Spinal Injections Explained
What Is It?
A discogram is a diagnostic injection performed into the disc (structure
between the veterbra) to view and assess the internal structure of a disc and
determine if it is a source of pain.
How Is It Done?
The patient is given intravenous medication as a relaxant and pain reliever. A
local anesthetic is injected into the patient's skin in the area that is being
examined. A needle is inserted through a previously placed needle in the skin
and into the disc under fluoroscopy. A saline solution and radio-opaque dye
are injected into the disc or discs if more than one disc is being examined. A
CT scan is usually performed on the painful disc after the dye is injected to
obtain images of the dye distribution. This will demonstrate annular tears,
scarring, disc bulges and changes in the nucleus of the disc.
Expected Results:
1. Recreation of painful symptoms if the disc/discs is/are abnormal.
2. Confirmation of a diagnosis and/or determination of which disc/discs is/are
the source of pain.
How Long Does It Take?
Thirty minutes plus an additional thirty minutes if a CT is indicated plus
recovery time of several hours.
II. EPIDURAL ANESTHETIC BLOCK and STEROID INJECTION
What Is It?
A block that is performed under fluoroscopy to confirm a specific
diagnosis and/or decrease pain and inflammation.
How Is It Done?
A local skin anesthetic is given. A special needle is then inserted
into the epidural space of the Cervical, Thoracic, lumbar or caudal spine.
Fluoroscopy is used to guide the needle and prevent complications from the
needle. Contrast medium is injected into the space to confirm proper placement
and outline the effect of the herniation on the spine and nerve roots, films
are taken for review with the patient. An anesthetic and then a steroid
(usually a long acting- slow release type of cortisone) are injected into the
epidural space.
EXPECTED RESULTS?
Relief of pain if the medication reaches the inflamed area or source of pain.
HOW LONG DOES IT TAKE?
Fifteen minutes plus approximately fifteen to forty-five minutes recovery time
depending or not as to whether sedation is given.
GLOSSARY
EPIDURAL - Space outside the dura or covering of the spinal cord and inside
the spinal canal. This space runs the length of the spine.
DURA - Hard covering of the spinal cord which prevents fluid from leaking out
and protects the spinal cord and nerve roots.
III. SELECTIVE NERVE ROOT BLOCK (SNRB)
WHAT IS IT?
A block that is performed to determine if a specific spinal nerve root is the
source of pain and reduce inflammation around the nerve root (usually from a
herniated disc at this level) thus decreasing or relieving the pain.
HOW IS IT DONE?
The patient is given a local anesthetic - the physician then locates, under
fluoroscopy, a specific spinal nerve root. A needle is introduced through the
skin into the area adjacent to the nerve root. Dye is injected to confirm
proper placement. Medication (anesthetic then steroid) is then injected into
the area bathing the nerve root.
EXPECTED RESULTS:
Relief of back and leg pain.
HOW LONG DOES IT TAKE?
Fifteen to twenty minutes. Plus recovery time.
FACET JOINT SYNDROME (Definition):
Perhaps for me this is the simplest problem to treat, but hardest to explain.
Even to doctors!!! The problem is that it was not understood until the late
1980s that the nerves to the Facet Joints could cause severe and diffuse pain.
The pain does not follow a nerve root. It is actually referred pain, as the
brain has trouble localizing these internal structures.
Consider the case of the man who has a heart attack and presents with pain
under his left side of his breast bone, piece of cake. Another man may have a
heart attack and present with pain in the left arm, jaw or even stomach or
gall bladder area. The problem is that pain is interpreted differentially in
different individuals.
It is usually caused by trauma (auto accidents, whiplash, a bad fall) or a degenerated or herniated disc. These all cause the spine to sub-lux (move out of joint) and the joint capsule is ripped.
It is usually worsened by sudden movements or prolonged episodes of poor posture, (e.g. kneeling in the garden, bending over to lift or straining to read a book or a computer terminal). Many patients find the worst time is at night, when all the muscles relax and the joints grind together.
It is typically mistaken for fibromyalgia or myo-fascial syndrome. Both of these are garbage or waste basket terms.
IV. FACET BLOCK (WHAT IS IT?):
A block (or local anesthetic injection) that is performed to confirm that a
facet joint is the source of pain and decrease pain and inflammation in a
facet joint or joints.
Actually this is the only true way to diagnose Facet Joint Syndrome, as an abnormal looking joint on X-ray or CT scan, may be painless, and vice versa a normal looking joint may be the pain generator.
HOW IS IT DONE?
The patient is given the option of light, (or deep in rare cases) IV sedation
under monitoring of the EKG, pulse oximeter, etc by a Board Certified
Anesthesiologist. A tiny needle (smaller than the size of a paper clip) is
then inserted into the area of the facet joint where the nerve reaches it (or
directly inside the facet capsule, in some cases) and the physician injects an
anesthetic and steroid.
