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Pain Conditions, Treatments, and Terminology

We here at Nexus Pain Specialists want you to have the best experience possible when you come to visit us.  That starts with our patients knowing what we do and why we do it.  Please feel free to read through the information listed below and contact us with any questions you might have.

What is a radiofrequency lesioning?
Radiofrequency lesioning is a procedure using a specialized machine to interrupt nerve conduction on a semi-permanent basis. You will not lose sensation or strength in your arm or leg as a result of the procedure. If effective, the procedure will relieve a significant portion of the pain for 6-9 months (can be as short as 3 months or as long as 18 months).

Am I a candidate for radiofrequency lesioning?
Radiofrequency lesioning is offered to patients with:

  1. Reflex sympathetic dystrophy (RSD) involving upper or lower extremities
  2. Mechanical neck or low back pain due to facet joint disease
  3. Radiculopathy (pinched nerve in the neck or the back) You must have responded well to local anesthetic blocks, to be a candidate for radiofrequency lesioning.

What are the benefits of radiofrequency lesioning?
The procedure disrupts nerve conduction (such as conduction of pain signals), and it may in turn reduce pain, and other related symptoms. Approximately 70-80% of patients will get a good block of the intended nerve. This should help relieve that part of the pain that the blocked nerve controls. Sometimes after a nerve is blocked, it becomes clear that there is pain from the other areas as well.

How long does the procedure take?
Depending upon the areas to be treated, the procedure can take from about twenty minutes to a couple of hours (when we include preparation and observation following the procedure).

Where is the procedure performed?
The procedure is usually performed in an operating room, sometimes in a fluoroscopy (x- ray) room. We have an operating room in our office in which we perform the procedure.

How is it actually performed?
Since nerves cannot be seen on x-ray, the needles are positioned using bony landmarks that indicate where the nerves usually are. Fluoroscopy (x-ray) is used to identify those bony landmarks. A local anesthetic (like Lidocaine) is injected to confirm proper placement. After confirmation of the needle tip position, a special needle tip is inserted. When the needle is in good position, as confirmed by x-ray, electrical stimulation is done before any lesioning. This stimulation may produce a buzzing or tingling sensation or may be like hitting your “funny bone”. You may also feel your muscles jump. You need to be awake during this part of the procedure so you can report what you`re feeling. The tissues surrounding the needle tip are then heated when electronic current is passed using the radiofrequency machine for a few seconds. This “numbs” the nerves semi-permanently.

Will the procedure hurt?
Nerves are protected by layers of muscle and soft tissues. The procedure involves inserting a needle through skin and those layers of muscle and soft tissues, so there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the radiofrequency needle.

Will I be “put out” for this procedure?
No. This procedure is done under local anesthesia. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easier to tolerate. The amount of sedation given generally depends upon the patient tolerance. It is necessary for you to be awake enough to communicate easily during the procedure.

How is the procedure performed?
It is done either with the patient lying on the stomach when working on the facet joints, low back for lumbar sympathetic nerves, and the back when lesioning the cervical (neck) area (e.g. Stellate Ganglion). The patients are monitored with EKG, blood pressure cuff, and blood oxygen-monitoring device. The skin on the back is cleaned with antiseptic solution and then the procedure is carried out. X-ray (fluoroscopy) is used to guide the needles.

What should I expect after the procedure?
Initially there will be muscle soreness for up to a week afterward. Ice packs will usually control this discomfort. After that first week is over, your pain may be gone or quite less.

What should I do after the procedure?
You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. You may want to apply ice to the affected area. Perform activities according to what your body can tolerate.

Can I go to work the next day?
You should be able to return to your work the next day. Sometimes soreness at the injection site causes you to be off work for a day or two.

How long will the effects of the procedure last?
If successful, the effects of the procedure can last from 3-18 months, usually 6-9 months.

How many procedures do I need to have?
If the first procedure does not relieve your symptoms completely, you may be recommended to have a repeat procedure after re-evaluation. Because these are not permanent procedures, they may need to be repeated when the numbness wears off (often 6-12 months).

Will the radiofrequency lesioning help me?
It is very difficult to predict if the procedure will indeed help you or not. Usually, the patients who have responded to repeated local anesthetic blocks will have better results.

What are the risks and side effects?
Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and the possibility of complications. The risks and complications are dependent upon the sites that are lesioned. Any time there is an injection through the skin, there is a risk of infection. This is why sterile conditions are used for these blocks. The needles have to go through skin and soft tissues, which will cause soreness. The nerves to be lesioned may be near blood vessels or other nerves which can be potentially damaged. Great care is taken when placing the radiofrequency needles, but sometimes complications occur. Please discuss your specific concerns with your physician.

Who should not have this procedure?
If you are allergic to any of the medications to be injected, if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid), or if you have an active infection going on near the injection site, you should not have the procedure. If you have not responded to local anesthetic blocks, you may not be a candidate for this procedure.

What should I know prior to and after the procedure?

  1. Only 70% of patients have a successful procedure even if the diagnostic procedure was completely successful. In other words, in 30% of patients the procedure fails even though the diagnostic procedure was successful.
  2. It can take as much as three weeks before the procedure begins to exert maximum effect.
  3. You may be sore or in pain as a result of the procedure for as much as a week after the procedure.
  4. You should resume your normal activities the day after the procedure as this will help facilitate healing and a quick return to function.
  5. The pain should begin to lessen on around day seven. If you are noticing an increased pain one week after the procedure and/or a burning sensation in the area of the procedure, notify your doctor.
  6. You will be given medications for post-operative pain management after the procedure.

Nexus Pain Specialists conducted a study to assess the effect of spinal cord stimulators on patients who had continued pain after previous spinal surgery. The study consisted of 50 patients who had undergone spinal cord stimulator implantation 18 months prior to the study. These patients were divided into two groups; 68% had mostly back pain, 32% had mostly leg pain. Each patient was contacted 18 months after their spinal cord stimulator was implanted to discuss what affect the spinal cord stimulator had on their pain. The results were:

  • 77.5% of patients that participated in the study reported an overall improvement in their quality of life
  • 92.5% of the patients in the study would have a spinal cord stimulator implanted again.
  • 92.5% of patients would recommend the spinal cord stimulator to a friend or family.
  • Patients reported an average of 60% reduction in pain directly from the spinal cord stimulator.
  • 87.5% of patients reported an increase in their ability to cope with pain.
  • 60% of patients made less doctor visits since implant.
  • 50% of patients were able to reduce the use of pain medications.
  • 20% of patients were able to completely eliminate use of pain medications.
  • The average patient used their spinal cord stimulator 12.3 hours per day.
  • Patients rated their quality of sleep to be a 5.7/10; their mood to be a 6/10, and their overall satisfaction to be a 7.7/10.
  • 62.5% reported an increase in their activity level
  • 50% reported an increase in their social activity
  • 44% reported they experienced better posture and stance
  • 55% patients were able to return to work and resume their hobbies.

