Procedures Performed – Arkam Rehman, M.D. has done maybe more than 100,000 needle procedures in his busy career when it comes to the spine alone. He is outstanding with anesthesia to make the patient comfortable so they experience least pain of any injection.
Epidural Steroid Injections
Epidural Steroid Injections (ESIs) are a common method of treating inflammation associated with low back related leg pain, or neck related arm pain. In both of these conditions, the spinal nerves become inflamed due to narrowing of the passages where the nerves travel as they pass down or out of the spine.
Why Get an Epidural Steroid Injection?
Narrowing of the spinal passages can occur from a variety of causes, including disc herniations, bone spurs, thickening of the ligaments in the spine, joint cysts, or even abnormal alignment of the vertebrae (‘slipped vertebrae’, also known as spondylolisthesis). The epidural space is a fat filled ‘sleeve’ that surrounds the spinal sac and provides cushioning for the nerves and spinal cord. Steroids (‘cortisone’) placed into the epidural space have a very potent anti-inflammatory action that can decrease pain and allow patients to improve function. Although steroids do not change the underlying condition, they can break the cycle of pain and inflammation and allow the body to compensate for the condition. In this way, the injections can provide benefits that outlast the effects of the steroid itself.
How Are Epidural Steroid Injections Performed?
There are three common methods for delivering steroid into the epidural space: the interlaminar, caudal, and transforaminal approaches. All three approaches entail placing a thin needle into position using fluoroscopic (x-ray) guidance. Prior to the injection of steroid, contrast dye is used to confirm that the medication is traveling into the desired area. Often, local anesthetic is added along with the steroid to provide temporary pain relief.
An interlaminar ESI, often referred to simply as an ‘epidural injection’, involves placing the needle into the back of the epidural space and delivering the steroid over a wider area. Similarly, the caudal approach uses the sacral hiatus (a small boney opening just above the tailbone) to allow for needle placement into the very bottom of the epidural space. With both approaches, the steroid will often spread over several spinal segments and cover both sides of the spinal canal. With a transforaminal ESI, often referred to as a ‘nerve block’, the needle is placed alongside the nerve as it exits the spine and medication is placed into the ‘nerve sleeve’. The medication then travels up the sleeve and into the epidural space from the side. This allows for a more concentrated delivery of steroid into one affected area (usually one segment and one side). Transforaminal ESIs can also be modified slightly to allow for more specific coverage of a single nerve and can provide diagnostic benefit, in addition to improved pain and function.
All three procedures are performed on an outpatient basis, and you can usually return to your pre-injection level of activities the following day. Some patients request mild sedation for the procedure, but many patients undergo the injection using only local anesthetic at the skin.
What Happens After the Injection?
The steroid will usually begin working within 1-3 days, but in some cases it can take up to a week to feel the benefits. Although uncommon, some patients will experience an increase in their usual pain for several days following the procedure. The steroids are generally very well tolerated, however, some patients may experience side effects, including a ‘steroid flush’ (flushing of the face and chest that can last several days and can be accompanied by a feeling of warmth or even a low grade increase in temperature), anxiety, trouble sleeping, changes in menstrual cycle, or temporary water retention. These side effects are usually mild and will often resolve within a few days. If you are diabetic, have an allergy to contrast dyes, or have other serious medical conditions, you should discuss these with your NASS doctor prior to the injection.
Epidural steroid injections have been performed for many decades, and are generally considered as a very safe and effective treatment for back and leg pain or neck and arm pain. Serious complications are rare, but could include allergic reaction, bleeding, infection, nerve damage, or paralysis. When performed by an experienced physician using fluoroscopic guidance, the risk of experiencing a serious complication is minimized. Overall, ESIs are usually very well tolerated and most patients do well.
Although not everyone obtains pain relief with ESIs, often the injections can provide you with improvement in pain and function that last several months or longer. If you get significant benefit, the injections can be safely repeated periodically to maintain the improvements. Injections are also commonly coupled with other treatments (medications, physical therapy, etc) in an attempt to either maximize the benefit or prolong the effects. You should consult with your NASS doctor to develop a comprehensive care plan. Read More
Facet joints are small joints at each segment of the spine that provide stability and help guide motion. The facet joints can become painful due to arthritis of the spine, a back injury, or mechanical stress to the back.
