Pain and Wellness Center - Education/Treatment - Articles of Interest

Lumbar facet joint injection

How do these injections work?
Lumbar facet joints have been implicated as a source of chronic pain in 15% to 40 % of the patients with chronic low back pain. Usually the pain is localized in one or both sides of the lower back and do not respond to prior conservative management. Various radiological studies have a poor correlation with the actual pain experienced by the patient. Injection of a local anesthetic mixed with or without steroids (cortisone) will numb the facet joint or the nerves arising from this structure. In this way, the painful signals will be blocked and the patient may feel relief anywhere between a few hours or a few months. This will allow the break of the pain cycle, while the patient can exercise and improve the muscle strength. If after two similar injections the pain returns, one may consider a radio frequency ablation (destruction) of the small nerves innervating these joints. This might afford a longer and more sustained pain relief. Usually more than one joint is involved and therefore more than on injection is needed per session.

These injections should be considered only after simpler interventions failed to produce any type of sustained relief.

What to expect during the procedure?
For optimal outcome, this procedure needs to be performed under fluoroscopic guidance. The patient lies on the stomach; the back is cleaned with an antiseptic solution and then a local anesthetic is used to numb the skin. Under direct X ray visualization the needles are introduced towards the target area. A mild, temporary discomfort may be perceived at the time of the injection. A mixture of local anesthetic with or without steroids will be injected through the needles.

After the injection the patient will keep a close diary of the pain level so a decision can be made regarding the next therapeutic step. A mild local discomfort may persist at the side of the injection for a day or two.

After the procedure is completed somebody needs to drive the patient home, since temporary residual numbness may be perceived in the back or legs. Further discharge instructions will be provided by our staff before leaving the surgical area. The following day the patient will be called by the nurse and the outcome will be reassessed. Also a follow up appointment will be set up in two to three weeks with one of the physicians.

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Cervical facet joint injection

How do these injections work?
Cervical facet joints have been implicated as a source of chronic pain in 30% to 45 % of the patients with chronic neck pain. Usually the pain is localized in one or both sides of the neck and does not respond to prior conservative management. Frequently the pain may radiate to the back of the head. Various radiological studies have a poor correlation with the actual pain experienced by the patient. Injection of a local anesthetic mixed with or without steroids ( cortisone) will numb the facet joint or the nerves arising from this structure. In this way, the painful signals will be blocked and the patient may feel relief anywhere between a few hours or a few months. This will allow the break of the pain cycle, while the patient can exercise and improve the muscle strength. If after two similar injections the pain returns, one may consider a radio frequency ablation ( destruction) of the small nerves innervating these joints. This might afford a longer and more sustained pain relief. Usually more than one joint is involved and therefore more than on injection is needed per session.

These injections should be considered only after simpler interventions failed to produce any type of sustained relief.

What to expect during the procedure?
For optimal outcome, this procedure needs to be performed under fluoroscopic guidance. The patient lies either on the back or stomach ( based on individual considerations). The neck is cleaned with an antiseptic solution and then a local anesthetic is used to numb the skin. Under direct X ray visualization the needles are introduced towards the target area. A mild, temporary discomfort may be perceived at the time of the injection. A mixture of local anesthetic with or without steroids will be injected through the needles.

After the injection the patient will keep a close diary of the pain level so a decision can be made regarding the next therapeutic step. A mild local discomfort may persist at the side of the injection for a day or two.

After the procedure is completed somebody needs to drive the patient home, since temporary residual numbness may be perceived in the back or legs. Further discharge instructions will be provided by our staff before leaving the surgical area. The following day the patient will be called by the nurse and the outcome will be reassessed. Also a follow up appointment will be set up in two to three weeks with one of the physicians.

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Thoracic facet joint injection

How do these injections work?
Thoracic facet joints have been implicated as a source of chronic pain in some patient with chronic thoracic pain. Usually the pain is localized in one or both sides of the midline and does not respond to prior conservative management. Frequently the pain may radiate to the anterior aspect of the chest. Various radiological studies have a poor correlation with the actual pain experienced by the patient. Injection of a local anesthetic mixed with or without steroids ( cortisone) will numb the facet joint or the nerves arising from this structure. In this way, the painful signals will be blocked and the patient may feel relief anywhere between a few hours or a few months. This will allow the break of the pain cycle, while the patient can exercise and improve the muscle strength. If after two similar injections the pain returns, one may consider a radio frequency ablation (destruction) of the small nerves innervating these joints. This might afford a longer and more sustained pain relief. Usually more than one joint is involved and therefore more than one injection is needed per session.