What is a Sacroiliac Joint Injection?
Sacroiliac Joint Injection is an injection of long lasting steroid (“cortisone”) in the Sacroiliac joints – which are located in the low back area.

What is the purpose of it?
The steroid injected reduces the inflammation and/or swelling of tissue in the joint space. This may in turn reduce pain, and other symptoms caused by inflammation / irritation of the joint and surrounding structures.

How long does the injection take?
The actual injection takes only a few minutes.

What is actually injected?
The injection consists of a mixture of local anesthetic (like lidocaine or bupivacaine) and the steroid medication (Betamethasone – Dexamethasone – Depo-medrol).

Will the injection hurt?
The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”). So, there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the needle into the joint.

Will I be “put out” for this procedure?
No. This procedure is done under local anesthesia. The amount of sedation given generally depends upon the patient tolerance.

How is the injection performed?
It is done with the patient lying on the stomach, under x-ray control. The patients are monitored with EKG, blood pressure cuff and blood oxygen-monitoring device. The skin in the back is cleaned with antiseptic solution and then the injection is carried out. After the injection, you are brought to a sitting position.

What should I expect after the injection?
Immediately after the injection, you may feel that your pain may be gone or quite less. This is due to the local anesthetic injected. This will last only for a few hours. Your pain will return and you may have a “sore back” for a day or two. This is due to the mechanical process of needle insertion as well as initial irritation form the steroid itself. You should start noticing pain relief starting the 5th day or so.

What should I do after the procedure?
You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. You may want to apply ice to the affected area. Perform the activities as tolerated by you.

Can I go to work to work the next day?
Unless there are complications, you should be able to return to your work the next day. The most common thing you may feel is a sore back.

How long will the effect of the medication last?
The immediate effect is usually from the local anesthetic injected. This wears off in a few hours. The cortisone starts working in about 5 to 7 days and its effect can last for several days to months.

How many injections do I need to have?
If the first injection does not relieve your symptoms in about a week to two weeks, you may be recommended to have one more injection. If you respond to the injections and still have residual pain, you may be recommended for a third injection.

Can I have more than three injections?
In a six-month period, we generally do not perform more than three injections. This is because the medication injected lasts for about six months. If three injections have not helped you much, it is very unlikely that you will get any further benefit from more injections. Also, giving more injections will increase the likelihood of side effects from cortisone.

Will the Sacroiliac Joint Injection help me?
It is very difficult to predict if the injection will indeed help you or not. Generally speaking, the patients who have recent onset of pain may respond much better than the ones with a long standing pain.

What are the risks and side effects?
Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain – which is temporary. The other risks involve, infection, bleeding, worsening of symptoms etc. The other risks are related to the side effects of cortisone: These include weight gain, increase in blood sugar (mainly in diabetics), water retention, suppression of body`s own natural production of cortisone etc. Fortunately, the serious side effects and complications are uncommon.

Who should not have this injection?
If you are allergic to any of the medications to be injected, if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid), or if you have an active infection going on near the injection site, you should not have the injection.

What is a Stellate Ganglion Injection?
Stellate Ganglion Injection is an injection of local anesthetic in the “sympathetic nerve tissue” – the nerves which are a part of Sympathetic Nervous System. The nerves are located on the either side of the voice box, in the neck.

What is the purpose of it?
The injection blocks the Sympathetic Nerves. This may in turn reduce pain, swelling, color, and sweating changes in the upper extremity and may improve mobility. It is done as a part of the treatment of Reflex Sympathetic Dystrophy (RSD), Sympathetic Maintained Pain, Complex Regional Pain Syndrome, and Herpes Zoster (shingles) involving upper extremity or head and face.

How long does the injection take? 
The actual injection takes only a few minutes.

What is actually injected?
The injection consists of a local anesthetic (like lidocaine or bupivacaine).

Will the injection hurt?
The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”). So, there is some discomfort involved. However, we may numb the skin and deeper tissues with a local anesthetic using a very thin needle before inserting the actual block needle.

Will I be “put out” for this procedure?
No. This procedure is done under local anesthesia. The amount of sedation given generally depends upon the patient tolerance.

How is the injection performed?
It is done either with the patient laying flat on their back. The chin is slightly raised. The patients are monitored with EKG, blood pressure cuff and blood oxygen-monitoring device. The skin in the front of the neck, next to the “voice box” is cleaned with antiseptic solution and then the injection is carried out.

What should I expect after the injection?
Immediately after the injection, you may feel your upper extremity getting warm. In addition, you may notice that your pain may be gone or quite less. You may also notice “a lump in the throat” as well as hoarse voice, droopy and red eye, and some nasal congestion on the side of the injection. You may also develop a headache.

What should I do after the procedure?
You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. Perform the activities as tolerated by you. Some of the patients may go for immediate physical therapy.

Can I go to work to work the next day?
Unless there are complications, you should be able to return to your work the next day. The most common thing you may feel is soreness in the neck at the injection site.

How long will the effect of the medication last?
The local anesthetic wears off in a few hours. However, the blockade of sympathetic nerves may last for many more hours. Usually, the duration of relief gets longer after each injection.

How many injections do I need to have?
If you respond to the first injection, you will be recommended for repeat injections. Usually, a series of such injections is needed to treat the problem. Some may need only 2 to 4 and some may need more that 10. The response to such injections varies from patient to patient.

Will the Stellate Ganglion Injection help me?
It is very difficult to predict if the injection(s) will indeed help you or not. The patients who present early during their illness tend to respond better than those who have this treatment after about six months of symptoms do. Patients in the advanced stages of disease may not respond adequately.

What are the risks and side effects?
This procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain – which is temporary. The other risk involves bleeding, infection, spinal block, epidural block, and injection into blood vessels and surrounding organs. Fortunately, the serious side effects and complications are uncommon.

Who should not have this injection?
If you are allergic to any of the medications to be injected, if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid), or if you have an active infection going on near the injection site, you should not have the injection.

Importance of sleep

  • Sleep is restorative
  • Increases energy
  • Increases motivation
  • Improves immune function

Chronic Insomnia – is defined as sleep difficulty at least three nights per week for 1 month or more

Consequences of Chronic Insomnia

  • Fatigue
  • Mood changes (depression, irritability)
  • Difficulty concentrating
  • Impaired daytime functioning
  • Muscle soreness
  • Decreased motivation

Sleep Hygiene

  • Wake up at the same time of day
  • Discontinue caffeine 4-6 hrs prior to sleep
  • Avoid nicotine (especially near bedtime)
  • Avoid heavy meals too close to bedtime
  • Regular exercise in late afternoon may deepen sleep
  • Avoid exercise within 3-4 hours of bedtime
  • Minimize noise, light, excessive temperatures
  • Move alarm clock away from the bed if it is a source of distraction

Medications used for sleep

  • The best choice for chronic insomnia are medications that can be used more long term. Traditional sleep aides (Ambien, Restoril, etc.) interfere with stage 4 sleep. This is the deepest stage of sleep where the body heals microscopic muscle tears and restores energy and vitality. People who use these types of medications never feel fully rested. There is another group of sleep aides that are safe to use long-term because they don’t interfere with the deepest sleep (stage 4). Examples of this group include Trazadone, Elavil, etc. Trazadone is an antidepressant with the side effect of drowsiness. This medication is taken every night, 2 hours before bedtime.
  • Tricyclic antidepressants, like amitriptyline (Elavil) or Nortriptyline (Pamelor) used at low doses (subtherapeutic for depression) can also be helpful and have an added benefit of pain relief for some types of pain specifically nerve pain

Non-medication therapies

  • Use the above sleep hygiene techniques
  • Relaxation techniques (deep breathing or deep muscle relaxation)
  • Meditation
  • Yoga

What is Discography?

