Pain Management - Interventional

Nerve blocks, epidural steroid injections and radiofrequency nerve ablation are non-operative forms of pain management. Therapeutic injections may be considered an adjunct to medication and physical therapy. Injection therapy may help control pain from degenerative disc disease, injury, osteoarthritis and other disorders of the spine. Pain management strives to relieve and control acute and chronic pain.

Table 1: Types of Pain

The following is a brief overview of different types of nerve blocks and epidural injections used to treat pain and discomfort caused by spinal disorders.

Nerve Blocks
A nerve block is an injection of medication onto or near nerves. The injected medication may include a local anesthetic, steroid and narcotic.

• Facet Joint Block and Medial Blocks
  Joint inflammation between the spinal bones can cause back pain. A facet joint block is an injection of local anesthetic and steroid medication into the joint. A medial block uses similar medication injected outside the joint space near the nerve that feeds that joint.
  
  
• Peripheral Nerve Block
  Paresthesias are sensations described as numbness, tingling, or a ’pins and needles’ feeling. These sensations may be caused by a disturbance in the peripheral nervous system. The nerves outside of the brain and spinal cord are the peripheral nerves. Sensory peripheral nerves transmit information to the central nervous system. Motor peripheral nerves transmit information from the brain.
  
  
• Selective Nerve Root Block (SNRB)
  Pain and discomfort from cervical or lumbar radiculopathy may be relieved by a SNRB. A radiculopathy is irritation and inflammation of a nerve root that serves a particular body part (eg arm, leg).
  
  
• Sympathetic Nerve Block
  Sympathetic nerves regulate part of the autonomic (involuntary) nervous system. This includes such bodily functions as sweating and blood flow. Conditions causing chronic pain often involve the sympathetic nerves.
  
  
• Epidural Steroid Injections
  The epidural space is the space surrounding the membrane that covers the spinal cord and nerve roots. Disorders such as spinal stenosis and herniated disc can cause nerve irritation, inflammation and pain. An epidural injection places anti-inflammatory medication (eg steroids) into the epidural space. Epidural injections are performed in the cervical, thoracic and lumbar spine.
  
  
• Sacroiliac Joint Injection
  The sacroiliac joint is the largest joint. It is located in the lower spine above the tailbone. Inflammation of the sacroiliac joint can cause low back and buttock pain. An injection of an anesthetic and steroid may help relieve joint pain.
  
  
• Radiofrequency Nerve Ablation
  Facet joints are one source of back pain. Radiofrequency nerve ablation uses radio waves to produce heat directed at a specific facet joint nerve. The heat destroys the nerve and relieves pain.

The ablation procedure is similar to a nerve block or spinal joint injection except two needles are inserted; each facet joint has two nerves. Fluoroscopic guidance is used to correctly position each needle. Then radiofrequency "radio waves" are directed through each needle. The ablation process takes about two minutes. The entire procedure takes about 2 hours.

Patient Restrictions
For safety, some patients are not allowed to undergo a spinal injection for the following reasons:

• Allergy to the drugs to be injected
• Anemia
• Asthma
• Bleeding problems
• Infection
• Kidney disease
• Pregnancy/breast-feeding
• Severe spinal abnormality

Patient Preparation: At Home
It is important to follow all pre-test instructions. These instructions generally include:

• Stop blood thinning medication 2 days prior to the test
• Do not take any aspirin product 5 days prior to the test
• Stop anti-inflammatory medication 5 days prior to the test (Vioxx™ or Celebrex™ is an exception)
• Stop pain medication 8 hours prior to the test
• Do not eat or drink 6 hours prior to the test
• Arrange for someone to provide transportation home

Patient Preparation: At the Medical Facility

• The medical staff will review the patient’s history, condition, medications taken on a daily basis, food and/or drug allergies, and other information.
• The patient changes into a gown and lies down in a hospital bed.The facility provides a secure place for the patient’s personal items.
• An EKG monitor (heart function), automatic blood pressure cuff (blood pressure), and oximeter (measures blood-oxygen levels) are attached to the patient. This equipment enables the medical staff to consistently monitor the patient’s vital signs before, during and after the procedure.
• Medication to relax the patient is administered by injection. In some cases, light intravenous sedation may be given.

What to Expect During the Procedure

• The procedure is performed in a sterile setting similar to an operating room.
• The injection site is cleaned and draped. Skin numbing medication is injected into and around the procedure site.
• Before proceeding, the fluoroscopy C-arm is positioned over the patient. Fluoroscopic guidance is used during the procedure to guide the needle into the proper position.
• After the needle is placed, an anesthetic and steroid are injected. An antibiotic may be included in the injection to prevent infection.

After the Procedure

• The patient is wheeled to the recovery area where the medical staff continues to monitor vital signs.
• Patients are usually discharged home when stable with written instructions.
• The area around the injection site will feel numb.
• Steroids may cause side effects that include blurred vision, frequent urination, increased thirst and change in blood sugar levels. If these side effects become bothersome or worsen, seek medical attention.
• If fever, chills, increased pain, weakness or loss of bowel/bladder function occurs, seek immediate medical attention.
• Follow-up with the treating physician.

Possible Complications
Spinal injections, like other medical procedures, have risks. Complications include risk of infection, low blood pressure, headache, and injury to nerve tissue.

Conclusion
We perform the full -range of therapies outlined above. Our medical team will carefully discuss the options with you, and give you detailed instructions for before and after the procedure.

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For additional health information, please contact Scoliosis and Spine Associates at our Manhattan, New York City medical practice (212) 986-0140.