Interventional Procedures

A selective nerve root block (SNRB) is a target-specific epidural steroid injection for diagnosing and treating back pain. During the procedure, your physician injects a small amount of steroid and numbing medication around the nerve roots exiting the spinal cord. The injection can be made in the neck, chest or back region. The SNRB allows the doctor to determine exactly what nerve root or roots are being affected.

WHO CAN BENEFIT

Sometimes the discs between a patient’s vertebrae tear due to physical trauma causing the chemicals inside them to leak out. When this occurs, the nerve roots become inflamed and the thick membrane surrounding the brain and spinal cord (the dura) triggers pain. A large disc tear may also cause a disc to bulge, further exacerbating the pain. Other conditions such as bone spurs (also called osteophytes) can also press against nerve roots and cause pain.

Selective nerve root blocks can help determine if a specific nerve root is causing your problem. Depending on the area of the back affected, your physician may perform a cervical (neck pain radiating to the arm), lumbar (lower back pain radiating to the leg) or thoracic nerve root block (upper back pain).

WHAT TO EXPECT

A local anesthetic will be used to numb your skin. For many patients, this will feel like a little pinch followed by a slight burning sensation. The doctor will then insert a thin needle directly into the epidural space guided by the fluoroscopy machine (a type of x-ray). A dye may also be injected to further ensure that the needle is at the correct spot. Once the doctor is sure that the needle is correctly placed, the medicine will be injected. During the injection of the steroid and local anesthetic, temporary achiness along the nerve root may be felt until the local anesthetic sets in which is usually within seconds.

AFTER THE PROCEDURE

Once the procedure is completed, you will be monitored for up to 30 minutes. We recommend you make arrangements for someone to take you home after the procedure as the sedation offered might make you drowsy. When you are ready to leave, our staff will give you discharge instructions along with a diary to track your pain. This helps our pain specialist determine how effective the injection is for your condition.

Following the procedure, it may help to move your back in ways that hurt before the injection to see if the pain is still there. Just make sure that you don’t overdo it. Take it easy for the rest of the day. You may feel immediate pain relief and numbness in your back for a limited period of time after the injection. This tells you the medication has reached the right spot. You can usually return to work the next day, but always check with your doctor.

Your pain may return after a short pain-free period, or may even be a little worse for a day or two. This may be caused by the needle irritation or by the corticosteroid itself. Corticosteroids usually take two to three days to and sometimes up to a week to start working.

TREATMENT EFFECTIVENESS

The relief of symptoms from a selective nerve root block varies among patients but can last from just a few days to several months. The extent and duration of pain relief you experience ultimately depends on the amount of disc, dura or nerve root inflammation you have. Other co-existing factors may be responsible for your pain. If your pain is due to injury of several different regions of the spine, more injections might be needed. Even if the injection offers only short-term relief, it does provide time for the nerve root and dura to heal for long-term pain alleviation.

A medial branch block procedure attempts to “block” or “numb” the nerves near the facet joints, so that they will be unable to carry pain sensation to the spinal cord. Medial branch nerves are found near facet joints in the spine. They transmit pain signals from the facet joints to the brain. For patients suffering from a facet joint injury, they may experience muscle tension that can even be severe depending on the type of injury.

WHAT TO EXPECT

After a local skin anesthetic is applied, your physician will use a fluoroscopy (x-ray) machine to place a needle along the nerves that supply the inflamed joint. Once the doctor is sure that the needle is correctly placed, the medicine will be injected. This will effectively block the transmission of pain signals from the facet joint to the brain. The medial branch nerves around an injured facet joint will become numb reducing your pain, enabling normal back movement.

AFTER THE PROCEDURE

After the procedure is finished, you will be monitored for up to 30 minutes. When you are ready to leave, our staff will give you discharge instructions along with a pain diary to track your pain. This helps your doctor determine how effective the injection is for your condition.

We recommend you take it easy for the rest of the day. You might try to move your back in ways that you were unable to move before but be careful not to overstress your back. You may feel immediate pain relief and numbness in your back for a limited period of time after the injection. This indicates that the procedure was performed in the correct location and the medication has taken affect. Patients can usually return to work the next day, but it is a good idea to cross-check with our specialist.