Discography is a diagnostic procedure in which x-ray dye (x-ray contrast) is injected into the
discs of the spine. After the x-ray dye is injected, an x-ray (called a “discogram”) is taken of the
discs. The discogram may be normal or may show tears (fissures) in the lining of the disc. The
results of discography are used to plan surgery or IDET (intradiscal electrothermal ) treatment.

What is the purpose of Discography?

Discography is done to answer the questions “Is my back pain or neck pain from a degenerated
disc?” and “Which discs -if any- are causing my pain?”

How do I know if my pain is from a damaged disc?

With age or from an injury, the wall of the spinal discs can get cracks or tears (fissures). This
condition is call Internal Disc Disruption or Degenerative Disc Disease. Also, the wall of the disc
can weaken and bulge out (a herniated disc). When the disc causes pain, the pain is usually felt
as a deep, aching pain in the back and sometimes in the buttocks and into the thigh. However,
pain from facet joints in the back and from the sacroiliac joints (SI joints) can be in the same
location and feel the same. The best way to tell if the pain is from a damaged disc is with
discography.

How is Discography performed?

The procedure is done in the operating room with fluoroscopic (x-ray) guidance. For lumbar
discography (discs in the low back), it is done with the patient lying on their stomach. For
cervical discography (discs in the neck), it is usually done with the patient lying on their back.
There will be an anesthesiologist or a nurse present during the procedure to monitor you and
administer intravenous sedation to help you be comfortable and relaxed. You are watched
closely with an EKG monitor, blood pressure cuff and blood oxygen-monitoring device. The skin
over the injection site(s) is cleaned with an antiseptic solution and then the injections are
carried out. After the injection, the patient is placed on their back or on their side.

What will I feel during the injection?

When a normal disc is injected, you will feel a sense of pressure, but not pain. When an
abnormal disc is injected, you will feel pain. It is important to try to tell if the pain you are
feeling is your usual pain or different. With each disc injected, you will be asked if it is painful,
where you feel the pain and whether it is in the same area as your usual pain.

How many discs will be injected?

Based on your symptoms and your MRI, we will identify which discs we suspect are causing
your pain. These discs will be injected. In addition, we inject a normal disc to serve as a
reference point.

How long does Discography take?

Discography takes about 30 minutes, depending on how many levels are injected.

What is actually injected?

The injection consists of x-ray dye (x-ray contrast). It is usually mixed with some antibiotics to
prevent infection.

Will the injections hurt?

The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus
shot”), so there is some discomfort involved. However, your doctor will numb the skin and
deeper tissues with a local anesthetic using a very thin needle prior to inserting the needle into
the disc. Most of the patients also receive intravenous sedation and analgesia, which makes the
procedure easy to tolerate.

You may have a flare-up of your back pain after the injection, but this gets better in a day or
two and can usually be managed with ice packs and oral pain medication.

Will I be “put out” for this procedure?

No. This procedure is done under local anesthesia. Injection of a medicine like Novocaine-
Lidocaine is performed to numb the skin. Most of the patients also receive intravenous
sedation and analgesia, to help them relax and make the procedure easier to tolerate. The
amount of sedation given depends upon the patient. You can be sleepy while the needles are
placed, but during the discogram injections, you need to be awake enough to tell the doctor
what you are feeling.

Will my pain be better after the injection?

No. Discography does not treat your condition. It is a diagnostic test that allows your doctors to
plan your therapy.

What should I do after the procedure?

You will need a ride home. We advise the patients to take it easy for a day or so after the
procedure. You may need to apply ice to the affected area for 20-30 minutes at a time for the
next day. Perform the activities as tolerated by you.

Can I go to work to work the next day?

We usually recommend taking 2-3 days off work after the injection.

What are the risks and side effects of discography?

Generally speaking, this procedure is safe. However, with any procedure there are risks, side
effects, and possibility of complications. The most common side effect is pain, which is
temporary. Sometimes, the discogram needle brushes past a nerve root and the nerve root is
irritated. This pain almost always gets better quickly. The other risks involve infection, bleeding,
and worsening of symptoms. Fortunately, the serious side effects and complications are
uncommon.

Who should not have this procedure?

If you are allergic to any of the medications to be injected, if you are on blood thinning
medications (e.g. Coumadin, Plavix, Ticlid), or if you have an active infection going on, you
should not have the procedure. You should not have discography if you have not tried simpler
treatments such as activity restriction and anti-inflammatory medications.

What is an Epidural Steroid Injection (ESI)?

The epidural steroid injection (ESI) is the placement of cortisone, a powerful anti-inflammatory agent, into the epidural space, which approximates the disc and spinal column. The epidural injection has been used for over 40 years as treatment for back pain. It involves using either steroids or anesthetic agents allowing good benefits with minimal risk factors. The main goal of the epidural injection is to shrink the swelling in bulging or herniated discs, and to decrease any inflammation that surrounds the disc and may be pressing on a spinal nerve. This is a common procedure. Because of the low risk and low incidence of any significant problems or side effects, this is felt to be a reasonable procedure to follow when traditional conservative therapy for disc pain has failed to provide improvement. A large percentage of patients upon whom this procedure is performed will get complete resolution of symptoms; a small percentage may experience no real improvement at all.

If there is improvement from the steroid epidural, it likely will occur over the next several days to two weeks. The improvement should not be expected immediately.

How long does the injection take?

The actual injection takes only a few minutes.

What is actually injected?

The injection consists of a mixture of local anesthetic (like lidocaine or bupivacaine) and the steroid medication (triamcinolone – Aristocortor methylprednisolone – Depo-medrol).

Will the injection hurt?

The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”). So, there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the Epidural needle. Also, the tissues in the midline have less nerve supply, so usually you feel strong pressure and not much pain. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easy to tolerate.

Will I be “put out” for this procedure?

No. This procedure is done under local anesthesia. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easier to tolerate. The amount of sedation given generally depends upon the patient tolerance.

How is the injection performed?

It is done either with the patient sitting up or on the side, or on your stomach. The patients are monitored with EKG, blood pressure cuff and blood oxygen monitoring device. The skin in the back is cleaned with antiseptic solution and then the injection is carried out. After the injection, you are placed on your back or on your side.

What should I expect after the injection?