These injections should be considered only after simpler interventions failed to produce any type of sustained relief.

What to expect during the procedure?
For optimal outcome, this procedure needs to be performed under fluoroscopic guidance. The patient lies either on stomach. The appropriate area is cleaned with an antiseptic solution and then a local anesthetic is used to numb the skin. Under direct X ray visualization the needles are introduced towards the target area. A mild, temporary discomfort may be perceived at the time of the injection. A mixture of local anesthetic with or without steroids will be injected through the needles.

After the injection the patient will keep a close diary of the pain level so a decision can be made regarding the next therapeutic step. A mild local discomfort may persist at the side of the injection for a day or two.

After the procedure is completed somebody needs to drive the patient home, since temporary residual numbness may be perceived in the back or legs. Further discharge instructions will be provided by our staff before leaving the surgical area. The following day the patient will be called by the nurse and the outcome will be reassessed. Also a follow up appointment will be set up in two to three weeks with one of the physicians.

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Epidural steroid injections

How do these injections work?
During these injections the steroid medication is deposited around the irritated nerve roots and the inflamed tissue surrounding these structures. The swelling around the nerve roots is due to either a herniated disc, osteoarthritic changes, spinal stenosis or a mechanical injury. Usually a very minute amount of inflammation is enough to create significant symptoms. The MRI studies may not necessary correlate with the clinical symptoms a patient is experiencing.

A series of three injections are usually performed , although the number is variable, based on the total amount of steroids received over a total of twelve months and the individual response to each injection. Based on the clinical presentation these injections can be given via a transforaminal or translaminar approach. Most frequently these injections are given in the lumbar or cervical spine, although rarely the thoracic spine may be involved as well. Approximately 70 % of the patients with leg or arm pain will improve after these injections, provided that they are seen within a reasonable time from the onset of the symptoms. Those patients with midline pain tend to be less responsive.

For certain patient who has scar tissue due to previous surgery, a catheter is used to break down this tissue or a medication (hyaluronidase and/or hypertonic saline) is injected for the same purpose. This will allow the steroid medication to reach the affected nerve roots and hopefully provide relief of pain. This is an epidural lysis of adhesions used primarily for patients who failed simpler modalities. A caudal (tail bone) approach may be chosen for those patient presenting with lumbar symptoms.

For those patients with scar tissue and recalcitrant pain, a more aggressive approach consists of lysis of adhesions via a catheter connected to a portable camera. This is called epiduroscopy and offers a direct visualization of the epidural space.

What to expect during the procedure?
For optimal outcome, this procedure needs to be performed under fluoroscopic guidance. The patient lies on stomach. The appropriate area is cleaned with an antiseptic solution and then a local anesthetic is used to numb the skin. A light sedative can be administered. Under direct x ray visualization the needle is introduced towards the target area. The correct location is determined based on clinical presentation and MRI studies. A mild, temporary discomfort may be perceived at the time of the injection. A contrast material may be used to increase the accuracy of the procedure and to ascertain that the medications are delivered at the right intended target. A mixture of local anesthetic with steroids will be injected through the needle.

After the injection the patient will keep a close diary of the pain level so a decision can be made regarding the next therapeutic step. A mild local discomfort may persist at the side of the injection for a day or two. Usually the improvement occurs within a few days after the injection. Some of the patients may fail to get better and further reassessment by the physician may be needed. Not all patient are alike, and each treatment needs to be tailored individually, based on clinical and radiological findings.

After the procedure is completed somebody needs to drive the patient home, since temporary residual numbness may be perceived. Further discharge instructions will be provided by our staff before leaving the surgical area. The following day the patient will be called by the nurse and the outcome will be reassessed. Also a follow up appointment will be set up in two to three weeks with one of the physicians.

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Vertebroplasty

Procedure
Percutaneous vertebroplasty may be performed to augment weakened vertebrae at the cervical level, though most clinical experience is in the thoracolumbar region. The approach is anterolateral with the patient supine for a cervical procedure, and posterolateral or transpedicular with the patient prone for thoracolumbar injections.