TREATMENT EFFECTIVENESS

The extent and duration of pain relief may depend on the amount of inflammation and how many areas are involved. Other co-existing factors may be responsible for your pain. If your pain returns within a short span of time, you may be a candidate for radiofrequency ablation of the medial branch nerves. This can provide a more sustained disruption of pain signals and often prolonged pain relief.

A radiofrequency ablation is an outpatient procedure that uses an electric current to heat up a small area of nerve tissue to stop it from sending pain signals. It is also known as facet thermal coagulation or rhizotomy. The procedure uses radiofrequency energy to disrupt the transmission of pain from the medial branch nerve to the brain. It is normally used to relieve chronic pain arising from a facet joint injury. These are the joints located in your spine that make it possible for you to bend and twist your back.

WHO CAN BENEFIT

The radio frequency ablation technique RFA is usually recommended if patients had prior successful median branch nerve block procedures. Along with providing lower back relief, the procedure can also provide relief for people with chronic pain in the neck and arthritic joints.

WHAT TO EXPECT

During the procedure, you pain specialist will numb your skin using a local anesthetic. The doctor then inserts a thin needle near the affected facet joint using the fluoroscopy machine (a type of x-ray) as a guide. This stimulates the nerve. If muscle twitching and pain is provoked, it indicates that the correct nerve has been targeted. Once the needle is properly placed, the nerve is numbed and radiofrequency energy is used to disrupt the medial branch nerve.

AFTER THE PROCEDURE

Once the procedure is completed, the patient is monitored for 30 minutes, and our staff provides discharge instructions when the patient is ready to leave. Before departing our facility, the patient is advised to track the pain as it helps to assess if the RFA procedure was effective. Muscle and/or nerve irritation may cause one to feel sore for one to four days after the procedure. In some cases, you may feel sore for up to 4 weeks following thermal coagulation. The back may feel numb, weak or itchy for a couple of weeks. Maximum pain relief normally comes in two to three weeks. Nerves regenerate after an RFA and pain may return after sometime. The time it takes varies from person to person and another RFA might be needed. RFA, if successful, can be repeated after six months.

TREATMENT EFFECTIVENESS

Pain relief from RFA can last from six to 12 months, and in some cases relief can last for years. More than 70% of patients treated with RFA experience pain relief, according to WebMD.

Spinal cord stimulator therapy is one of the latest advancements in science used to treat and manage chronic pain. This neuromodulation technique treats chronic pain arising from the lower back, the neck, after failed back surgeries and complex regional pain syndrome.

WHAT TO EXPECT

During this minimally invasive procedure, the pain specialist places a small electrical device (a wire-like electrode) next to the affected area outside the spinal cord. The electrode delivers rapid electrical pulses that are felt like mild tingles. During the testing period (trial), the electrode is connected to an external device, and if the trial is successful (usually seven days), a small generator gets implanted into the patient’s body for long-lasting pain relief. Electric pulses are delivered from the generator to the nerve or nerves using one or several electrodes, similar to heart pacemakers. The patient can control stimulation by turning the device on and off and adjusting stimulation parameters as needed.

AFTER THE PROCEDURE

Once the procedure is completed, you will be monitored for 30 minutes, and our staff will provide you with discharge instructions when you are ready to leave. After the procedure, you should track your pain during the whole trial period. You are not allowed to take shower, or take tub bath during this trial period. You should be able to return to work the next day, but it is always a good idea to check with your physician.

TREATMENT EFFECTIVENESS

Published studies of spinal cord stimulation show good to excellent long-term relief in 50 to 80% of patients suffering from chronic pain. After surgery, muscle and/or nerve irritation may cause you to feel sore for one to four days after the procedure. Your back may feel itchy during this trial period. Following the seven-day trial, you will return for a follow up, and the electrode (wire) will be taken out of your back. At this time, you and your physician will determine if this therapy was successful for you or not. If you receive more than 50% pain relief, you may be referred for permanent implantation of SCS.