Immediately after the injection, you may feel that your legs are slightly heavy and may be numb. Also, you may notice that your pain may be gone or quite less. This is due to the local anesthetic injected. This will last only for a few hours. Your pain will return and you may have a “sore back” for a day or two. This is due to the mechanical process of needle insertion as well as initial irritation form the steroid itself. You should start noticing pain relief starting the 3rd or 5th day or so.

What should I do after the procedure?

You should have a ride home. Patients are advised to rest on the day of the epidural, although bed rest, while preferable, is not required.  By the next day, previous activities can be resumed. An occasional patient will feel such significant relief that they are tempted to resume various strenuous activities.

They are cautioned not to do this, however. It is generally advised to pursue a course of gradual increase in activity, often coordinated with physical therapy or other training once the injections have been completed.

Can I go back to work the next day?

You should be able to unless there were complications with the procedure. Usually you will feel some back pain or have a “sore back” only.

How long does the effect of the medication last?

The immediate effect is usually from the local anesthetic injected. This wears off in a few hours. The cortisone starts working in about 3 to 5 days and its effect can last for several days to a few months.

How many injections do I need to have?

If the first injection does not relieve your symptoms in about a week to two weeks, we may recommend that you have one more injection. Similarly if the second injection does not relieve your symptoms in about a week to two weeks, you may be recommended to have a third injection.  Additional injections have additive effect.

Can I have more than three injections?

In a six month period, we generally do not perform more than three injections. This is because the medication injected lasts for about six months. If three injections have not helped you much, it is very unlikely that you will get any further benefit from more injections. Also, giving more injections will increase the likelihood of side effects from cortisone.

Will the Epidural Steroid Injection help me?

It is very difficult to predict if the injection will indeed help you or not. Generally speaking, the patients who have “radicular symptoms” (like sciatica) respond better to the injections than the patients who have only back pain. Similarly, the patients with a recent onset of pain may respond much better than the ones with a long standing pain. Also, the patients with back pain mainly due to bony abnormality may not respond adequately.

What are the risks and side effects?

Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain – which is temporary. The other risk involve spinal puncture with headaches, infection, bleeding inside the Epidural space with nerve damage, worsening of symptoms etc. The other risks are related to the side effects of cortisone: These include weight gain, increase in blood sugar (mainly in diabetics), water retention, suppression of body`s own natural production of cortisone etc.

Who should not have this injection?

If you are allergic to any of the medications to be injected, if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid), or if you have an active infection going on near the injection site, you should not have the injection.

Transforaminal vs. Translaminar Injection

Doctors divide the spine up into three different areas or regions.  The area of the back located between the lowest rib and the pelvis is referred to as the lumbar spine.  The area of the back that the ribs attach to is the thoracic spine and the neck is called the cervical spine.

There are two different methods to place steroid on an inflamed nerve in the spine.  One is a direct approach referred to as a transforaminal approach.  In this method, the inflamed nerve is directly targeted and a small amount (usually 1 ml) of steroid and local anesthetic is injected right at the level of inflammation.  The other method targets multiple nerves in the spine both on the right and left sides.  This method spreads steroid (a potent anti-inflammatory) over many nerves (usually 4-8 nerves) using a large amount of fluid (usually 10cc’s).  This method is less specific at identifying a so call “pain generator” (the nerve responsible for producing the patients’ pain).  However, it is useful to treat certain conditions in which multiple nerves are involved (i.e.: spinal stenosis).   

 

What is a Facet Joint Injection?

Facet Joint Injection is an injection of long lasting steroid (“cortisone”) in the facet joints – which are located in the back area, as a part of the bony structure.

What is the purpose of it?

The steroid injected reduces the inflammation and/or swelling of tissue in the joint space. This may in turn reduce pain, and other symptoms caused by inflammation / irritation of the joint and surrounding structures.

How long does the injection take?

The actual injection takes only a few minutes.

What is actually injected?

The injection consists of a mixture of local anesthetic (like lidocaine or bupivacaine) and the steroid medication (celestone or betamethasone or dexamethasone)

Will the injection(s) hurt?

The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”) so there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the needle into the joint. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easy to tolerate.

Will I be “put out” for this procedure?

No. This procedure is done under local anesthesia. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easy to tolerate. The amount of sedation given generally depends upon the patient tolerance.

How is the injection performed?

Under x-ray control, either the patient lies on the stomach for lumbar (lower back) injections, or in a sitting position for the cervical (neck area) injections. The patients are monitored with EKG, blood pressure cuff and blood oxygen-monitoring device. The skin in the back is cleaned with antiseptic solution and then the injection is carried out. After the injection, the patient is placed on their back or on their side.

What should I expect after the injection?

Immediately after the injection, you may feel that your pain may be gone or is quite lessened. This is due to the local anesthetic injected. This will last only for a few hours. Your pain will return and you may have a “sore back” for a day or two. This is due to the mechanical process of needle insertion as well as initial irritation form the steroid itself. You should start noticing pain relief starting the 5th day or so.

What should I do after the procedure?

You should have a ride home. We advise the patients to take it easy for a day or two after the procedure. You may want to apply ice to the affected area. Perform activities as tolerated by you.

Can I go to work to work the next day?

Unless there are complications, you should be able to return to your work the next day. The most common thing you may feel is sore back.

How long the effect of the medication lasts?

The immediate effect is usually from the local anesthetic injected. This wears off in a few hours. The cortisone starts working in about 5 to 7 days and its effect can last for several days to a few months.

How many injections do I need to have?

If the first injection does not relieve your symptoms in about a week to two weeks, you may be recommended to have one more injection. If you respond to the injections and still have residual pain, you may be recommended for a third injection

Can I have more than three injections?

In a six-month period, we generally do not perform more than three injections. This is because the medication injected lasts for about six months. If three injections have not helped you much, it is very unlikely that you will get any further benefit from more injections. Also, giving more injections will increase the likelihood of side effects from cortisone.

Will the Facet Joint Injection help me?

It is very difficult to predict if the injection will indeed help you or not. Usually the patients who have recent onset of pain may respond much better than the ones with long standing pain.

What are the risks and side effects?

Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain – which is temporary. The other risks involve, infection, bleeding, worsening of symptoms, spinal block, epidural block etc. The other risks are related to the side effects of cortisone: These include weight gain, increase in blood sugar (mainly in diabetics), water retention, suppression of body`s own natural production of cortisone etc. Fortunately, the serious side effects and complications are uncommon.

Who should not have this injection?

If you are allergic to any of the medications to be injected, if you are on a blood thinning medication (e.g. Coumadin), or if you have an active infection going on, you should not have the injection.

 

 

What is an Intrathecal Pump Implant (“Spinal Morphine Pump”)?

An Intrathecal Pump is a specialized device, which delivers concentrated amounts of medication(s) into spinal cord area via a small catheter (tubing).

Am I a candidate for Intrathecal Pump Implant (“Spinal Morphine Pump”)?

Currently, Intrathecal Pump is offered to patients with : Chronic and severe pain who have not adequately responded to other treatment modalities. Some of the examples are: failed back syndrome, cancer pain, RSD. These patients receive infusion of painkillers such as Morphine.

