Trigger Point Injections

Used for muscle tightness and muscle injury in conjunction with a stretching program. Involves the injection of local anesthetic (and/or steroid/Botox) when appropriate.

Back Pain

• Back pain effects more than 85% of all Americans during their lifetime. It can have many causes such as disc pathology, joint pathology, ligament/bone pathology and muscular origins. Pain is usually self-limited and with time should resolve in less than six weeks although if loss of strength, sensory or change in bowel/bladder function occur, this is more urgent and warrants immediate medical attention. Bed rest is not advised nor is the use of lumbar support for more than two weeks. Most sources of pain respond to conservative treatment such a physical therapy, anti-inflamatory medications and topical pair relievers. Acute pain is generally viewed as less than six weeks while chronic pain is generally termed after six months. There is no blood test for pain. The diagnosis and treatment require careful history and physical exam along with proper use of radiographs (xray, CT, MRI) and nerve conduction studies (EMG/NCV) While some back pain presents abruptly after an accident or event (lifting a heavy object) a greater proportion of low back pain occurs insidiously (reaching for a tooth brush). Tumors benign and malignant make up a very small fraction (less than 1%) but need to be considered when neurological symptoms appear and resolution does not occur.
• List of common causes: include muscle strain, degenerative disc disease, disc bulging, disc herniation, joint inflammation (facet and sacroiliac), sciatica (pinched nerve), fractures of vertebrae and lumbar spinal stenosis, prior surgery (post laminectomy syndrome)
• Treatments: For these groups of patients, many will respond to interventional pain procedures, depending on the source of the discomfort. These pain generators and their treatments may include: epidurals, facet blocks

Physical Therapy

Used to improve mobilization, strengthening and range of motion, mobilization, stabilization and strengthening. Ultrasound, electrical stimulation, ice, heat, bracing and exercise are utilized by trained physical therapists.

Neck Pain

• This type of pain may not just be limited to the neck but can extend to the head, shoulder and arms. The neck, like the lower back, is composed of many parts, including joints, discs, muscles and nerves. Any of these components can lead to inflammation and pain. For acute pain (less than six weeks onset), most sources of pain respond to conservative treatments, such as physical therapy, chiropractic therapy, anti-inflammatory drugs, oral steroids and possible superficial cortisone injections.
• Unfortunately, there is a subset of people whose pain is so severe that activities or work are extremely limited. Or, the pain extends beyond six weeks. For these groups of patients, many will respond to interventional pain procedures, depending on the source of the discomfort.
• List of common causes: spinal stenosis, herniated disc, degenerative disc, muscle spasms, occipital neuralgia, facet joint disease, atlantoaxial joint disease, cervicogenic headaches
• Treatments: Treatments are determined by the specific cause, which we determine at consult. epidurals, facets

Epidural Steroid Injections

Injections of local anesthetic and steroid to target an inflamed spinal nerve or disc under fluoroscopic (x-ray) guidance. Often used for sciatica, pinched nerves, radiculopathy, degenerative disc disease, bulging or herniated discs. Can also be referred to as a nerve block or selective root block. May aid in diagnostic workup or therapeutic treatment. Can be accomplished in the cervical (neck), thoracic (mid back) and the low back (lumbar) segments. May be accomplished with sedation when requested.

Sciatica

• Can be referred to as as pinched nerve, radiating leg pain, electric shocks, walking pain, standing pain, bending over pain
• List of common causes: can include disc bulge, ruptured disc, pinched nerve, disc herniation, slipped disc
• Treatments are determined by the specific cause, which we determine at consult
• Treatments: epidurals, facets, patients whose pain is resistant to conservative treatment may respond to advanced pain management injections treatments such as transforaminal epidural steroid injections and neuroplasty (lysis of adhesions)

Facet Blocks / Facet Injections

Targeting of the joints and their innervations to help diagnose pain generation from spinal joints in the cervical (neck), thoracic (mid-back), lumbar (low back) segments. This is commonly referred to as mechanical spine pain. Some forms of sciatica and radiculopathy are actually a referred pain from a spinal joint that can mimic a pinched nerve. Accomplished under fluoroscopy (x-ray) and sedation when requested.