Peripheral nerve stimulation (PNS), is a procedure similar to spinal cord stimulation frequently used to treat chronic pain. According to the International Neuromodulation Society, it was actually invented in the mid-1960s before the SCS. Some of the common applications of PNS include treatment of back pain, occipital nerve stimulation for treatment of migraine headaches and pudendal nerve stimulation.

WHAT TO EXPECT

During this minimally invasive procedure, our pain specialist places a small electrical device (a wire-like electrode) next to one of the peripheral nerves under x-ray guidance (fluoroscopy). The electrode delivers rapid electrical pulses that are felt like mild tingles. During the testing period (trial), the electrode is connected to an external device, and if the trial is successful, a small generator gets implanted into the patient’s body.

AFTER THE PROCEDURE

Once the procedure is completed, you will be monitored for 30 minutes. Our staff will also provide you with discharge instructions when you are ready to leave. You would be able to return to work the next day but it is always a good idea to check with your physician. Muscle and/or nerve irritation may cause you to feel sore for one to four days after the procedure. You will be required to follow up in clinic after the trial is over (usually seven days), when electrode will be taken out and you next option will be discussed with a physician.

TREATMENT EFFECTIVENESS

Peripheral nerve stimulation (PNS) has a high success rate for reducing pain. However, it’s important to note that the rate of reduction in pain will vary from patient to patient.

Kyphoplasty/ Vertebroplasty is a minimally invasive surgery used to treat spinal compression fractures. It uses special balloons to inflate inside the collapsed/ fractured spine and thereafter, bone cement is injected to correct spinal deformities and restore lost height. Because the procedure prevents bone fragments from rubbing together, it can also help alleviate pain.

WHAT TO EXPECT

Prior to the procedure being done, you will be asked to fast for about six hours before the procedure.  Once you arrive at our facility, pour pain specialist physician will perform this procedure with you in conscious sedation. Our medical team may start an intravenous line and monitor your vital signs for the duration of the procedure.  Once you are sedated, the doctor will insert a hollow needle directly into the nerve ganglion guided by the fluoroscopy machine (a type of x-ray) which will be used to inject the cement. A dye may also be injected to further ensure that the needle is at the correct spot.  Once the doctor is sure that the needle is correctly placed, a balloon is inserted and inflated to make space for the cement. Once the space is opened up, the bone cement is injected. The needle is removed and the area is bandaged up.

Collapsed vertebrae- Elevated through balloon inflation and cement insertion

AFTER THE PROCEDURE

Once the procedure is completed, you will be monitored for up to 30 minutes. When you are ready to leave, our staff will provide you with discharge instructions.  Immediate pain and soreness is normal in the first 48 hours after the procedure and ice packs can help relieve these symptoms. Check with the doctor before resuming normal activities or resuming any bone-strengthening supplements or medications. Our office will schedule a follow-up visit with the doctor to check your progress.

TREATMENT EFFECTIVENESS

You may quickly notice that you have less pain than you did before the surgery. Following the procedure, only about 10 percent of people end up with additional compression fractures, according Heathline.com.

Your brain and spinal cord are bathed in fluid which acts as a shock absorber and.  A spinal tap, also called a lumbar puncture, is a procedure doctors use to remove and test some of this liquid, called cerebrospinal fluid (CSF). It helps the physician diagnose disorders of the brain and spinal cord, including multiple sclerosis, bacterial infections, headaches and hemorrhage.

WHAT TO EXPECT

The area where your physician will draw CSF from is first cleansed and covered. Then the doctor will apply a local anesthetic to numb the area of your spine. A long, thin hollow needle is inserted in the space between the vertebrae and draw one to two tablespoons of CSF for further analysis. It is recommended that you keep well hydrated after the procedure is completed as the loss of CSF might cause some headaches for up to two – three days after the procedure. Please contact your healthcare provider immediately if your symptoms worsen or extend beyond 3 days.

AFTER THE PROCEDURE

Following the procedure, you may need to lie on your back or stomach for a few hours. Try to avoid any strenuous activities a day or so after the procedure. A nonprescription pain-relieving medication can help reduce any headache or back pain.

TREATMENT EFFECTIVENESS

A spinal tap by itself can’t confirm or rule out a diagnosis of a brain or spinal cord disorder. It must be part of the total picture of testing for these health-related issues. The results of the procedure, however, can help doctors see whether your body’s immune system is attacking itself, which is what happens in multiple sclerosis.