What is the purpose of it?

This device delivers concentrated amounts of medication into spinal cord area allowing the patient to decrease or eliminate the need for oral medications. It delivers medication around the clock, thus eliminating or minimizing breakthrough pain and/or other symptoms.

How long does the procedure take?

It is done in two stages. In the first stage, a single injection is made to assess effectiveness and screen for unwanted side effects. If this trial is successful in relieving symptoms, then the permanent device is placed under the skin. The patients have to meet certain other screening criteria before implanting the pump.

Will the procedure hurt?

The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”), so there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the needle. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easier to tolerate.

Will I be “put out” for this procedure?

The trial is done under local anesthesia with patients mildly sedated. The amount of sedation given generally depends upon the patient tolerance. For the pump placement, patients are given stronger intravenous sedation and analgesia.

How is the procedure performed?

It is done with the patient lying on the side. Sometimes the tubing is placed with the patient sitting up. The patients are monitored with EKG, blood pressure cuff and blood oxygen-monitoring device. The skin is cleaned with antiseptic solution and then the procedure is carried out. X-ray (fluoroscopy) is used to guide the needle for inserting the tubing.

Where is the tubing inserted? Where is the pump placed?

Tubing is inserted in the midline at the lower back. The pump is then placed on the side of the abdomen.

What should I expect after the procedure?

If the procedure is successful, you may feel that your pain may be controlled or is quite lessened. The pump is adjusted electronically to deliver adequate amount of medication.

What should I do after the procedure?

The morphine pump trial is an out-patient procedure. The patient is kept in the office for an hour after the procedure to monitor their relief.  The implant of the morphine pump is normally a day-procedure and patients are kept overnight for observation and pump adjustment.

How long will the pumps last?

The medication contained within the pump will last about 1 to 3 months depending upon the concentration and amount infused. It is then refilled via a tiny needle inserted into the pump chamber. This is done in the office and it takes only a few minutes. The batteries in the pump may last 3 to 5 years depending upon the usage. The batteries cannot be replaced or recharged. The pump is replaced at that time.

Will the Intrathecal Pump Implant (“Spinal Morphine Pump”) help me?

It is very difficult to predict if the procedure will indeed help you or not. For that reason a trial is carried out to determine if a permanent device (pump) will be effective to relieve your pain or not.

What are the risks and side effects?

Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. Please discuss your concerns with your physician.

Who should not have this procedure?

If you are allergic to any of the medications to be injected, if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid), or if you have an active infection going on, you should not have the procedure. The patients also have to meet certain other screening criteria before implanting the pump.

 

 

What is a Lumbar Sympathetic Block?

Lumbar Sympathetic Block is an injection of local anesthetic in the “sympathetic nerve tissue” – the nerves which are a part of Sympathetic Nervous System. The nerves are located on the either side of spine, in the back.

What is the purpose of it?

The injection blocks the Sympathetic Nerves. This may in turn reduce pain, swelling, color, and sweating changes in the lower extremity and may improve mobility. It is done as a part of the treatment of Reflex Sympathetic Dystrophy (RSD), Sympathetic Maintained Pain, Complex Regional Pain Syndrome, and Herpes Zoster (shingles) involving lower extremity.

How long does the injection take?

The actual injection takes only a few minutes.

What is actually injected?

The injection consists of a local anesthetic (like lidocaine or bupivacaine). Epinephrine (adrenaline) or Clonidine may be added to prolong the effects of the injection.

Will the injection hurt?

The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”). So, there is some discomfort involved. However, we may numb the skin and deeper tissues with a local anesthetic using a very thin needle before inserting the actual block needle. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easy to tolerate.

Will I be “put out” for this procedure?

No. This procedure is done under local anesthesia. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easy to tolerate. The amount of sedation given generally depends upon the patient tolerance.

How is the injection performed?

It is done with the patient lying on their stomach. The patient is monitored with EKG, blood pressure cuff and blood oxygen-monitoring device. Temperature sensing probes are also placed on the patient’s feet. The skin on the back is cleaned with antiseptic solution and then the injection is carried out. Fluoroscopy (X-rays) is used to guide the needle(s) in the proper position.

What should I expect after the injection?

Immediately after the injection, you may feel your lower extremity getting warm. In addition, you may notice that your pain may be gone or quite less. You may also notice some weakness and/or numbness in the leg, which is temporary.

What should I do after the procedure?

You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. Perform the activities as tolerated by you. Some of the patients may go for immediate physical therapy.

Can I go to work to work the next day?

Unless there are complications, you should be able to return to your work the next day. The most common thing you may feel is soreness in the back at the injection site.

How long the effect of the medication lasts?

The local anesthetic wears off in a few hours. However, the blockade of sympathetic nerves may last for many more hours. Usually, the duration of relief gets longer after each injection.

How many injections do I need to have?

If you respond to the first injection, you will be recommended for repeat injections. Usually, a series of such injections is needed to treat the problem. Some may need only 2 to 4 and some may need more than 10. The response to such injections varies from patient to patient.

Will the Lumbar Sympathetic Block help me?

It is very difficult to predict if the injection(s) will indeed help you or not. The patients who present early during their illness tend to respond better than those who have this treatment after about six months of symptoms do. Patients in the advanced stages of disease may not respond adequately.

What are the risks and side effects?

This procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain – which is temporary. The other risk involves bleeding, infection, spinal block, epidural block, and injection into blood vessels and surrounding organs. Fortunately, the serious side effects and complications are uncommon.

Who should not have this injection?

If you are allergic to any of the medications to be injected, if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid), or if you have an active infection going on near the injection site, you should not have the injection.

 

 

What is a Medial Branch?

Facet joints are innervated or “supplied” by nerves called “medial branches”. These nerves carry the pain signals to the spinal cord and the signals eventually reach the brain, where the pain is noticed.

What is the purpose of it?

If the nerves are “blocked” or “numbed”, they will not be able to carry pain sensation to the spinal cord. It is like temporarily cutting off “wires”. Therefore, if the pain is due to facet joint arthritis, you should have relief from pain and stiffness.

Once it is determined that the pain is indeed due to facet joint disease, we can use a procedure called “Radiofrequency Lesioning” and prevent the conduction of pain information for several weeks to months.

So, in a way, medial branch block is a temporary and diagnostic procedure.

How long does the injection take?

The actual injection takes only a few minutes. The more nerves to be blocked, the more time it takes.

What is actually injected?

The injection consists of a local anesthetic (like lidocaine or bupivacaine).

Will the injection hurt?

The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”). Therefore, there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle before inserting the needle into the joint.

Will I be “put out” for this procedure?

No. This procedure is done under local anesthesia. The amount of sedation given generally depends upon the patient`s tolerance.

How is the injection performed?

Under x-ray control, it is done either with the patient lying on the stomach for the upper and low back pain, or lying on the back for the cervical (neck area) injections. The patients are monitored with EKG, blood pressure cuff and blood oxygen-monitoring device. The skin in the back is cleaned with antiseptic solution and then the injection is carried out.