Sedation along with local anesthesia allow for intraprocedure monitoring of neurological status; alternatively, general anesthesia may be used. 6 imaging consists of biplanar fluoroscopy6 in most cases, and occasionally CT and fluoroscopy together.5 A 10-12 gauge needle is used to enter the lumbar vertebral body under fluoroscopic guidance (12-13 ga. ?thoracic, 15 ga.? cervical spine). When needle position is satisfactory, the injectable compound (such as PMMA) is prepared and mixed with radio-opaque barium sulfate or tantalum powder to increase fluoroscopic visibility. Because of the high viscosity of PMMA, it is necessary to inject the material via several small (1-2 cc) syringes. The material is injected into the vertebral body, under continuous fluoroscopic monitoring. The lateral view is especially important because one risk of the procedure is leakage of cement into the spinal canal or neural foramina. Leakage may occur through venous channels, lytic posterior body wall lesions, or an iatrogenically perforated medial pedicle wall. Injection is stopped when cement reaches the posterior wall on a lateral view, or when it is seen to enter parts of the vertebral venous plexus, where venous embolism to the lungs is a theoretical concern. Deramond et al. 7 have described a second injection through the other pedicle if filling is <50 % on fluoroscopy (Figure 1). Pre-procedure CT scanning helps to identify anatomical features predisposing leakage, such as lytic cortical defects. Leakage through endplates into the disk space has been noted be asymptomatic and inconsequential.6-9 Leakage into the paravertebral soft tissues potentially threatens the femoral nerve in the lumbar region, and the intercostals nerves in the thoracic region.

Injection may be uni- or bi-pedicular, and typically up to 2-3 levels are treated in one session. Afterward, the patient is positioned supine and observed carefully for 24 hours. Immediate post-procedure CT scan and plain films are reviewed for leakage. Common side effects include post-procedure fever, which is thought to be an inflammatory response to the cement, and is treated with non-steroidal medications. Transient exacerbation of pain, also thought to be mediated by inflammation, can also occur. New paresthesias or partial motor deficits on post-procedure exam are treated with steroids in the absence of obvious physical compression of the nerve roots or spinal cord by cement leakage. If any leakage associated with a neurological change or deficit is detected during or after the procedure, a stand-by orthopedic or neurosurgical team must be available to decompress the neural elements and remove the leaked cement. There have been a few reported instances of this serious complication.8-10

Initial hospitalization averaged 4 days,8 although this has decreased to 1-2 days. Patients are allowed to get out of bed and bear full weight the day after the procedure.

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Radiofrequency Treatment

How does it work?
When causative treatment is not feasible and when various conservative treatments failed, invasive modalities may be considered for the treatment of chronic pain.

Radiofrequency ( RF) is one of those invasive forms of treatment. Prior to performing a RF lesion, a clear attempt for a diagnosis is made, usually with blocks involving injection of local anesthetic medication around the suspicious nerve believed to be the pain generator.

During RF treatment a needle is introduced through the skin towards the target neural tissue. The needle is connected to a generator, having the ability to test motor and sensory feeling, showing the clinician the proximity of the needle to the desired nerve believed to be involved in the generation of the specific chronic pain syndrome. Current will flow through the needle producing heat at the very tip of the electrode, thus heating and destroying the targeted tissue. The concept of this technique is that the pain signals will fail to reach the brain, and the pain sensation will be removed. Care is taken during such a procedure to avoid the destruction of the vital motor nerves which sometimes may course along the nerves needed to be ablated. This technique has been refined in early 1980, after the introduction of small insulated electrodes.

As an alternative to thermal destruction of the small nerves, one may use the so called "pulsed radiofrequency technique" when lower temperatures are generated at the tip of the needle, therefore avoiding the proper nerve destruction and some residual discomfort ensuing after the procedure. The technique seems to work by merely changing the electric field surrounding the nerve. This method applies short pulses of 20 ms at a high voltage to neural tissue. The heat is therefore dissipating and the final temperature reaching the target is around 42 degrees centigrade, compared to 70 or 80 degrees used for the traditional method. This is used preferentially for pain syndromes involving the peripheral nerves. Further studies are needed to validate this new modality, although clinical results are encouraging.

Most of the best studies available for RF are involving the LUMBAR AND CERVICAL FACETS, thus dealing with pain from spinal origin. The efficacy of this method was validated by well conducted prospective randomized studies. Clearly this technique should not be used alone, by rather implemented with a vigorous rehabilitation program to address the deconditioning of the weak muscles.

Over the past years the technique has been extended to may other indications for the treatment of spinal, visceral ( pancreatic pain), headache and cancer pain.