Occipital nerve blocks are used for the treatment of chronic migraines as well as cluster or tension type headaches. They are especially helpful for patients experiencing pain starting at the back of the head near the neck, and radiating outward throughout the skull.   The procedure blocks the disproportionate or chronic signals that are sent to the brain and processed and perceived as headache pain. Pain relief by this procedure can last up to several months, depending on the response of the individual patient to this treatment.

WHAT TO EXPECT

A local anesthetic will be used to numb your skin. The doctor will then insert a thin needle near the occipital nerve. Once the doctor is sure that the needle is correctly placed, the medicine will be injected.

AFTER THE PROCEDURE

Once the procedure is completed, you will be monitored for up to 30 minutes. When you are ready to leave, our staff will give you discharge instructions along with a pain diary to track your pain. This helps your doctor determine how effective the injection is for your condition. The time elapsed before you experience pain relief varies from person to person; it may be nearly instantaneous for one individual, but it may take a day or more for another.

TREATMENT EFFECTIVENESS

The patient may not notice the full effect of the nerve block until a few days after the procedure. Pain relief may last a month or more, at which point the patient may arrange for a repeat injection. Some patients may require two injections in quick succession to elicit an optimal effect.

Intercostal Nerve Blocks

An intercostal nerve block is an interventional pain management technique used to relieve pain in the chest area. Pain may be caused by a herpes zoster infection (or “shingles”) or a surgical incision. Intercostal nerves are located under each rib. When they get irritated or inflamed, it can cause pain.

WHAT TO EXPECT

For intercostal nerve blocks, a local anesthetic and a steroid is injected under the rib to reduce the inflammation and alleviate the pain. This technique can also be used to help diagnose the source of pain. The doctor performs the procedure by inserting a thin needle near the occipital nerve, guided by the fluoroscopy machine (a type of x-ray). A dye may also be injected to further ensure that the needle is at the correct spot.  Once the doctor is sure that the needle is correctly placed, the medicine will be injected.

AFTER THE PROCEDURE

Once the procedure is completed, you will be monitored for up to 30 minutes. When you are ready to leave, our staff will give you discharge instructions along with a pain diary to track your pain. This helps your doctor determine how effective the injection is for your condition. The time elapsed before you experience pain relief varies from person to person; it may be nearly instantaneous for one individual, but take a day or more for another.

TREATMENT EFFECTIVENESS

The patient may not notice the full effect of the nerve block until a few days after the procedure. Pain relief may last a month or more, at which point the patient may arrange for a repeat injection. Some patients may require two injections in quick succession to elicit an optimal effect.

A bursa is a gel-filled sac that helps muscles and tendons glide over bones. We have bursae in our shoulders, elbows, hips, knees and other parts of our body. Inflammation of the bursa can cause joint pain. Bursa injections are interventional procedures that can help soothe joint pain caused by arthritis, bursitis and other painful inflammatory diseases.

WHAT TO EXPECT

A local anesthetic will be used to numb your skin. The doctor will then insert a thin needle near the affected bursa or joint which is guided by a fluoroscopy machine (a type of x-ray). A dye may also be injected to further ensure that the needle is at the correct spot.  Once the doctor is sure that the needle is correctly placed, the medicine will be injected.

AFTER THE PROCEDURE

Once the procedure is completed, you will be monitored for up to 30 minutes. When you are ready to leave, our staff will give you discharge instructions along with a pain diary to track your pain. This helps your doctor determine how effective the injection is for your condition. The time elapsed before you experience pain relief varies from person to person; it may be nearly instantaneous for one individual, but take a day or more for another.

TREATMENT EFFECTIVENESS

The patient may not notice the full effect of the nerve block until a few days after the procedure. Pain relief may last a month or more, at which point the patient may arrange for a repeat injection. Some patients may require two injections in quick succession to elicit an optimal effect.

Peripheral nerve blocks (PNB) prevent or relieve pain by interrupting pain signals that travel along a nerve to the brain. They are commonly used for surgical anesthesia as well as for both postoperative and nonsurgical analgesia. They can also be used to help a patient’s dependency on opioids. Nerve blocks do not have many of the side effects of general anesthesia, such as nausea, vomiting, and tiredness.