What should I expect after the injection?

Immediately after the injection, you may feel that your pain may be gone or quite lessened. This is due to the local anesthetic injected. This may last only for a few hours. Your pain will return and you may have a “sore back or neck” for a day or two. This is due to the mechanical process of needle insertion. It is very important for you to keep a track of your pain and stiffness for the next 2 to 12 hours following injections. Your response to the injections will determine if the facets are the cause of your pain or not.

What should I do after the procedure?

You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. You may want to apply ice to the affected area. Perform your usual activities as tolerated.

Can I go to work to work the next day?

Unless there are complications, you should be able to return to your work the next day. The most common thing you may feel is sore back or neck.

How long does the effect of the medication last?

The immediate effect is from the local anesthetic injected. Depending upon the medication injected, it can last from 2 hours to 8 hours. Of course, if the facet joints are not the source of your pain, you may not have much relief.

How many injections do I need to have?

Usually one session is enough to determine if the facet joints are the most likely source of your pain or not. However, the “placebo response” can be as high as 30 to 40 % and some patients may be recommended to have a repeat diagnostic injection. In addition, “False Positive” responses can occur.

Will the procedure help me?

If the pain is originating mostly from the facet joints, you should benefit from this procedure on a temporary basis. Some do get a “placebo response” and others may get a “False-Positive” response. Please remember that these are diagnostic injections only and last only for a few hours. These are done to determine if the pain is coming from the facet joints or not, and if the pain is coming from the facet joints, we will recommend “Radiofrequency Lesioning” which will “numb” the same nerves for many weeks to months.

What are the risks and side effects?

Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain – which is temporary. The other risks involve, infection, bleeding, worsening of symptoms, spinal block, epidural block etc. Fortunately, the serious side effects and complications are uncommon.

Who should not have this injection?

If you are allergic to any of the medications to be injected, if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid), or if you have an active infection going on near the injection site, you should not have the injection.

 

 

Thoracic Facet Joint Syndrome

The thoracic spine is the upper region of the back.

The diagnosis of thoracic facet joint syndrome is given to patients whose pain arises from the thoracic zygapophysial (facet) joints located in the upper back. These joints can produce a constant aching pain located in the mid back usually between the shoulder blades.

The most common treatment for this type of pain is a thoracic medial branch block.  If the medial branch block is successful, then the longer lasting radiofrequency lesioning can be administered.

Lumbar Radiculopathy

Lumbar refers to the area of the back that is situated between the lowest ribs and the pelvis (L1-L5).

Radiculopathy is a disease of the spinal nerve roots that usually causes a patient to feel pain, weakness, and numbness radiating from the spine. This pain is most commonly felt in the arms and legs.

A common treatment for this type of pain is a lumbar epidural steroid injection (ESI).

 

 

Chronic Pancreatitis
Chronic inflammation of the pancreas is called chronic pancreatitis. This results in attacks of abdominal pain.

Chronic pancreatitis can be treated with celiac plexus blocks and radio frequency treatments.

Celiac refers to a large area of nerves in the abdomen—pancreas, liver, gall bladder, stomach, and intestine.

After a patient has undergone the proper diagnostic tests (nerve block injections), our doctors educate our patients about radio frequency lesioning—a procedure that typically results in 12-24 months of pain relief.

Using high-frequency radio waves and heat, our physicians pulse the pain generating nerve. Through this process, the pain sensory on the nerve is de-activated. The nerve is still functioning, but there is no more pain. Most insurance companies will cover this treatment at least once a year.

“Many conditions can be treated by simply targeting the painful nerve and treating it with our radio frequency procedures. Thanks to these medical advances, we can offer effective treatments without the risk and recovery time of surgery,’” says Dr. Richard Rosenthal, the medical director of Nexus Paincare.

Celiac Plexus Nerve Block
Lumbar refers to the area of the back that is situated between the lowest ribs and the pelvis (L1-L5). Celiac refers to a large area of nerves in the abdomen—pancreas, liver, gall bladder, stomach, and intestine.

A nerve block is a diagnosing tool that helps our doctors to know exactly which nerves are causing our patients to feel pain. Our doctors use a live x-ray-type machine (flouroscopy) to see the patients’ bone structures. They are often able to tell, based on the patients’ description, the general area where the pain is being generated. Our physicians select the nerve that is likely the cause of the pain. That nerve is temporarily numbed with lidocaine (the same numbing medication dentists use). The Celiac plexus nerve block is conducted along the lower thoracic spine and blocks the pain signals to the organs.

If the patient feels relief for a few hours before the lidocaine effects wear off, then the doctor can likely conclude that the pain generating nerve has been correctly identified. This process is repeated another time, just to assure that the pain relief was not a placebo effect. After two successful nerve blocks, our physicians educate our patients and move on to a more permanent treatment that will likely produce pain relief for 12-24 months—radio frequency lesioning.

Celiac Plexus Radio Frequency
Celiac refers to a large area of nerves in the abdomen—pancreas, liver, gall bladder, stomach, and intestine.

After a patient has undergone the proper diagnostic tests (nerve block injections), our doctors educate our patients about radio frequency lesioning—a procedure that typically results in 12-24 months of pain relief.

Using high-frequency radio waves and heat, our physicians pulse the pain generating nerve. Through this process, the pain sensory on the nerve is de-activated. The nerve is still functioning, but there is no more pain. Most insurance companies will cover this treatment at least once a year.

“Many conditions can be treated by simply targeting the painful nerve and treating it with our radio frequency procedures. Thanks to these medical advances, we can offer effective treatments without the risk and recovery time of surgery,’” says Dr. Richard Rosenthal, the medical director of Nexus Paincare.

Complex Regional Pain Syndrome
An extremely uncommon condition, complex regional pain syndrome typically affects an arm or leg. This syndrome happens often, but not always, after a traumatic event. This condition is often associated with intense burning or aching pain, swelling, skin discoloration, temperature change, and excessive sweating.

Lumbar Sympathetic Block
Lumbar refers to the area of the back that is situated between the lowest ribs and the pelvis (L1-L5).

What is a Lumbar Sympathetic Block? Lumbar Sympathetic Block is an injection of local anesthetic in the “sympathetic nerve tissue” – the nerves that are a part of Sympathetic Nervous System. The nerves are located on the either side of spine.

What is the purpose of it? The injection blocks the Sympathetic Nerves. This may in turn reduce pain, swelling, color, and sweating changes in the lower extremity and may improve mobility. It is done as a part of the treatment of Reflex Sympathetic Dystrophy (RSD), Sympathetically Maintained Pain, Complex Regional Pain Syndrome, and Herpes Zoster (shingles) involving lower extremity.

How long does the injection take? The actual injection takes only a few minutes.

What is actually injected? The injection consists of a local anesthetic (like lidocaine or bupivacaine). Epinephrine (adrenaline) or Clonidine may be added to prolong the effects of the injection.

