Back pain will affect nearly all adults at some point in their lifetime. In most patients, pain will resolve with rest and, perhaps, anti-inflammatory medications. However, in about 10 % of patients, pain will persist and the need for more aggressive treatment will become necessary.
Epidural steroid injections have historically been the first-line treatment of choice in the minimally invasive treatment of pain of the neck and back. First described in 1953, the technique is utilized in a large percentage of patients with unrelenting pain. Most patients are treated with 1-3 injections and pain relief may be observed quickly, in a matter of a few days, in up to 90% of patients.
The exact mechanism of pain relief with the use of steroid placement in the spinal epidural space remains somewhat controversial. It is well known that injury to the spine and its supporting structures (discs, ligaments, joints, etc.) can cause the release of substances that cause inflammation and irritation of the nerve fibers in and around the spinal canal. Steroids may help reduce this inflammatory effect and lessen the irritation of the nerve fibers, resulting in reduction of pain.
Cervical Epidural Steroid Injection brochure
Cervical Transforaminal Epidural Steroid Injection brochure
Thoracic Epidural Steroid Injection brochure
Thoracic Transforaminal Epidural Steroid Injection brochure
Lumbar Epidural Steroid Injection brochure
Lumbar Transforaminal Epidural Steroid Injection brochure
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Selective nerve block is a minimally invasive technique that can be performed in a matter of minutes, often without the need for any sedation, utilizing CT or x-ray guidance. The procedure may offer great benefit to the patient from both a therapeutic and diagnostic point of view. While epidural steroid injections are utilized to cover a relatively large area of spinal nerve tissue with a relatively dilute solution of anti-inflammatory agent, a guided selective nerve block delivers a relatively concentrated mixture, both anti-inflammatory steroid and/or anesthetic agent, directly to one or two specific nerve fibers or bundles. This may affect very effective and rapid pain relief.
While patients may obtain significant pain relief in a matter of a few minutes, the diagnostic information obtained from this same injection may be invaluable. Many patients present with an uncertain or confounding pain picture, with pain symptoms which do not equate with findings witnessed on physical exam or identified on CT or MRI examinations. Changes related to prior surgery or old traumatic events may obscure pertinent findings on these same studies.
With guided selective injections, slight contact of the injection needle with the suspected target may perfectly replicate the patients’ pain symptoms. Clear identification of this pain target may allow a more well-focused treatment plan and may eliminate or minimize the need for, at least, focus and minimize any subsequent surgical intervention.
Cervical Selective Nerve Root Block brochure
Stellate Ganglion Block brochure
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Back and neck pain may be extremely complex and is often multifactorial in nature. A variety of causative factors include disc disease, ligament injury, infection, cancer and a variety of inflammatory diseases. Facet joint disease is often a contributing cause to the pain complex and, while the exact prevalence of facet pain is unknown, it is known to be a relatively common etiology of neck and low back pain.
The facet joint is a true synovial-lined joint, similar to the hip or knee joint. It allows rotation and flexion between the vertebrae similar to any other true joint and sits posterior to the vertebral bodies themselves. The most common condition affecting the facet joints is osteoarthritis, an inflammatory degenerative condition that results in loss of joint cartilage and leads to erosions and overgrowth of the bone underlying the cartilage. This bony change may lead to narrowing of the spinal canal and spinal stenosis or may narrow the openings that allow nerves to pass out of the canal, called foraminal stenosis. Most commonly, however, this arthritic change leads to irritation and inflammation of the nerve roots that supply the joint space, resulting in associated pain.
As these facet changes may be subtle and confounding, CT and MR imaging may not always be reliable. Careful patient history and physical exam may be crucial in the diagnosis of facet-related pain. The facet is served by a small nerve fiber called the medial branch which is key to facet pain. In many cases, a test injection of anesthetic is used to evaluate the relevance of the facet to the patients’ pain. If there is good reduction of pain, a more permanent treatment may be used to deaden the nerve (neurolysis or rhizotomy) in an attempt to affect term relief.