This is done under fluoroscopy. I usually do the first one with a short acting local to quickly diagnose the levels of facet injury involved.
EXPECTED RESULTS:
Decrease in or relief of back pain. More importantly confirmation of the
diagnosis, with the allowance of rational treatment.
HOW LONG DOES IT TAKE?
Fifteen to Thirty minutes, depending on the number of levels performed.
Note injections may be done in conjunction with massage, myo-fascial release, or "light" physical therapy especially ultrasound and stimulation. Chiropracty will universally aggravate Facet Joint Syndrome and must be avoided at all costs.
RISK/BENEFIT RATIO:
Probably the easiest of all interventional procedures (provided done by a
Board Certified physician with experience), with the lowest risk and most
benefits.
OTHER THERAPY:
Once, the diagnosis is made by a prognostic block, the block may be
repeated with a longer acting local and depot steroid preparation. Some milder
cases may be treated, by improving posture, spine bracing during
lifting/exercise and anti-arthritic agents such as Motrin or the newer (Cox-2)
inhibitors such as Celebrex or Vioxx. If the pain recurs, pulsed
radiofrequency is the definitive treatment (see inside).
FACET JOINT SYNDROME (Definition):
A constellation of symptoms which result in diffuse pains that do not fit a
clear nerve root pattern (e.g. not sciatica), these pains are worsened with
movement of the spine, poor posture, often sleep, sometimes associated with
cold burning sensations, usually worsened by cold damp weather and are now
known to emanate from the tiny medial branch nerves that supply the facet
joint.
REMEMBER THE ONLY WAY TO DEFINITIVELY MAKE THE DIAGNOSIS IS BY A
DIAGNOSTIC/PROGNOSTIC FACET BLOCK
V. COSTOVERTEBRAL JOINT BLOCK
WHAT IS IT?
A block that is performed under fluoroscopy to identify the costovertebral
joint as the pain generator and decease or relieve pain in that area and out
toward the lateral rib cage.
HOW IS IT DONE?
The patient is placed in a prone position and given a local skin anesthetic.
Under fluoroscopy the specific costovertebral joint(s) is identified. A needle
is placed in that area(s) and an anesthetic and steroid are injected.
HOW LONG DOES IT TAKE?
Fifteen to thirty minutes.
EXPECTED RESULTS?
Initially, when a needle is inserted in the costovertebral area(s), there will
be a reproduction of pain. Following injection of the medications there may be
relief of pain and increased mobility. Duration of relief varies with the
individual.
VI. SYMPATHETIC NERVE BLOCK
WHAT IS IT?
A block that is performed to determine if there is damage to the sympathetic
nerve chain and if it is the source of pain. This is a diagnostic test
primarily, but it may provide relief far in excess of the duration of the
anesthetic.
HOW IS IT DONE?
A local skin anesthetic is given in the lumbar or thoracic area of the back. A
needle is then inserted into the back under fluoroscopy next to the vertebral
body at the block may be performed on both sides of the spine if symptoms are
on both sides. An anesthetic medication will be injected into the appropriate
ganglion area of suspected pain.
EXPECTED RESULTS:
The patient may note redness of the upper or lower extremity and a feeling of
warmth.
HOW LONG DOES IT TAKE?
It takes thirty minutes for the procedure followed by evaluation and recovery
for several hours.
USUAL COURSE OF TREATMENT
Once the sympathetic chain is identified as the source of pain, medications
may be given by mouth to decrease this type of pain. I usually perform
repeated injections of the sympathetics to try and shut the pain generation
cycle down. If repeat blocks fail, then I perform pulsed or conventional
radiofrequency (see below) denervation or sympathectomy of these nerves to
permanently shut the pain generation down.
VII. STELLATE GANGLION BLOCK (Cervical Sympathetic Block)
WHAT IS IT?
A block that is performed under fluoroscopy to determine if the sympathetic
nerve chain in the neck is the source of the patient's arm pain. This is
primarily a diagnostic block but it may provide pain relief in excess of the
duration of the anesthetic.
HOW IS IT DONE?
A local skin anesthetic is given near the base of the neck on the affected
side. A needle is inserted near the transverse process of the cervical spine
(usually at the cervical-6 level) with the guide of fluoroscopy. Sterile
tubing is attached to the needle and anesthetic medication is slowly injected
through the tubing.
HOW LONG DOES IT LAST?
It takes less than thirty minutes for the procedure followed by evaluation and
recovery for several hours.
EXPECTED RESULTS?
The patient may note increased warmth and redness of the painful arm during
and after the injection. The patient can expect hoarseness of their voice,
redness of the eye, drooping of the eyelid and pupillary constriction for four
to eight hours after the injection. Pain relief may be noted immediately.