Will the injection hurt? The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”). So, there is some discomfort involved. However, we may numb the skin and deeper tissues with a local anesthetic using a very thin needle before inserting the actual block needle. Most of the patients also receive oral sedation and analgesia, which makes the procedure easy to tolerate.

Will I be “put out” for this procedure? No. This procedure is done under local anesthesia. Most of the patients also receive oral sedation and analgesia, which makes the procedure easy to tolerate. The amount of sedation given generally depends upon the patient’s tolerance.

How is the injection performed? It is done with the patient lying on their stomach. The patients are monitored with EKG, blood pressure cuff and blood oxygen-monitoring device. Temperature sensing probes are also placed on the feet. The skin on the back is cleansed with an antiseptic solution and then the injection is carried out. Fluoroscopy (X-rays) is used to guide the needle(s) into the proper position.

What should I expect after the injection? Immediately after the injection, you may feel your lower extremity getting warm. In addition, you may notice that your pain may be less, or gone. You may also notice some weakness and/or numbness in the leg – which is temporary.

What should I do after the procedure? You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. Perform activities only as tolerated. Some of the patients may go for immediate physical therapy.

Can I go to work to work the next day? Unless there are complications, you should be able to return to your work the next day. The most common thing you may feel is soreness in the back at the injection site.

How long the effect of the medication lasts? The local anesthetic wears off in a few hours. However, the blockade of sympathetic nerves may last for many more hours. Usually, the duration of relief gets longer after each injection.

How many injections do I need to have? If you respond to the first injection, you will be recommended for repeat injections. Usually, a series of such injections is needed to treat the problem. Some may need only 2 to 4 and some may need more that 10. The response to such injections varies from patient to patient.

Will the Lumbar Sympathetic Block help me? It is very difficult to predict if the injection(s) will indeed help you or not. The patients who present early during their illness tend to respond better than those who have this treatment after about six months of symptoms. Patients in the advanced stages of disease may not respond adequately.

What are the risks and side effects? This procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain – which is temporary. The other risk involves bleeding, infection, spinal block, epidural block, and injection into blood vessels and surrounding organs. Fortunately, the serious side effects and complications are uncommon.

Who should not have this injection? If you are allergic to any of the medications to be injected, if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid), or if you have an active infection going on near the injection site, you should not have the injection.

Lumbar Sympathetic Radio Frequency
Lumbar refers to the area of the back that is situated between the lowest ribs and the pelvis (L1-L5). This procedure is used to treat pain in the arm or leg that occurs after some type of traumatic injury. This pain is referred to as RSD. The pain is burning in nature and can even make the skin sensitive to the touch.

Lumbar Sympathetic RF—Patients who receive relief from a lumbar sympathetic block (LSB) on two separate occasions are candidates for this procedure. If the LSB is effective in relieving the extremity pain, then the lumbar sympathetic RF has an 85% chance of completely relieving the pain on a more long-term basis. A small percentage of patients experience a recurrence of symptoms after about 9 months at which time the procedure can be repeated.

These procedures require the use of fluoroscopy for accurate needle placement. The reason to proceed to the sympathetic RF is to avoid the high cost associated with the use of an operating room. In the past, up to 15 LSBs would be done on a given patient in order to abort the pain of RSD. Because the RF procedure is safe and not higher risk than an LSB, it is to the patient’s and payer’s benefit to proceed immediately with the sympathetic RF rather than continue performing blocks.

Stellate Ganglion Block
The stellate ganglion is a star-shaped body of nerve cells located at the base of the neck. From this body of cells, sympathetic nerve fibers are distributed to the face and neck, as well as to blood vessels and organs of the upper body.

A nerve block is a diagnosing tool that helps our doctors to know exactly which nerves are causing our patients to feel pain. Our doctors use a live x-ray-type machine (flouroscopy) to see the patients’ bone structures. They are often able to tell, based on the patients’ description, the general area where the pain is being generated. Our physicians select the nerve that is likely the cause of the pain. That nerve is temporarily numbed with lidocaine (the same numbing medication dentists use).

If the patient feels relief for a few hours before the lidocaine effects wear off, then the doctor can likely conclude that the pain generating nerve has been correctly identified. This process is repeated another time, just to assure that the pain relief was not a placebo effect. After two successful nerve blocks, our physicians educate our patients and move on to a more permanent treatment that will likely produce pain relief for 12-24 months—radio frequency lesioning.

Stellate Ganglion Radio Frequency
The stellate ganglion is a star-shaped body of nerve cells located at the base of the neck. From this body of cells, sympathetic nerve fibers are distributed to the face and neck, as well as to blood vessels and organs of the upper body.

After a patient has undergone the proper diagnostic tests (nerve block injections), our doctors educate our patients about radio frequency lesioning—a procedure that typically results in 12-24 months of pain relief.

Using high-frequency radio waves and heat, our physicians pulse the pain generating nerve. Through this process, the pain sensory on the nerve is de-activated. The nerve is still functioning, but there is no more pain. Most insurance companies will cover this treatment at least once a year.

“Many conditions can be treated by simply targeting the painful nerve and treating it with our radio frequency procedures. Thanks to these medical advances, we can offer effective treatments without the risk and recovery time of surgery,’” says Dr. Richard Rosenthal, the medical director of Nexus Paincare.

Once the procedure has been completed, our physicians usually recommend a course of physical therapy to prevent recurrence of the condition.

Stellate Ganglion Injection
What is a Stellate Ganglion Injection? Stellate Ganglion Injection is an injection of local anesthetic in the “sympathetic nerve tissue” – the nerves which are a part of Sympathetic Nervous System. The nerves are located on the either side of the voice box, in the neck.

What is the purpose of it? The injection blocks the Sympathetic Nerves. This may in turn reduce pain, swelling, color, and sweating changes in the upper extremity and may improve mobility. It is done as a part of the treatment of Reflex Sympathetic Dystrophy (RSD), Sympathetic Maintained Pain, Complex Regional Pain Syndrome, and Herpes Zoster (shingles) involving upper extremity or head and face.

How long does the injection take? The actual injection takes only a few minutes.

What is actually injected? The injection consists of a local anesthetic (like lidocaine or bupivacaine).

Will the injection hurt? The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”). So, there is some discomfort involved. However, we may numb the skin and deeper tissues with a local anesthetic using a very thin needle before inserting the actual block needle.

Will I be “put out” for this procedure? No. This procedure is done under local anesthesia. The amount of sedation given generally depends upon the patient tolerance.

How is the injection performed? It is done either with the patient laying flat on their back. The chin is slightly raised. The patients are monitored with EKG, blood pressure cuff and blood oxygen-monitoring device. The skin in the front of the neck, next to the “voice box” is cleaned with antiseptic solution and then the injection is carried out.

What should I expect after the injection? Immediately after the injection, you may feel your upper extremity getting warm. In addition, you may notice that your pain may be gone or quite less. You may also notice “a lump in the throat” as well as hoarse voice, droopy and red eye, and some nasal congestion on the side of the injection. You may also develop a headache.