For instance the THORACIC FACETS, SACROILIAC JOINT ,and DORSAL ROOT GANGLION can be targeted as well while treating spinal pain.

THE SPLACHNIC NERVES are a well known target for abdominal pain.

THE SPHENO PALATINE GANGLION, C2/ C3 DORSAL ROOT GANGLION, AND TRIGEMINAL GANGLION are well known, albeit frequently missed pain generator for recalcitrant headache.

Peripheral nerves, such as SUPRASCAPULAR NERVE ( chronic shoulder pain ) TIBIAL POSTEIOR NERVE ( leg pain) and INTERCOSTAL NERVE (chest wall pain) , can be treated with pulsed RF with relative long relief.

RF of the STEALLATE GANLION and LUMBAR SYMPATHETIC PLEXUS are used in the early treatment of chronic regional pain syndrome ( formally known as RSD ). The rational is to use this technique in order to obtain longer relief than with the traditional local anesthetic blocks.

What to expect during the procedure?
For optimal outcome, this procedure must be performed under fluoroscopic guidance. The position of the patient varies according to each individual procedure. The appropriate area is cleaned with an antiseptic solution and then a local anesthetic is used to numb the skin. A light sedative can be administered, but the patient remains awake so during the electrical test stimulation we can get an exact understanding of the proximity of the electrode to the target area. Under direct x ray visualization the actual electrode is introduced towards the target area. A mild, temporary discomfort may be perceived at this time . A contrast material may be used to increase the accuracy of the procedure.

A mild local discomfort may persist at the side of the injection for a few days. This can be treated with ice or a mild pain medication. If successful, the patient will start feeling better three to seven days after the procedure.

After the procedure is completed somebody needs to drive the patient home, since temporary residual numbness may be perceived. Further discharge instructions will be provided by our staff before leaving the surgical area. The following day the patient will be called by the nurse and the outcome will be reassessed. Also a follow up appointment will be set up in three to four weeks with one of the physicians.

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Spinal Cord Stimulator

How does it work?
This is a minimally invasive technique developed in the early 1970s which is very helpful for patients with intractable low back pain, arm and leg pain, chronic regional pain syndrome ( also known as RSD) , interstitial cystitis. In general this modality is used when more conservative treatments failed to produce any consistent and long term relief. The number one indication in USA applies for patients with " failed back syndrome".

In general spinal cord stimulation ( SCS) targets painful conditions related to various degree of permanent nerve damage. Initially it was believed that this works mostly through action on the dorsal columns of the spinal cord, however recent studies indicate that also a vast array of neural mediators are implicated in the analgesic process.

In the initial trial phase, screening epidural electrodes are placed through a needle in the epidural space, just behind the spinal cord. These electrodes are complex wires which are connected to an outside battery and when turned on, a tingling is reproduced , overlapping the painful area. The trial period is going on for a few days, until a consensus is reached between the patient and the physician, whether this is successful or not. At least 50% reduction of pain is required for a trial to be considered successful. Thereafter the trial electrodes are removed and later on the patient will undergo a surgical implantation of new electrode lead and a power source called pulse generator. The latter is a small box which looks like a cardiac pacemaker. All these components are implanted under the superficial tissues, so nothing remains visible from outside.

Controversies still exist among specialists whether to implant a single versus a dual lead, a four versus an eight electrode system. Each patient should be individually assessed in order to match the best system for a specific condition. Also a psychological screening is usually required by the insurance company before each implantation.

There are two types of pulse generators : (1) a completely internal pulse generator containing a battery, and (2) an internal pulse generator supplied by external power through a radiofrequency " antenna" applied to the skin. The battery containing pulse generator is the preferred modality, since is more convenient to use and it is easily adjusted. The disadvantage of this specific modality is that it requires battery changes every three to six years, based on the time the stimulator is used throughout the day. This is however a minimal surgical intervention under local sedation.

The implanted pulse generator can be turned on and off by the patient using a small telemetry device or a magnet. A separate external programmer allows for more complex internal pulse generator reprogramming by the physician. These adjustments may be necessary from time to time.

There is substantial scientific evidence on the efficacy of SCS for the treatment of patients with intractable nerve pain, failed back syndromes and chronic regional pain syndrome. Numerous studies have shown decreased pain intensity scores, functional improvement and decrease medication use with the use of SCS devices. It has been shown that certain patients with failed back syndrome respond better to SCS than re-operation.

General contraindications are : infections, drug abuse, severe psychiatric disease and coagulations abnormalities.