A cervical, thoracic or lumbar facet joint injection involves injecting a small amount of local anesthetic (numbing agent) and/or steroid medication, which can anesthetize the facet joints and block the pain. The pain relief from a facet joint injection is intended to help a patient better tolerate a physical therapy routine to rehabilitate his or her injury or back condition.
Facet joint injections usually have two goals: to help diagnose the cause and location of pain and also to provide pain relief:
• Diagnostic goals: By placing numbing medicine into the facet joint, the amount of immediate pain relief experienced by the patient will help determine if the facet joint is a source of pain. If complete pain relief is achieved while the facet joint is numb, it means that joint is likely a source of pain.
• Pain relief goals: Along with the numbing medication, a facet joint injection also includes injecting time-release steroid (cortisone) into the facet joint to reduce inflammation, which can sometimes provide longer-term pain relief. Read More
Lumbar discography is an injection technique used to evaluate patients with back pain who have not responded to extensive conservative (nonsurgical) care regimens. The most common use of discography is for surgical planning prior to a lumbar fusion.
This diagnostic procedure – also called a discogram – is a controversial one.
- The protagonists of discography believe the information gleaned from this examination is unobtainable any other way.
- The procedure’s antagonists feel the responses evoked from disc pressurization are not useful in evaluating back pain patients.
This article does not extol the use of discography; rather it addresses some aspects of the procedure that may make a patient more at ease with what is an uncomfortable exam.
Indications for a Discogram
The indications for getting a discogram prior to a lumbar fusion surgery are extremely variable amongst spine surgeons. Ordering the procedure depends on access to a skilled discographer. A discogram is basically a very subjective test, and if there are no experienced discographers available, then the spine surgeon may forego the test since a poorly done discogram does not yield any useful information. Read More
(Intradiscal Electrothermal Annuloplasty)
Provides a new alternative to other surgical procedures for patients who suffer from back pain caused by certain types of disc problems.
It is a fairly advanced procedure made possible by the development of electrothermal catheters that allow for careful and accurate temperature control. The procedure works by cauterizing the nerve endings within the disc wall to help block the pain signals.
What is IDET and what does it do for Back Pain Management?
IDET is a minimally invasive outpatient surgical procedure developed over the last few years to treat patients with chronic low back pain that is caused by tears or small herniations of their lumbar discs.
How does IDET Work?
• The procedure is performed with a local anaesthetic and mild intravenous sedation
• A hollow introducer needle is inserted into the painful lumbar disc space using a portable X-ray machine for proper placement
• An electrothermal catheter (heating wire) is then passed through the needle and positioned along the back inner wall of the disc (the annulus), the site believed to be responsible for the chronic pain
• The catheter tip is then slowly heated up to 90 degrees Celsius for 15-17 minutes
• The heat contracts and thickens the collagen fibers making up the disc wall, thereby promoting closure of the tears and cracks. Tiny nerve endings within these tears are cauterized (burned), making them less sensitive. Read More
Sacroiliac Joint Injections
Sacroiliac Joint Injections
—also called a sacroiliac joint block—is primarily used either to diagnose or treat low back pain and/or sciatica symptoms associated with sacroiliac joint dysfunction.
The sacroiliac joints lie next to the spine and connect the sacrum with the hip on both sides. There are two sacroiliac joints, one on the right and one on the left. Joint inflammation and/or dysfunction in this area can cause pain. Read more about Sacroiliac Joint Dysfunction.
The purpose of a sacroiliac joint injection is two-fold: to diagnose the source of a patient’s pain, and to provide therapeutic pain relief. At times, these are separated and a patient will undergo a purely diagnostic or therapeutic injection, although often the two are combined into one injection.