Duration of relief is variable. The patient must assess their pain relief over
the first three to four hours after the injection and report this on a diary
card.
Again as in above, one can repeat this block many times in the hopes of
shutting the pain generation down. I only rarely do a permanent block at this
area, due to the permanent changes of the eye and the voice, I usually will
prefer to do a thoracic sympathectomy if necessary (see above).
VIII. CONVENTIONAL FACET NEUROTOMY (Medial Branch Rhizotomy)
WHAT IS IT?
Facet neurotomy is a procedure, which results in interruption of the nerve
supply to a facet joint. This interruption known as denervation, is
accomplished by a radio-frequency probe that heats and destroys the 2 small
nerve branches to each facet joint. These nerves are called the medial
branches.
HOW IS IT DONE?
With the patient in a prone position and under local anesthesia and
fluoroscopic guidance, a radio-frequency needle is advanced to the base of the
transverse processes. The needle is placed along the course of the medial
branch. The needle is heated to 70 to 80° C for 90 seconds. At least 2
branches for each joint are treated in this same manner.
HOW LONG DOES IT TAKE?
The neurotomy takes 30 to 45 minutes, depending on the number of levels to be
done. The patient is then recovered in the observation area for 30 minutes to
1 hour.
POTENTIAL RISK?
Increased localized back pain and/or leg pain can be expected from several
days to several weeks and rarely several months. Destabilization of the facet
joint is a risk and post injection training to strengthen the extensor muscles
can prevent this possibility.
EXPECTED OUTCOME?
Following the neurotomy, there is a 70% chance of pain relief, if the symptoms
are only from the facet joints. This typically lasts for 9 months to 1 1/2
years. The nerve eventually grows back and the procedure can be repeated.
While the patient is experiencing pain relief, vigorous physical therapy is
necessary to try and strengthen the involved facet joint(s). Many patients
have a combination of facet and discogenic pain, and require separate
treatments.
IX. PULSED RADIOFREQUENCY FACET NEUROTOMY (Medial Branch Rhizotomy with Pulsed Radiofrequency)
This is similar to the Conventional Facet Neurotomy; except that pulsed radiofrequency waves are delivered at a lower temperature (just three to five degrees over body temperature). It is thought that by avoiding the burning, that less damage to the nerve is done, and that there are fewer tendencies for the nerve to want to regenerate. In addition, the pulse radiofrequency creates an Electro-magnetic field that may reprogram the DNA in the nerve to stop pain transmission. This technique was recently FDA approved.
HOW LONG DOES IT TAKE?
The neurotomy takes 30 to 45 minutes, depending on the number of levels to be
done. The patient is then recovered in the observation area for 30 minutes to
1 hour.
POTENTIAL RISK?
Increased localized back pain and/or neck pain can be expected from several
days to two weeks and rarely beyond this. There is less nerve damage potential
than the conventional neurotomy and thus in my opinion it is the procedure of
choice. It may be in the DNA or other structures of the nerve are scrambled,
as opposed to the whole nerve being burned with conventional radiofrequency.
GLOSSARY
FACET JOINTS
Joints located on the back of the spine on each side where one vertebra
slightly overlaps the adjacent vertebrae. They guide and allow the complicated
movements of the spine. They get are like the facets of a diamond, which is
smooth and have almost no friction.
FLUOROSCOPY
X-ray like imaging (which uses much less radiation) of a part of the body that
is displayed on a screen or monitor in the block suite - this facilitates and
assures proper placement of the needle and medication. There is also an
intensifier, which magnifies the image, and improves the accuracy of the
treatment. Furthermore, a hard copy can be made for insurance, medical legal
and purposes of comparison.
INFLAMMATION
Tissue reaction to irritation
SYMPATHETIC NERVES
A network of nerves extending the length of the spine that control some of the
involuntary functions of the body such as opening and narrowing blood vessels.
They are involved in RSD or Chronic Regional Pain Syndrome.
DEFINITIONS:
FACET JOINT SYNDROME
A constellation of symptoms which result in diffuse pains that do not fit a
clear nerve root pattern (e.g. not sciatica), these pains are worsened with
movement of the spine, poor posture, often sleep, sometimes associated with
cold burning sensations, usually worsened by cold damp weather and are now
known to emanate from the tiny medial branch nerves that supply the facet
joint.
REMEMBER THE ONLY WAY TO DEFINITIVELY MAKE THE DIAGNOSIS IS BY A
DIAGNOSTIC/PROGNOSTIC FACET BLOCK
FACET NEUROTOMY
Is a procedure that results in interruption of the nerve supply to a facet
joint.
PAIN BLOCK
Is an anesthetic injection near or in a certain area that is thought to cause
or generate pain.