Patients should clearly understand all the risks, benefits and alternatives of this modality.

What to expect during the procedure
The patient is placed in a face down position. The appropriate area is cleaned with an antiseptic solution and then a local anesthetic is used to numb the skin. A light sedative is usually administered, but the patient remains awake during the test stimulation . Under direct x ray visualization the actual lead is introduced through a needle towards the target area. A mild, temporary discomfort may be perceived at this time.

If the trial stimulation is successful, the implantation will follow within a few weeks. This procedure is again carried on under mild sedation and at least two small incisions are made in order to accommodate the implanted lead, pulse generator and the extension cable. The procedure can last between two to four hours and the patient can be discharged home the same day. The patient will be taught how to safely use the device at home and he or she will be able to use it immediately after the implantation takes place . Pain pills will be given after the procedure due to expected post operative pain.

The incision staples need to be removed two weeks after the implantation. During this interval the patient should avoid showers and should keep the incision covered in order to avoid any infections. Strenuous activities are to be avoided in the first few months after the procedure, so scar tissue will form and will further anchor the lead in place.

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Nucleoplasty and IDET

How does it work?
Leg pain with or without back pain, emanating from a disc herniation, can also be treated through a minimally invasive percutaneous technique such as chemonucleolysis ( chymopapain) , automated percutaneous lumbar discectomy , laser discectomy and nucleoplasty. Each technique has advantages and disadvantages and should individually be applied to each patient, based on the clinical presentation.

Nucleoplasty utilizes a Perc-D Spine Wand , which is a 1 mm diameter bipolar instrument designed for decompression of the disc nucleus, using energy and heat.

Initially an ablation lesion is made by advancing the wand in a controlled manner into the nucleus. After this the wand is withdrawn and a bipolar coagulation lesion is performed. The thermal effect produces a denaturization of the inner disc proteins called collagen, with shrinkage and widening of the previously created channel. As a result of this the intradiscal pressure and volume are reduced. A total of 6 similar lesions are performed. Throughout this phase minimal discomfort is usually perceived by the patient.

Intradiscal electrothermal annuloplasty (IDET) began to be performed in 1998 and represents a deviation from the focus on disc decompression. The concept is that thermal heating of the posterior annulus (a component part of the disc) could seal and denervate the annulus by destroying certain nerve fibers responsible for the propagation of the pain from the disc to the central nervous system. Candidates for this procedure are usually young patients who have predominant mid axial pain with little or no radiation to the legs. These patients need to undergo a prior discography diagnostic test, before embarking into this intervention. Given the alternatives of a spinal fusion ( with considerably more morbidity and mortality) or doing nothing, an IDET procedure becomes an attractive modality for this subgroup of patients. At present time we have no studies showing long term efficacy ( beyond 5 years) of this procedure. Present studies however show 75 % chance of improvement, one or two years post procedure. Possible complication, albeit rare, should be discussed prior to undergoing a nucleoplasty or IDET procedure.

What to expect during the procedure?
The patient is placed in a face down position. The appropriate area is cleaned with an antiseptic solution and then a local anesthetic is used to numb the skin. A light sedative is usually administered, but the patient remains awake. Under direct x ray visualization a needle is introduced towards the targeted disc area. A mild, temporary discomfort may be perceived at this time. The specific catheter for either nucleoplasty or IDET is deployed through the needle to the desired area of the disc and the procedure is completed : the channels are created with the nucleoplasty and the heating of the annulus take place with the IDET procedure for 16 minutes.

Strenuous activities are to be avoided in the first few months after the procedure and a rehabilitation program is started. After the IDET a back brace is prescribed for the first month to decrease the possible muscle spasm ensuing the procedure. Discharge instructions are given and a follow up is set within one month.

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Discography

How does it work?
Discography can be performed for the lumbar, thoracic and cervical disks. Most frequently the lower lumbar disks are the target.

This is a purely DIAGNOSTIC procedure which involves the puncture of the nucleus of the disc ( the most inner aspect of each disc) for instillation of contrast material. This will provide direct information about nuclear morphology, inside pressure and integrity of the vertebral endplates and annulus. The resulting changes in the volume and pressure produce direct stimulation of the disc. Patient respond to the stimulation in a measure of ranking the type of concordant pain ( the pain which is experienced during the normal daily activities). This is closely correlated with the disc morphology (disc tears, spread of the dye beyond the disc borders) and pressure.

