (the surrounding membrane of the lungs) if done near the ribcage or at the neck, failure to alleviate the pain, or increase of the pain.

N/A

N/A

AMNIONIC MEMBRANE/STEM CELL

What is it?

Amniotic Membrane InjectionThe amniotic membrane injection uses a dehydrated form of human amniotic membrane.

Human amniotic membrane is derived of the same nutrients and growth factors that facilitate fetal growth. The naturally present cells include cytokines, carbohydrates, lipids, hyaluronic acid, growth factors, and multipotent cells.

These tissues provide a non-steroidal mechanism to alleviate pain through reducing inflammation.

The injection substance is derived from live willing donors and does not involve any fetal tissue. In addition, the amniotic membrane material is FDA regulated and processed in an ISO certified lab, so all major diseases are ruled out.

How does it Work?

Amniotic Membrane InjectionAmniotic membrane, which is rich in stem cells, can help repair the worn out, damaged tissues in pathological joint conditions, osteoarthritis, tendinopathies, and other inflammatory disease.

The pain arises when the nerves in the outer portion of the discs are irritated, which then signal the brain to trigger a pain response.

The naturally present cells in amniotic fluid have anti-inflammatory and regenerative properties to provide a non-steroidal approach to long lasting pain relief.

The regenerative effect of stem cell rich tissue can reduce further degeneration providing a longer lasting relief without the side effects of steroid injections.

The doctor will injected the stem cell rich sample into the damaged portion of the tissue or joints using fluoroscopic or ultrasound guidance.

When it is Recommended?

Amniotic membrane application is recommended for patients suffering from debilitating musculoskeletal pain where conservative management options such as activity restriction, medications, physical therapy, chiropractic treatment and steroid injections have failed, and surgery is the only option.

What are the Results?

Research has demonstrated the regenerative potential of amniotic membrane stem cells. Animal studies showed cartilage defects can be enhanced by the implantation of mesenchymal stem cells, and in the treatments of various pathological conditions of joints with no single unfavorable reaction. Hence, amniotic membrane is an exciting new treatment option that patients with chronic musculoskeletal pain might want to consider.

N/A

N/A

VISCOSUPPLMENTATION

Osteoarthritis of the knee is one of the leading causes of disability in the United States. It develops slowly and the pain it causes worsens over time. Although there is no cure for osteoarthritis, there are many treatment options available to help people manage pain and stay active.

In its early stages, arthritis of the knee is treated with nonsurgical methods. Your doctor may recommend a range of treatments, including:

Changes in activity level
Weight loss
Pain relievers, such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen
Physical therapy
Corticosteroid injections
Another treatment option is a procedure called viscosupplementation. If you have tried all other nonsurgical treatment methods and your pain continues to limit your activities, viscosupplementation may be an option.

In this procedure, a gel-like fluid called hyaluronic acid is injected into the knee joint. Hyaluronic acid is a naturally occurring substance found in the synovial fluid surrounding joints. It acts as a lubricant to enable bones to move smoothly over each other and as a shock absorber for joint loads. People with osteoarthritis have a lower-than-normal concentration of hyaluronic acid in their joints. The theory is that adding hyaluronic acid to the arthritic joint will facilitate movement and reduce pain.

The most recent research, however, has not found viscosupplementation to be effective at significantly reducing pain or improving function. Although some patients report pain relief with the procedure, some people are not helped by the injections.

Viscosupplementation was first used in Europe and Asia, and was approved by the U.S. Food and Drug Administration in 1997. Several preparations of hyaluronic acid are now commercially available.

Depending on the product used, you will receive one to five shots over several weeks.

During the procedure, if there is any swelling in your knee, your doctor will remove (aspirate) the excess fluids before injecting the hyaluronic acid. Usually, the aspiration and the injection are done using only one needle injected into the joint, Some doctors may prefer to use two separate syringes.

For the first 48 hours after the shot, you should avoid excessive weight bearing on the leg, such as standing for long periods, jogging or heavy lifting.

N/A

N/A