Degenerative Spine

• Associated with spinal bone spurs, degenerative disc disease, spinal stenosis, facet arthritis, arthritic spine, walking pain, standing pain
• List of common causes: This condition is found in most people as they age. For many, this doesn’t cause any pain. For some this can lead to considerable discomfort. This condition be genetic, or as a result of certain life styles or careers.
• Treatments: An MRI may demonstrate the presence of spinal bone spurs. Patients whose pain is resistant to conservative treatment may respond to advanced pain management injections. Several injections are available and specific to the type of pain the patient presents with. These may include but are not limited to transforaminal epidural steroid injections, facet blocks, rhizotomies, epidurals and europlasty.

Radiofrequency Lesioning / Rhizotomy / Ablation

Used after a diagnosis of joint pain generators are made for more long-lasting results. Small lesions using radio waves are applied by small needles to destroy pain fibers in the joints of the spine (facets), knees and hips. Fluoroscopic (x-ray) guidance is used with sedation when requested.

Spinal Stenosis

• This condition generally occurs over time and leads to narrowing of bone around the spinal cord or spinal nerve roots. The pain that results from lumbar spinal stenosis may include lower back and leg pain. For the cervical region, the pain may involve both the neck and arm.
  A subcategory of spinal stenosis includes neurogenic claudication. This condition leads to pain with walking or standing for more than 10 minutes. Frequently, patients must sit for a period of time before the pain will resolve. Characteristically, walking in a shopping mall requires frequent breaks of sitting.
• Treatments: With the combination of conservative treatments and epidural steroid injections, many patients will have the pain well controlled. For those that continue to have considerable limitations to walking and standing, options may include spinal surgery or the nonsurgical route of the MILD procedure (minimally invasive lumbar decompression)

Neuroplasty / Lysis of Adhesions

Catheter guided placement of epidural steroids and enzymes to break up surgical and non-surgical adhesions in the epidural space. This allows greater mobility of an impinged nerve root by adhesive material. Used for post laminectomy syndrome, sciatica, radicular pain, and degenerative disc disease. Can be used in the cervical (neck), thoracic (mid-back), lumbar(low back) segments. Utilizes fluoroscopy (x-ray) and sedation when requested.

RSD/CRPS

• Known as complex regional pain syndrome, reflex sympathetic dystrophy, sympathetic pain. Usually involves arms, hands, legs, feet PAIN
• Telltale signs frequently include: sensitivity to touch, swelling, color changes, temperature changes
• Treatments: Successful treatment of this condition is dependent on early recognition and early intervention. Workup is essential and may include but are not limited radiologic studies, and nerve studies.
• Treatments may include therapy and medications. If ongoing pain continues, therapy is not tolerated, or decreasing function of the effected body part is noted, the patient would then be considered for therapeutic sympathetic nerve blocks. Such examples include a stellate ganglion block or lumbar sympathetic block, performed under fluoroscopic guidance. These injections allow treatment of the pain, increased tolerance to physical therapy, and increased function. The use of IV sedation or monitored anesthesia care is frequently during these procedures used to avoid any discomfort from the procedure itself.

Sacroiliac Joint Injections

A concentrated dose of local anesthetic and steroid to reduce inflammation within the joint is used for diagnosis and treatment with the aid of fluoroscopy (x-ray).

Facet Pain

• This type of pain originates at the facet joint. In the cervical spine, one can experience neck pain with or without shoulder pain, upper arm pain, headaches and facial pain. This type of discomfort can be brought on with changes of neck position and may disrupt one’s sleep.
  In the lower back, one can experience pain in multiple areas, including the lower back, buttock, and upper legs. This type of pain is frequently brought on with getting out of bed, getting up from chair, leaning over, or with standing.
• Treatments: Radiologic findings may or may not show obvious changes at the facet joint. When conservative treatments, such as therapy and anti-inflammatory drugs fail to provide relief, fluoroscopic directed injections may provide considerable and long term relief. These injections may include diagnostic testing such as facet medial branch nerve blocks and more long term approaches via a rhizotomy.

Stellate Ganglion Blocks

Injections for sympathetic pain issues in the upper extremity (complex regional pain syndrome (CRPS) and reflex sympathetic dystrophy (RSD). Assists with diagnostics and therapeutic treatment. These injections are placed under the skin in the anterior neck with x-ray (fluoroscopy) and with sedation, identify and treat sympathetic symptoms after trauma and surgery as well as peripheral vasculature disease and Raynaud’s Syndrome including pain, swelling, color change, temperature change, hair and nail bed changes and inability to touch the effected limb.