A diagnosis of internal disc disruption can be made via discography and this is fundamentally different from symptomatic disc herniation when nerve compression produces leg pain as the dominant complaint. MRI is a powerful tool in detecting disc abnormalities. This is however an extremely non sensitive test in detecting the painful discs, since many patients have abnormal MRI studies with no pain whatsoever. The discogram comes to complement the MRI studies for the purpose of diagnosis of those disc pathologies potentially amenable to treatment. These myriads of treatments include IDET and instrumental spinal fusion. Discography remains the most accurate method of establishing annular competence. This treatment should not be applied to patients who are severely depressed, have active infections or have a very low threshold for pain.

Discography is planned only for patients who have exhausted other conservative measures and continue to display unrelenting chronic pain. Possible side effects should be judiciously balanced against the potential benefits.

Discograms in the thoracic and cervical area can be performed as well, while the procedure itself can be more challenging. Again each patient should be individually assessed and all the benefits , risks and alternatives should be clearly understood.

What to expect during the procedure?
The patient is place on a face down position for the lumbar and thoracic discogram, while for the cervical discogram a face up position is chosen.

The appropriate area is cleaned with an antiseptic solution and then a local anesthetic is used to numb the skin. A light sedative is usually administered, but the patient remains awake during the procedure. It is imperative that the true level of pain is clearly assessed during the provocation testing, so that prior to this step no opioid analgetics are given. When the needle penetrates the outer aspect of the annulus a vague, diffuse cramp like discomfort is perceived in the back area. This is short lasting. After the needles are placed in the involved disks, each needle is pressurized and the level of pain is closely monitored, while each pressure is separately recorded. At the end , before the needles are removed a small amount of antibiotic medication is injected. This is shown to significantly decrease the chance of disc infection ( discitis), an unlikely event which can occurs in 0.3 to 0.5 % of a the cases.

Some transient discomfort may persist for a few days after the procedure, which generally responds very well to anti inflammatory medication and light analgetics.

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Sacroiliac Joint Injection
Sacroiliac joint has been implicated as a source of chronic pain in up to 30 % of the patients with chronic low back pain. Usually the pain is localized in one or both sides of the lower back and does not respond to prior conservative management. Quite often the pain may radiate to the leg, groin , buttock or middle of the back. Various radiological studies have a poor correlation with the actual pain experienced by the patient. Injection of a local anesthetic mixed with or without steroids (cortisone) will numb the sacroiliac joint or the nerves arising from this structure. In this way, the painful signals will be blocked and the patient may feel relief anywhere between a few hours or a few months. Steroids are various anti inflammatory agents injected in conjunction with the local anesthetic medications. This will allow the break of the pain cycle, while the patient can exercise and improve the muscle strength. If after two similar injections the pain returns, one may consider a radio frequency ablation (destruction) of the small nerves innervating this joint. This might afford a longer and more sustained pain relief. These injections should be considered only after simpler interventions failed to produce any type of sustained relief.

What to expect during the procedure?
For optimal outcome, this procedure needs to be performed only under fluoroscopic guidance. The patient lies on the stomach; the back is cleaned with an antiseptic solution and then a local anesthetic is used to numb the skin. Under direct X ray visualization the needles are introduced towards the target area. A mild, temporary discomfort may be perceived at the time of the injection. A mixture of local anesthetic with or without steroids will be injected through the needles.

After the injection the patient will keep a close diary of the pain level so a decision can be made regarding the next therapeutic step. A mild local discomfort may persist at the side of the injection for a day or two.

After the procedure is completed somebody needs to drive the patient home, since temporary residual numbness may be perceived in the back or legs. Further discharge instructions will be provided by our staff before leaving the surgical area. The following day the patient will be called by the nurse and the outcome will be reassessed. Also a follow up appointment will be set up in two to three weeks with one of the physicians.

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Drug Delivery Devices

Intrathecal drug delivery uses an implantable drug infusion system ( pumps) to deliver very low amounts of opioids or other analgesics directly into the intrathecal ( spinal fluid ) space.

Continuous infusion provides a stable concentration of drug in the spinal fluid, thus avoiding fluctuations associated with bolus injections.


Although morphine is currently the only FDA approved opioid agent, other medications are currently used for patients who can not tolerate morphine or are not responsive to it.

These pumps are used for patients who failed simpler and less invasive modalities.

Patients should clearly understand all the risks, benefits and alternatives of this modality.