Medial Branch Block brochure
Facet Joint Injection brochure
Thoracic Facet RF Neurotomy brochure
Lumbar RF Neurotomy brochure
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It is estimated that 90% of patients with advanced stage cancers will experience severe pain and that 30% of all cancer patients will experience pain regardless of cancer stage. Pain will usually increase as cancer progresses. It is also estimated that as many as 50% of cancer patients may be undertreated for their pain.
Pain associated with cancer can be related to a number of causes:
The most common cause of cancer pain is related to invasion of bony structures by metastatic cancer. Up to 75% of patients with metastases experience pain. If tumor invades the spinal column, this may weaken the vertebrae and lead to collapse. Vertebroplasty is a technique that may help strengthen the weakened bone and also diminish pain sensation in the affected vertebrae, leading to improved function and diminished pain.
The second most common cause of cancer pain, and often the most severe, is related to direct invasion of organs and nerve tissue by tumor. This is often the case with tumors of the abdomen and is often seen with tumors of the pancreas. In these cases, narcotic medications may not be able to adequately control associated pain. Celiac block is a technique that may eliminate pain or allow more regulated control with medication by deadening invaded nerve fibers and diminishing sensation of pain.
Whenever possible, the best treatment for pain associated with cancerous disease is usually removal of the tumor. When this is not possible, a well controlled regimen of narcotic medications may allow very adequate function in some cases. Unfortunately, however, some cancer pain can be complex and present in multiple locations. Uncontrolled pain can affect the patients’ ability to function and quality of life, regardless of treatment prognosis. In these difficult cases, minimally invasive options may allow better control of pain and improved quality of life for the patient.
Epidural for Cancer brochure
Celiac Plexus Block brochure
Vertebroplasty brochure
Intrathecal Pump Implant brochure
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Osteoporosis is a common condition of aging caused by diminishing bone strength and bone mass in the vertebrae of the spinal column. As the disorder progresses, the vertebrae become thin and porous, similar to a sponge. Minimal trauma can lead to collapse of the vertebral body which can result in severe pain, loss of mobility, and a hunched-back appearance. It is estimated that 26% women above age 50 will demonstrate a compression fracture on x-ray, and symptomatic vertebral fracture is actually more common that symptomatic hip fracture in the elderly population.
Until recently, most patients with symptomatic vertebral fracture had little in the way of a definitive treatment option and long-term pain medication may have been the only treatment option. Vertebroplasty is a technique for the placement of bone cement into the weakened vertebral body to improve strength of the porous bone, preventing further collapse, diminishing pain and allowing improved function. The procedure has a high rate of success in appropriately selected patients and may often be performed on an outpatient basis. Multiple fractured vertebral bodies may be treated in a single treatment session.
The procedure is often useful in the setting of osteoporotic fracture but may be invaluable in the setting of cancer pain, for stabilization of bone weakened by invasive or metastatic tumor. Vertebroplasty may even also be used as an adjunct to open surgical stabilization when disease is extensive.
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Trigger point is the term used to describe hypersensitivity in a taut, knot-like muscle. It is thought that the hypersensitivity develops in response to repetitive pain or trauma to a muscle bunder, leading to localized pain. Trigger points may be associated with repetitive stress but may also be associated with an injury that affects the nerve supply to a muscle group.
On exam, a trigger point can often be identified by placing the fingers in the region of the patient’s pain. The trigger point will feel like a firm knot, harder than the surrounding tissue. Pain will often be elicited with compression of the knot-like area.
Trigger points can lead to a variety of symptoms, ranging from migraine headaches and low back pain, to more complex pain syndromes such as fibromyalgia and myofascial pain syndrome.
A trigger point injection is placed directly within the trigger point area and may provide almost immediate relief of pain. Trigger point injections are often performed in a series of three, about a week apart. Trigger point injections are often combined with physical therapy to work and stretch the affected muscle group and affect healing of the damaged muscle.