Sacral Pain / Sacroiliac Joint Inflammation

• Can relate to sacroiliac joint inflammation, tailbone pain, sacral fracture
• This type of pain can be more commonly associated with sitting pain, lying down pain, or experienced with crossing the legs
• Treatments: When conservative treatments, such as therapy and anti-inflammatory drugs fail to provide relief, fluoroscopic directed injections may provide considerable and long term relief.

Lumbar Discogram / Cervical Discogram

The placement of a needle into the center of a disc to determine whether the disc is a possible pain generator. Procedure is accomplished with x-ray (fluoroscopy) and sedation. Contrast is placed in center of the disc (nucleus) to assess for leaks and pain reproduction as well as measuring the pressures in the disc. Allows for further surgical and non-surgical treatment planning. Used for disc herniation, disc bulge, degenerative disc disease.

Occipital Neuralgia

• The occipital pain is routinely experienced at the base of the skull, It can radiate to the top of the head. In fact, occipital neuralgia can mimic other types of headaches. This problem, may be associated with cervicogenic headaches, and degenerative cervical spine.
• Treatments: Coanalgesic medications may help, such as antiseizure medications, antidepressants, muscle relaxants as well as physical therapy.
  When this condition persists, the patient may then respond to focus directed injections such as occipital nerve blocks or C2 nerve blocks,

MILD Procedure

Minimally invasive lumbar decompression is used for lumbar spinal stenosis by using small tools without surgical scalpels to remove excess bone and tissue with is restricting blood supply when a patient stands and walks leading to pain and cramping in the back and lower extremities.

Thoracic Spine Pain

• Also referred to as midback pain, upper back pain. This condition may or may not be accompanied by pain spreading to the sides or chest.
• Common causes may include: degenerative disc disease , thoracic disc herniation, facet joint or vertebral fracture, spinal lesion and spinal stenosis. A comprehensive work up should be included for this type of pain and may include radiologic studies.
• Treatments: Based upon the specific cause, treatments may include conservative approaches, spinal injections, kyphoplasty, and possible surgery.

Spinal Cord Stimulator

Placement of electrodes through a needle to block pain signals from the spine and extremities. Used in the lumber (low back), thoracic (mid back) and cervical neck segments.

A 7-day trial begins with a small electrode (wire) placed with an epidural needle and while the needle is removed the electrode is left in the epidural space and attached to an external power source. The initial electrode is removed easily after 7 days in all cases. If the trial is deemed successful, then a new set of electrodes are place with or without a generator (pacemaker battery) or a Bluetooth setup for a ore permanent placement.

The electrodes are controlled by a small handheld controller that the patient can carry. Used for post-laminectomy syndrome in all areas of the spine, failed back syndrome, complex regional pain syndrome/ reflex sympathetic dystrophy, peripheral neuralgia, extremity nerve injury and pain from peripheral vasculature.

Knee Pain

• For those patients already diagnosed with arthritis of the knee or with ongoing knee pain despite having knee surgery, multiple treatment options have likely already been considered. These treatments may have included therapy, anti-inflammatory agents, cortisone injections, viscosupplementation injections and consideration of a knee replacement.
• Treatments: For patients that have failed conservative treatment, are reluctant to undergo surgery, are at high risk for surgery or already failed surgery, they may be a candidate for genicular nerve block and subsequent neurotomy/COOLIEF nerve lesioning.

Kyphoplasty

Targeting collapsed vertebral bodies with bone cement to treat the fracture. Accomplished under Xray (fluoroscopy) with needle placement into the bone which is then followed by a ballon spacer which is followed by a bone cement.

WHIPLASH

• With this condition, one can experience neck pain with or without shoulder pain, upper arm pain, headaches or facial pain. This type of discomfort can be brought on with changes of neck position and may disrupt one’s sleep.
  Radiologic findings may or may not show obvious changes at the facet joint
• Treatments: When conservative treatments, such as therapy and anti-inflammatory drugs fail to provide relief, fluoroscopic directed injections may provide considerable and long term relief. Such injections may include facet medial branch nerve blocks and more long term treatments via a rhizotomy.