Diagnosis: A diagnostic SI joint injection is used to confirm a suspected diagnosis of sacroiliac joint dysfunction. This is done by numbing the sacroiliac joint with local anesthetic (e.g. lidocaine). The injection is performed under fluoroscopy (X-ray guidance) for accuracy. Once the needle has entered the sacroiliac joint, contrast is injected into the joint to ensure proper needle placement and proper spread of medication. The numbing medication is then injected into the joint.
After the numbing medication is injected, the patient is asked to try and reproduce the pain by performing normally painful activities. If the patient experiences 75-80% pain relief for the normal duration of the anesthetic, a tentative diagnosis of SI joint dysfunction is made. A second diagnostic sacroiliac injection should be performed using a different numbing medication (e.g. Bupivicaine) in order to confirm the diagnosis. Read More
Diagnostic Hip Joint Injections
The hip joint is a large joint where the leg joins the pelvis. If this joint experiences arthritis, injury, or mechanical stress, one may experience hip, buttock, leg, or low back pain.
A hip joint injection may be considered for patients with these symptoms. The injection can help relieve the pain, as well as help diagnose the direct cause of pain.
Purpose of Hip Joint Injections
Hip joint injections involve injecting medicine directly into the joint. These injections can help diagnose the source of pain, as well as alleviate the discomfort:
• Diagnostic function: By placing numbing medicine into the joint, the amount of immediate pain relief experienced will help confirm or deny the joint as a source of pain. If complete pain relief is achieved while the hip joint is numb it means this joint is likely to be the source of pain.
• Pain relief function: Along with the numbing medication, time-release cortisone is also injected into these joints to reduce inflammation, which can often provide long term pain relief. Read More
Intra Articular Stem Cells
A crucial requirement for MSC-based OA therapy is the delivery of the cells to the defect site. Direct intra-articular injection might be possible in early stages of the disease when the defect is restricted to the cartilage layer, whereas a scaffold or matrix of some kind would be required to support the MCSs in cases where the subchondral bone is exposed over large areas
Intra Discal Stem Cells
About half of chronic low back pain is felt to stem from the intervertebral disc, generally from small tears in the outer portion of the disc. This is often referred to as “discogenic pain.” Intradiscal PRP is a procedure in which platelet-rich plasma is used for healing of the disc tissue. If we feel that your back pain may be stemming from the intervertebral disc, you may be a candidate to for PRP.
Nerve Block for Pain Relief
A nerve block relieves pain by interrupting how pain signals are sent to your brain. It is done by injecting a substance, such as alcohol or phenol, into or around a nerve or into the spine.
Nerve blocks may be used for several purposes, such as:
• To determine the source of pain.
• To treat painful conditions.
• To predict how pain will respond to long-term treatments.
• For short-term pain relief after some surgeries and other procedures.
• For anesthesia during some smaller procedures, such as finger surgery.
Nerve blocks are used to treat chronic pain when drugs or other treatments do not control pain or cause bad side effects. A test block is usually performed with local anesthetic. If you achieve good pain relief from the local anesthetic, your doctor may inject a nerve block, such as alcohol or phenol.
What To Expect After Treatment
Nerve blocks numb the nerves touched by the drugs. This relieves pain by interrupting the pain signal sent by the nerves to your brain. Depending on the type of nerve block, your pain may be numbed for a short time or a long time. Read More
Trigger Point Injections
Trigger Point Injection for Pain Management
Trigger point injection (TPI) may be an option for treating pain in some patients. TPI is a procedure used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax. Many times, such knots can be felt under the skin. Trigger points may irritate the nerves around them and cause referred pain, or pain that is felt in another part of the body. More to see
What Happens During a Trigger Point Injection?