WHAT TO EXPECT

During the procedure, a doctor will inject a local anesthetic with a steroid close to the injured nerve to decrease the conduction of pain signals along the nerve. This will numb the part of your body that needs surgery for up to 24 hours after surgery. In cases of specific sensory nerves, cold or heat can be utilized to provide a longer term nerve block for up to six to nine months. Neurolytic substances such as phenol or alcohol can be used in cases of terminal illness to provide long term and compassionate pain relief.

AFTER THE PROCEDURE

Complications from a peripheral nerve block are rare but can include bruising, infection, soreness at the injection sight, weight gain, bleeding, rash or nerve injury. Ice can be applied to the injection site for up to 20 minutes three times a day on the day or two after the procedure to minimize local inflammation from the injection.

TREATMENT EFFECTIVENESS

Most patients will reap the benefits of a peripheral nerve blocker by lessening nausea following surgery, providing better pain relief after surgery and reducing the amount of general anesthesia needed during surgery. This helps patients wake up even faster.

The sympathetic nervous system is a part of the autonomic nervous system that controls the body’s involuntary activities. A sympathetic nerve block can be used to diagnose or treat pain involving the nerves of the sympathetic nervous system. It call also help provide control over involuntary body functions. Depending on the location of your pain, your physician will decide to perform one of the following procedures:

• Stellate Ganglion Injection (targets pain Face and upper body)
• Lumbar Sympathetic Injection (targets pain in lower body)
• Hypogastric Plexus Block (targets chronic stomach pain)
• Ganglion Impar Block (targets visceral, pelvic, genital, perianal and anal pain)

 WHO CAN BENEFIT

Sympathetic nerve blocks can provide pain relief to patients suffering from blood vessel spasms, some types of chronic stomach pain, Raynaud’s syndrome, excessive sweating and complex regional pain syndrome.

WHAT TO EXPECT

Prior to this procedure, you will be asked to fast for about 6 hours. Our pain specialist will perform this procedure with you under appropriate sedation if necessary. Our medical team may start an intravenous line and monitor your vital signs for the duration of the procedure.  Once you are sedated the doctor will insert a thin needle directly into the nerve ganglion guided by the fluoroscopy machine (a type of x-ray). A dye may also be injected to further ensure that the needle is at the correct spot.  Once the doctor is sure that the needle is correctly placed, the medicine will be injected.

AFTER THE PROCEDURE

Once the procedure is completed, you will be monitored for up to 30 minutes. When you are ready to leave, our staff will provide you with discharge instructions along with a pain diary to track your pain. This helps your doctor determine the efficacy of the treatment for you.

TREATMENT EFFECTIVENESS

A sympathetic nerve block is a relatively safe procedure. You can usually go home afterward and return to your normal activities after a day of rest. If you had IV sedation, you’ll probably need to have someone drive you home.

Side effects after a sympathetic block may include temporary soreness, a feeling of warmth, or some weakness. If you’ve received a nerve block in the stellate ganglion, you may experience some temporary voice changes, eyelid droop, or difficulty swallowing. Until swallowing is back to normal, avoid large bites of food and sip liquids carefully.

Physical therapy, talk therapy, and pain medicine may all be part of your treatment along with sympathetic block. In most cases, you will be given a series of blocks to get the best possible response. The level of pain relief a patient observe varies from case to case with some patients experiencing several weeks/months of pain relief. The effect of the medication will lessen with time, and you may consider returning for a subsequent dose for continued pain relief.

Discography is a procedure for diagnosing painful tears in the intervertebral discs found between the bones of the spine. Common tests such as MRIs can show disc bulges and nerve root compression, but may miss tears or leaks in discs. Generally, patients who undergo discography have not gotten satisfactory pain relief from non-operative measures such as medication, physical therapy and modified activities. They usually have had back pain for at least 4 to 6 months.