A thorough understanding of the potential long term side effects of the medications is required. This modality is designed to ease the pain and improve function. This in itself is not a cure of the basic problem for this therapy is applied.

Chronic conditions responsive to an implantable pump are : intractable leg and back pain after backsurgery, old compression fracture, spinal stenosis, cancer pain and certain chronic neuropathic ( nerve ) painful syndromes.

There are 5 phases of treatment : initial patient education, patient selection and screening test, preoperative care and maintenance.

A screening test is performed prior to the actual implantation of the pump. This is performed over a few days, when the actual medication is given to the patient in the intrathecal or the epidural space. The medication is given in incremental doses, until a response is noted or side effects are present. During the screening test a pain diary is kept in which pain severity is recorded on a scale from 0 to 10. Only those patients who pass the screening test are considered to be candidates for the actual implant. A 50 % improvement of the pain is usually required before proceeding with the implantation. A thorough psychological examination is also required.

The actual implantation takes place in the operating room, most of the time under general anesthesia. A girdle is used by the patient in the immediate post operative period. Usually the patient is kept over night in the hospital for observation.

Maintenance requires regular refills of the pump at two to three months interval . This is done in the office, as an outpatient preocedure.

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Trigger Point Injections

How does it work?
A trigger point is a spastic muscle band or palpable knot in a muscle that can cause localized pain or referred pain. Trigger points are due to localized muscle injury, stress, poor posture, or as a secondary response to an underlying pain generator (primary cause of pain) such as a disc herniation. Often the spasms worsens the pain which leads into a cycle resulting in more spasms and pain. If the trigger points are confined to the same or limited muscle groups, the disorder is referred to Myofascial pain. Fibromyalgia is a syndrome involving trigger points throughout the musculoskeletal system. The pain is most often described as an achy pain or stiffness. Other symptoms of Fibromyalgia may include insomnia, anxiety, fatigue, depression.

Trigger point injections are injections of local anesthetic agent such as lidocaine into the trigger points. The basis for a trigger point injection is to cease the conduction of pain signals from the spastic muscle. This will hopefully break the cycle of the muscle spasms.

Stretching is encouraged immediately following trigger point injections to improve range of motion. Heat application and TENS (trans electrical nerve stimulation) may also help prolong the relief. The addition of cortisone may provide benefits though anti-inflammatory properties.

Potential complications of trigger point injections (as with any invasive procedure) include: worsening of pain, nerve damage, allergic reaction, and infection. Trigger point injections involving muscles over the ribs have the additional complication of a tension pneumothorax, which is the build up of air between the inside lining of the chest wall and the lungs. This is an extremely rare complication; however, it will often require the placement of a chest tube placement between the ribs for several days to decrease the air pressure between the inner lining of the chest wall and the lungs.

If repeated trigger point injections provide excellent short term relief, botulism toxin injections may be an option to provide prolonged relief.

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Botox injections for chronic pain

How does it work?
Various myofascial pain disorders may benefit from botuninim injections. These conditions include torticolis (severe neck muscle spasms), muscle tension headaches, chronic muscle spasms, and other spastic myofascial pain disorders such as those from stroke and multiple sclerosis.

Botulinum toxin is a substance made by the bacteria Clostridium botulinum, the same bacteria that can cause botulism which often leads to death due to severe paralysis of muscles throughout the body. This may sound concerning: however, the substance made for medical use is an inactive form of the toxin several thousand times less potent than that needed to cause botulism.

There are currently two medically approved uses of the butulinum toxin: Botox® and Myobloc®. Most people associate "botox" use for wrinkles. Botulinum toxin is effective for reducing wrinkles by causing temporary partial paralysis of the underlying injected muscles which thereby reduces muscle tone and smoothes out the wrinkles.

Both Botox® and Myobloc® effectively reduce painful muscle spasm. Gradual relaxation of muscle spasm develops over one to two weeks after the injection. The reduction of muscle spasm typically last up to three months.

Potential complications of butulinum toxin injections (as with any invasive procedure) include: worsening of pain, nerve damage, allergic reaction, and infection. Temporary side effects from the drug may include flue like symptoms, increase in pain, weakness in the muscles injected, body aches, dry mouth, and hoarseness.

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Pharmacologic management of chronic pain

How does it work?
The World Health Organization has developed a 3-step ladder to treat pain based upon mild, moderate, or severe pain. Each phase includes adjuvants, supplemental medications, to address pain.