In the TPI procedure, a health care professional inserts a small needle into the patient’s trigger point. The injection contains a local anesthetic or saline, and may include a corticosteroid. With the injection, the trigger point is made inactive and the pain is alleviated. Usually, a brief course of treatment will result in sustained relief. Injections are given in a doctor’s office and usually take just a few minutes. Several sites may be injected in one visit. If a patient has an allergy to a certain drug, a dry-needle technique (involving no medications) can be used. Read More
Prolotherapy and Chronic Back Pain
Prolotherapy is an injection procedure used to treat connective tissue injuries of the musculoskeletal system that have not healed by either rest or other nonsurgical therapies in order to relieve back pain. The injections promote a healing response in small tears and weakened tissue, with the goal of alleviating back pain and improving function. Prolotherapy is also referred to as sclerosant therapy, sclerotherapy, regenerative injection therapy, “proliferative” injection therapy, and nonsurgical ligament reconstruction.
Prolotherapy has been used in pain management and treatment of numerous conditions, including back pain and neck pain due to spine related conditions such as:
• Degenerative disc disease
• Sacroiliac problems
A theory behind prolotherapy is that back pain is related to activation of pain receptors in tendon or ligament tissues, which are sensitive to stretching, pressure, etc. It is thought that the cause of back pain is from ligamentous laxity. Read More
What Is Bursitis?
Bursitis is the inflammation or irritation of the bursa. The bursa is a sac filled with lubricating fluid, located between tissues such as bone, muscle, tendons, and skin, that decreases rubbing, friction, and irritation.
What Causes Bursitis?
Bursitis is most often caused by repetitive, minor impact on the area, or from a sudden, more serious injury. Age also plays a role. As tendons age they are able to tolerate stress less, are less elastic, and are easier to tear.
Overuse or injury to the joint at work or play can also increase a person’s risk of bursitis. Examples of high-risk activities include gardening, raking, carpentry, shoveling, painting, scrubbing, tennis, golf, skiing, throwing, and pitching. Incorrect posture at work or home and poor stretching or conditioning before exercise can also lead to bursitis.
An abnormal or poorly placed bone or joint (such as length differences in your legs or arthritis in a joint) can put added stress on a bursa sac, causing bursitis. Stress or inflammation from other conditions, such as rheumatoid arthritis, gout, psoriatic arthritis, thyroid disorders, or unusual medication reactions may also increase a person’s risk. In addition, an infection can occasionally lead to inflammation of a bursa.
Who Usually Gets Bursitis?
Bursitis is more common in adults, especially in those over 40 years of age.
What Parts of the Body Does Bursitis Affect?
• Achilles tendon
What Are the Symptoms of Bursitis?
The most common symptom of bursitis is pain. The pain may build up gradually or be sudden and severe, especially if calcium deposits are present. Severe loss of motion in the shoulder — called “adhesive capsulitis” or frozen shoulder — can also result from the immobility and pain associated with shoulder bursitis. Read More
Headache Nerve Blocks
What are nerve blocks for headache?
A nerve block is the injection of medication onto or near nerves. It involves the use of a small needle attached to a syringe containing medication to decrease or stop passage of nerve impulses that may carry pain signals to the brain or spinal cord. Nerve blocks are used to treat pain when drugs or other treatments do not control pain or are not tolerated because of side effects. Nerve blocks are effective for many headache conditions, including migraine and cluster headache. Most nerve blocks for headaches are performed in the back of the head over the occipital bone and nerve, but any nerve on the scalp can be injected. The medications injected include a local anesthetic and sometimes a steroid.
You may have even had a nerve block without knowing it: — dentists commonly use nerve-blocking agents to numb your mouth during potentially painful procedures.
Who should receive nerve blocks?
Nerve blocks are most commonly performed for patients who have a headache attack that will not stop even after using prescribed or over the counter medications. Patients with migraine who have a headache attack that will not stop after 3 straight days (called “status migrainosus”) may benefit, as may patients with cluster headache who are in a tough bout of frequent and severe attacks. They may also be offered to patients who have chronic migraine who are suffering from an exacerbation of their frequent, severe, or continuous headache.
How are nerve blocks performed?
Nerve blocks for headache most often take place in the office setting and usually take only minutes to perform. The patient may be seated or lying down, usually without any sedation. The injection itself will be administered with a syringe attached to a needle much like one that would be used for a routine vaccination. More than one injection may be required, depending on how many areas of pain you have, how large an area needs to be covered, or the type of headache disorder that is being treated. When finished, you will be allowed to rest for several minutes to let the medication take effect and to make sure no serious side effects develop.