WHAT TO EXPECT

During discography, a thin needle is inserted into the center of a disc. It is usually performed under IV sedation to help the patient relax. The doctor may also apply a local anesthetic to numb your skin. An X-ray contrast dye is then injected into the disc to identify whether or not the disc is painful. The dye also functions to outline the tears in the disc. The procedure is repeated on several discs to pinpoint the location of pain and the torn disc.

During the procedure the physician will check for any increase in your pain. Therefore, it is important to describe any pain you feel to your doctor. A healthy disc will not cause your usual pain but a torn disc may. If you feel a different pain or soreness, be sure to explain that it hurts but it is not your usual pain. This will help the doctor determine the discs responsible for your pain.

AFTER THE PROCEDURE

After the procedure, you will be monitored for up to 30 minutes. When you are ready to leave, the clinic will give you discharge instructions. You will be sent for a CT scan to get an image of your discs. A follow up appointment will be scheduled with the doctor to discuss the results of the discography and your doctor will recommend the best treatment for you based on the results.

TREATMENT EFFECTIVENESS

You may feel increased pain in your back after discography. This indicates that your doctor may have found the source of your pain. You can resume work a day or two after discography, but always check with your doctor.

In 2010, the FDA approved the use of BOTOX® for chronic migraines patients experiencing 15 or more headaches a month. Its effect on migraines was discovered coincidentally when people who were having the injections to lessen lines and wrinkles in their foreheads noticed that their headaches were improved. It is considered a preventive, not abortive, medication for debilitating migraine headaches. Botox Injections show maximum effect with repeat treatment every 12 weeks over a period of 6-9 months.

WHO CAN BENEFIT

The FDA approves the use of BOTOX® to treat chronic migraine in adults who are age 18 or over.  BOTOX® is considered an “off-label” treatment if it’s used for children or adolescents. This means that a doctor can prescribe it, but insurance companies might not pay for it. Before your insurance company will approve BOTOX® as a treatment for your chronic migraine, you typically must have tried and failed to respond to two other preventative treatments.

WHAT TO EXPECT

When you receive your first BOTOX® treatment, expect the appointment to take about 20 minutes. The doctor uses a very small needle that feels like a pinprick. He or she injects small amounts of BOTOX® around pain fibers that are involved in headaches. It enters the nerve endings around where it is injected and blocks the release of chemicals involved in pain transmission. Each treatment typically involves 31 injections in seven key areas of the head and neck.

AFTER THE PROCEDURE

It can take up to six months to see the maximum benefit from BOTOX®. In the meantime, you can continue your regular medications with no risk of a drug interaction. The most common side effect from a BOTOX® injection is a sore neck. We recommend using an ice pack to reduce the discomfort.

TREATMENT EFFECTIVENESS

According to the American Migraine Foundation, BOTOX® prevents migraine headaches before they start, but takes time to work. It can take up to six months to see the maximum benefit. One treatment lasts from 10 to 12 weeks, and patients reported that two treatments reduced the number of headache days by approximately 50%.

An intercostal nerve block is an interventional pain management technique used to relieve pain in the chest area. Pain may be caused by a herpes zoster infection (or “shingles”) or a surgical incision. Intercostal nerves are located under each rib. When they get irritated or inflamed, it can cause pain.

WHAT TO EXPECT

For intercostal nerve blocks, a local anesthetic and a steroid is injected under the rib to reduce the inflammation and alleviate the pain. This technique can also be used to help diagnose the source of pain. The doctor performs the procedure by inserting a thin needle near the occipital nerve, guided by the fluoroscopy machine (a type of x-ray). A dye may also be injected to further ensure that the needle is at the correct spot.  Once the doctor is sure that the needle is correctly placed, the medicine will be injected.

AFTER THE PROCEDURE

Once the procedure is completed, you will be monitored for up to 30 minutes. When you are ready to leave, our staff will give you discharge instructions along with a pain diary to track your pain. This helps your doctor determine how effective the injection is for your condition. The time elapsed before you experience pain relief varies from person to person; it may be nearly instantaneous for one individual, but take a day or more for another.

TREATMENT EFFECTIVENESS

The patient may not notice the full effect of the nerve block until a few days after the procedure. Pain relief may last a month or more, at which point the patient may arrange for a repeat injection. Some patients may require two injections in quick succession to elicit an optimal effect.