The First Step Ladder
The first step ladder consists of NSAID's (nonsteroidal anti-inflammatory drugs) and acetaminpin (Tylenol). All NSAID's are equivalent in pain relief with the exception of indomethocin (Indocin) for acute gout. NSAID's vary in frequency of dosing and severity of side effects. NSAID's are contraindicated in patients with aspirin/NSAID allergy, active bleeding disorders such as GI bleeding, and aspirin/NSAID induced allergy. Caution is advised in patients with history of nasal polyps, hypertension (high blood pressure), congestive heart failure, and history of GI bleeding and other bleeding disorders. Common NSAID's include ibuprofen (Motrin), naproxen sodium (Naprosyn), diclofenac (Voltaren), meloxicam (Mobic), and indomethacin (Indocin). New NSAID's called COX II inhibitors include valdecoxib (Bextra), celecoxib (Celebrex), and rofecoxib (Vioxx). The COX II inhibitors, unlike traditional NSAID's, have little to no effect on the stomach lining, resulting in less GI discomfort and bleeding.

Acetaminophen (Tylenol) is another appropriate first line medication for mild to moderate pain. Unlike NSAID's, acetaminophen lacks anti-inflammatory properties. Acetaminophen is generally well tolerated and has minimal to no side effects.

The Second Step Ladder
The Second Step Ladder includes opiate medications for moderate pain. Acetaminophen is often added to provide additional relief by targeting additional pain receptors. Common opiate and acetaminophen combinations include: Vicodin, Percocet, and Darvocet. Common adverse effects include constipation, dizziness, confusion, nausea, drowsiness, respiratory depression (slowing or cessation of breathing), and addiction.

Tramadol is a newer nonscheduled (noncontrolled) medication that provides pain by targeting the mu opiate receptor and inhibiting the reuptake of norepinephrine and serotonin. Common adverse effects include nausea, vomiting, and dizziness. Potentially but rare serious adverse effects include addiction and increased risk of seizures (especially when on certain antidepressants). Ultracet is the combination of tramadol and acetaminophen. Advantages of Ultracet over tramadol include: less side effects, quicker onset, and longer duration of action.

The Third Step Ladder
The Third Step Ladder includes various opiate medications for severe pain. These are often in an extended relief form known as "long acting opiates" which reduces required frequency. Common long acting opiates include Duragesic, Oxycontin, and Methadone. MS Contin, Avinza, and Kadian are common extended relief forms of morphine. Some studies indicate that Methadone provides better relief for various nerve pain disorders and has a less occurrence of tolerance over other opiates. Duragesic is an opiate in the form of a patch that is applied to the skin every two or three days. Duragesic often provides superior improvement in functional status to patients due to decreased dosing frequency.

Patients receiving opiate medications on a regular basis are required to sign an opiate contract. An opiate contract outlines an agreement between the patient and prescriber. As an overview, terms include: renewing prescriptions only during office visits, not exceeding prescribed doses, filling prescriptions with only one pharmacy, and submitting urine or blood for random drug screening to ensure compliance. By signing an opiate contract, you acknowledge that lost, stolen, or damages opiate medications may not be replaced. In addition, signing of an opiate contract also proclaims your awareness of potential abuse and addiction of opiate medications. Some, but not all patients with chronic non malignant pain may benefit from short or long term opioid intake. A careful assessment will be made and tailored for each individual patient. Opioid should not be the only modality to treat pain syndromes , but rather should be use in conjunction with a multi disciplinary approach, including physical therapy, holistic approaches, behavioral modifications, and spinal injections.

Adjuvants
Adjuvants are used to supplement opiates in the treatment of various pain disorders. Adjuvants include antidepressants, anticonvulsants (seizure medications), and Lidoderm Patch. An older class of antidepressants called tricyclic antidepressants (TCA's) are also helpful for insomnia. Amitriptyline, nortriptyline, and desipramine are common TCA's.

Anticonvulsants may provide partial relief with various pain disorders, especially those involving neuropathic pain (pain from nerve disorders). Common anticonvulsants include Neurontin, Topamax, Tegretol, Trileptal, and Zonegran. As with antidepressants, anti-convulsants require slow titration with improvement taking up to two to three weeks after increases.

Lidoderm Patches contain the anesthetic lidocaine. Currently, Lidoderm patches are only approved by the FDA for pain following shingles, known as Post Herpetic Neuralgia. Up to three patches may be worn together for twelve hours on, twelve hours off.

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