How do nerve blocks work?
The medication delivered by the injection will be placed as close to the nerve in the area of the pain as possible. It will then “shut down” the pain receptors within the nerve causing the problem. If steroid is used, it reduces the inflammation and swelling of tissue around the nerves, which may help reduce pain. However, nerve blocks do not work for headache just by a numbing effect on the scalp. They likely have secondary effects on the head pain pathway in the brain that far outlast the duration of numbing the blocked nerves. Read More
Cosmetic Uses of Botox
Doctors have been using Botox for years to successfully treat wrinkles and facial creases. Botox is a brand name of a toxin produced by the bacterium Clostridium botulinum. There are also other brand names, such as Dysport and Xeomin.
How Does Botox Work?
Botox blocks signals from the nerves to the muscles. The injected muscle can’t contract. That makes the wrinkles relax and soften.
Botox is most often used on forehead lines, crow’s feet (lines around the eye), and frown lines. Wrinkles caused by sun damage and gravity will not respond to Botox.
How Is a Botox Procedure Done?
Getting Botox takes only a few minutes and doesn’t require anesthesia. Botox is injected with a fine needle into specific muscles with only minor discomfort.
It generally takes three to seven days to take full effect, and it is best to avoid alcohol starting at least one week before the procedure. You should also stop taking aspirin and anti-inflammatory medications two weeks before treatment to reduce bruising.
How Long Does a Botox Injection Last?
The effects from Botox will last four to six months. As muscle action gradually returns, the lines and wrinkles begin to reappear and need to be treated again. The lines and wrinkles often appear less severe with time because the muscles are being trained to relax. Read More
Platelet Rich Plasma Injections
Platelet activation plays a key role in the process of wound and soft tissue healing. The use of platelet rich plasma (PRP), a portion of the patient’s own blood having a platelet concentration above baseline, to promote healing of injured tendons, ligaments, muscles, and joints, can be applied to various musculoskeletal problems. Clinical studies have demonstrated that PRP injections have improved function and decreased pain to various maladies.
Prolotherapy is an injection-based complementary and alternative medical (CAM) therapy for chronic musculoskeletal pain. It has been used for for approximately 100 years, however, its modern applications can be traced to the 1950s when the prolotherapy injection protocols were formalized by George Hackett,1 a general surgeon in the U.S., based on his clinical experience of over 30 years. While prolotherapy techniques and injected solutions vary by condition, clinical severity, and practitioner preferences, a core principle is that a relatively small volume of an irritant or sclerosing solution is injected at sites on painful ligament and tendon insertions, and in adjacent joint space over the course of several treatment sessions. Interest in prolotherapy among physicians and patients is high. It is becoming increasingly popular in the U.S. and internationally, and is actively used in clinical practice. A 1993 survey sent to osteopathic physicians estimated that 95 practitioners in the US were estimated to have performed prolotherapy on approximately 450,000 patients. However, only 27% of surveys were returned, likely dramatically underestimated true number of practitioners. 5 No formal survey has been done since 1993. The current number of practitioners actively practicing prolotherapy is not known but is likely several thousand in the US based on attendance at CME conferences and physician listings on relevant websites. Prolotherapy has been assessed as a treatment for a wide variety of painful chronic musculoskelatal conditions which are refractory to “standard of care” therapies. While anecdotal clinical success guides the use of prolotherapy for many conditions, clinical trial literature supporting evidence-based decision-making for the use of prolotherapy exists for low back pain, several tendinopathies and osteoarthritis. Read More
Cooled Radio Frequency
Cooled radiofrequency (cooled RF) is a minimally invasive treatment option targeting nerves that are causing pain. Cooled RF can be used to alleviate pain from back pain, sacroiliac joint pain, hip pain, knee pain. During the procedure, an electrode is inserted in the area near the irritated nerves. The electrode heats and cools a small area of nerve tissue, decreasing pain signals from that specific area.
Spinal Cord Stimulation
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 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.
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