Lumbar Sympathetic Blocks

Injections on the side of the lumbar spine to assist diagnosis of sympathetic pain issues (complex regional pain syndrome (CRPS) and reflex sympathetic dystrophy (RSD). These injections help lower extremity pain that presents with limb pain, color change, temperature change, swelling, inability to touch the limb, loss of hair and nail bed changes.

They can additionally assist therapeutically and be used in combination with radio frequency lesioning if necessary for longer acting relief. Can occur after surgery or trauma to the limb. Accomplished under x-ray (fluoroscopy) and with sedation. Can additionally be used for peripheral vasculature disease pain.

Groin Pain

• Can include hip pain or lower belly pain
• Possible causes include: Post hernia repair, hip arthritis
• Treatments: COOLIEF

Peripheral Nerve Stimulator

For pain relief to the shoulder, arm, wrist, hand, leg, and knee when most other procedures have failed. Surgery may have already been performed. This approach allows us to place a specialized catheter under the skin and adjacent to the irritated or abnormal nerves. The device sends a painless electric impulse across several layers of tissue until it reaches the painful nerves. The electric impulse suppresses the painful nerves and can minimize or eliminate the pain.

This is a two step process. The first part includes a temporary trial, lasting about five days. The second part includes permanent placement of the catheter, with the excess placed under the skin. With the approach used, this type of treatment is always reversible, with removal of the catheter/lead if necessary.

Back Pain Even After Having Back Surgery

• This condition may or may not include buttock or leg pain
  Sources of this pain may include, spinal stenosis at other levels, facet arthritis, sacroiliac joint inflammation or even scar tissue. Conservative treatments may frequently be dictated by your spine surgeon. If pain persists beyond reasonable expectations, an MRI post surgery will likely be required.
• Treatments: Specialized treatments are available for this condition including selective nerve blocks, epidural neuroplasty and even consideration of a spinal cord stimulator trial.

COOLIEF

A specialized technique that helps with chronic knee pain, and arthritis where the patient does not wish to proceed with a total knee replacement. It addresses considerable hip pain, where the patient failed a hip replacement or wishes to avoid surgery.

With this technique the painful nerves are eliminated or broken down under live x-ray (fluoroscopy) , providing long term relief. This relief can last a full year. This procedure only affects the pain nerves. It does not cause numbness, or weakness.

Facial Pain

• Ongoing pain in the face can be due to numerous conditions. Some of these causes include trigeminal neuralgia, supraorbital neuralgia, infraorbital neuralgia, and temporomandibular joint dysfunction (TMJ). For most people suffering from chronic facial pain, multiple medical specialists have already been consulted.
• Treatments: For those people that continue to suffer from considerable pain despite proper treatment, specialized nerve blocks under fluoroscopic guidance may be considered, based upon the diagnosis made.

Intercostal Blocks

Used for chest wall pain from trauma/rib fracture. Used for diagnostic to distinguish from abdominal issues versus abdominal wall issues. Utilizes fluoroscopy (x-ray) and sedation when requested.

Shingles / Post Herpetic Neuralgia

• This condition occurs following a painful Shingles outbreak. This type of exquisite pain can be constant, sensitive to touch and travels along the site of the healing rash.
• Common locations of this type of pain include the thoracic spine, chest wall, and near the eye and scalp.
  Initial treatments should include an antiviral medication. Other agents may include topical agents, oral neuropathic medications and possibly analgesics. With the persistence of severe pain, this condition than moves into the chronic stage, known as Post Herpetic Neuralgia.
• Treatments: Interventional pain treatments, when performed in these early stages, may break the pain cycle and assist with resolution of the pain syndrome.
  These include specialized injections called sympathetic blocks, and possibly epidural placed injections.

Peripheral Nerve Blocks

Nerves such as the ilioingual (groin pain/post hernia surgery), lateral femoral cutaneous nerve (thigh pain), sciatic/piriformis (leg pain), suprascapular block (shoulder). Fluoroscopic (x-ray) guidance utilized along with sedation.

Other Conditions

• Hip pain, wrist pain, trigeminal neuralgia

Cranial Nerve Blocks

Nerve blocks used for trigeminal neuralgia and facial pain. Fluoroscopic (x-ray) guidance utilized along with sedation.

Joint Blocks / Arthrography

Injections in the shoulder, hip, knees, wrists, ankles for diagnostic and therapeutic purposes. Can utilize fluoroscopy or ultrasound guidance.