Trigger Point Injection brochure
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It is well established that 70-90% of all persons will experience low back pain at some point in their lives. While most pain will resolve in 1-3 months with rest, medications and therapy, a significant number of patients will go on to experience chronic pain, and a number of these cases will be caused internal derangement of the intervertebral disc and associated “discogenic pain”. While still not completely understood, it is known that nerve fibers do exist in the outer covering of the intervertebral disc (the annulus fibrosus) and that there may be ingrowth of nerve fibers in chronically degenerated and damaged disc. These nerves may become irritated by increasing pressure in the weakened disc by the release of irritant substances caused by the breakdown of disc material. In these cases MRI may be equivocal or confusing as degenerative changes may be occurring at multiple levels and it may not be clear which degenerating disc is leading to the pain symptoms.
Discography is the only imaging procedure that is able to directly relate the appearance of the intervertebral disc to the patients’ pain response. While it should never be the primary imaging modality in the assessment of back pain, discography does allow visualization of the damaged disc in association with replication of the patients’ pain symptoms when the small amount of x-ray contrast is injected (concordant examination). The presence of a concordant exam indicates a strong likelihood that the offending degenerated disc is the source of the patient’s pain.
Disc nucleoplasty is a percutaneous, minimally invasive procedure used in the treatment of discogenic pain where no significant disc material has extended into the spinal canal. A small needle is placed into the disc to send pulses of radio waves into the disc material, causing vaporization of a small amount of disc material to relieve pressure in the disc space and allow the disc to resume a more normal configuration. This may relieve bulging of the disc and resultant pressure on surrounding structures. Nucleoplasty is often used in combination with bed rest, physical therapy and anti-inflammatory medications, which allows patients to return to normal activities in as little as a few weeks.
Discography brochure
Percutaneous Disc Nucleoplasty brochure
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Despite meticulous technique and years of surgical experience, some scarring may occur within and around the spinal canal following surgical intervention for a number of disorders. The scar tissue is most commonly caused by a small amount of bleeding into the spinal epidural space following surgery but may also in the absence of surgery following infection or even a large disc rupture. This scar tissue may irritate nerve fibers, often leading to severe and chronic pain.
The epidural neurolysis procedure is used to soften and release some of the scar tissue from the nerve tissue and allows penetration of anti-inflammatory medications into and around the spinal nerves.
RACZ Caudal Neurolysis brochure
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The spinal cord stimulator is a small device implanted under the skin surface, connected to a small set of electrodes that extend to the spinal canal. The device uses low-level electrical stimulation of the spinal nerves to block pain impulses from passing through the spinal cord to the brain, and there by impeding the pain sensation. By blocking these pain signals, the overall sense of pain may be markedly reduced and quality of life may be significantly improved.
Some indications for the placement of a spinal cord stimulator include failed back syndrome where surgery is unable to control pain despite a good technical outcome, chronic unrelenting back pain failing other therapies, complex regional pain syndrome with chronic unexplained burning pain in the extremities, stump pain after amputation and pain after spinal cord injury.
Spinal cord stimulator candidates usually will have failed all conservative treatment options and no further surgical options are typically available. In these cases a trial stimulator test is often performed to determine best lead position and evaluate patient response to the treatment. This trial is usually performed for 3-5 days. The typical goal is at least 50% improvement in the patients’ pain level to initiate permanent implantation of the stimulator device.
Spinal Cord Stimulator brochure
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The sacroiliac joint is a thin, but elongated joint in the low back that connects the wings of the pelvis to the sacrum of the lower spine. This joint has a synovial lining, similar to the lining of the large hip and knee joints, and can be impacted by changes of osteoarthritis in a similar fashion to these larger joints.
Sacroiliac joint pain may be very non-specific and cause pain in the legs, groin and low back region that can mimic pain of many other causes. When sacroiliac pain is suspected, injection of the joint space may serve a dual purpose. A small amount of local anesthetic mixed with steroid solution allows early onset of pain along with the more extended anti-inflammatory pain relief of the steroid. The rapid onset anesthetic effect will also help to confirm or deny the injected joint as the source of the patient’s pain, further defining a continuing treatment plan that may include anti-inflammatory medications and/or physical rehabilitation.
Sacroiliac Joint Injection brochure
580 W College Ave., 4th Floor
Marquette, MI 49855
Phone: 906-225-3054
Toll Free: 1-800-562-9753 x3054