What should I do after the procedure? You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. Perform the activities as tolerated by you. Some of the patients may go for immediate physical therapy.

Can I go to work to work the next day? Unless there are complications, you should be able to return to your work the next day. The most common thing you may feel is soreness in the neck at the injection site.

How long will the effect of the medication last? The local anesthetic wears off in a few hours. However, the blockade of sympathetic nerves may last for many more hours. Usually, the duration of relief gets longer after each injection.

How many injections do I need to have? If you respond to the first injection, you will be recommended for repeat injections. Usually, a series of such injections is needed to treat the problem. Some may need only 2 to 4 and some may need more that 10. The response to such injections varies from patient to patient.

Will the Stellate Ganglion Injection help me? It is very difficult to predict if the injection(s) will indeed help you or not. The patients who present early during their illness tend to respond better than those who have this treatment after about six months of symptoms do. Patients in the advanced stages of disease may not respond adequately.

What are the risks and side effects? This procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain – which is temporary. The other risk involves bleeding, infection, spinal block, epidural block, and injection into blood vessels and surrounding organs. Fortunately, the serious side effects and complications are uncommon.

Who should not have this injection? If you are allergic to any of the medications to be injected, if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid), or if you have an active infection going on near the injection site, you should not have the injection.

Sympathetic Ganglion Block
Sympathetic pertains to the sympathetic nervous system or one of its nerves. This nervous system is responsible for regulating our heart rate, breathing and other bodily functions that are not usually under our conscious control. Sometimes this nervous system malfunctions and causes a burning pain in an arm or leg. A sympathetic block is used to alleviate this type of pain.

A ganglion is a mass of cell bodies.

A nerve block is a diagnosing tool that helps our doctors to know exactly which nerves are causing our patients to feel pain. Our doctors use a live x-ray-type machine (flouroscopy) to see the patients’ bone structures. They are often able to tell, based on the patients’ description, the general area where the pain is being generated. Our physicians select the nerve that is likely the cause of the pain. That nerve is temporarily numbed with lidocaine (the same numbing medication dentists use).

If the patient feels relief for a few hours before the lidocaine effects wear off, then the doctor can likely conclude that the pain generating nerve has been correctly identified. This process is repeated another time, just to assure that the pain relief was not a placebo effect. After two successful nerve blocks, our physicians educate our patients and move on to a more permanent treatment that will likely produce pain relief for 12-24 months—radio frequency lesioning.

Mechanical Low Back Pain
Mechanical low back pain is pain that worsens with activity and is relieved by rest. There are three common causes for mechanical low back pain—a tear in the disc, inflammation of the facet, or inflammation of the sacroiliac (SI) joint.

The concept of mechanical low back pain refers to pain originating from the spine. Steven Kuslich et al was the first to identify potentially painful structures within the spinal axis. This was done by stimulating various tissues during operation under local anesthesia and determining if a pain response was elicited. He found the following tissues capable of generating a pain response—ligaments, fascia, muscles, intravertebral discs, facet/SI joints, periosteum and nerve root dura (Kuslich el al. The tissue origin of low back pain and sciatica: a report of pain response to tissue simulation during operation on the lumbar spine using local anesthesia. (Orthop Clin North Am 1991;22:181-187). Bogduk postulated that for a tissue to cause back pain, it should have a nerve supply; should be capable of causing pain similar to that seen clinically, ideally in normal volunteers; should be susceptible to diseases or injuries that are known to be painful; and should have been shown to be a source of pain in patients, using diagnostic techniques of non reliability and validity (Bogdik N. low back pain. Clinical anatomy of lumbar spine and sacrum. Third edition. Churchill Livingston, New York, 1997;pp 187-213). Schwarzer identified the causes and prevalence of mechanical low back pain meeting the above criteria as intravertebral disc in 40% of patients, facet joints in 15-40%, and sacroiliac joint in 30%(Schwarzer et al. The relative contributions of the disk and facet joint in chronic low back pain. Spine 1994; 19: 801-806). Other potential causes which have since been identified include segmental instability and dural tethering after operation resulting in low back pain. Traditionally, the tools used in the clinical diagnosis of spinal pain lack reliability and/or validity. For this reason, it has been said that clinical features, diagnostic imaging or neurophysiologic studies do not permit the accurate diagnosis of causation of low back pain in 85 percent of patients in the absence of disk herniation and neurological deficit. However, Bogduk postulated that precision diagnostic injections could assist in arriving at a definitive diagnosis in low back pain in approximately 70 to 80% of patients based on Schwarzer`s studies (Bogduk N. musculoskeletal pain: toward precision diagnosis. Progress in pain research and management. In Jensen TS, Turner JA, Wiesenfield-Hallin Z. proceedings of the 8th world Congress on pain. IASP Press, Seattle, 1997,pp 507-525). In a recent study by Manchikanti et al, the relative prevalence of pain generators within the spine was as follows: facet joint 40%, lumbar disc 26%, and SI joint 2% (Manchikanti et al. Contributions of various structures in chronic low back pain. Pain Physician. Vol 4, No 4, Oct 2001). Although the exact prevalence of various contributors to mechanical low back pain remains controversial, the structures known to cause the problem are well defined and include facet joints, intervertebral discs and SI joints.

 

Lumbar Facet Joint Arthritis
Lumbar refers to the area of the back that is situated between the lowest ribs and the pelvis (L1-L5).

Facet joints, also known as zygapopysial joints, are pairs of joints (about the size of a finger nail) that are located on the backside of the spine at each disc level. These joints add stability and help the spine from moving too far. There are nerve endings both on the outside and inside of each of these joints.

Facet joints can suffer from arthritis. There are different forms of arthritis; each has a different cause. The most common form of arthritis, osteoarthritis (degenerative joint disease) is a result of trauma to the joint, infection of the joint, or age.

 

Lumbar Facet Joint Syndrome
Lumbar refers to the area of the back that is situated between the lowest ribs and the pelvis (L1-L5).

Lumbar facet joint syndrome—this diagnosis is given to patients whose pain arises from the zygapophysial joints located in the posterior part of the spine. The prevalence of this syndrome varies according to author. In 1994, Schwarzer et al showed that in younger aged, injured worker with chronic back pain, the prevalence was about 15%. The next year, Schwarzer and others established the prevalence in older, non-injured, rheumatology patients was 40%. An article by Manchikanti et al in 2001, he showed facet joint pain to be the most common cause for chronic low back pain with a prevalence in a heterogeneous group of patients of 40%. There are no clinical features that allow a physician to accurately predict that pain in a patient with back pain arises from the facet joint (Manchikanti et al. The inability of the clinical picture to characterize pain from facet joints. Pain Physician 2000; 3: 158-166). The only accurate method of diagnosing the condition is positive response to MBB (Dreyfuss P et al. Specificity of lumbar medial branch and L5 dorsal ramus blocks; a computed tomographic study. Spine 1997; 22:895-902). Although clinical features cannot be used to accurately diagnose the condition, there are certain clinical features that increase the likelihood of zygapophysial joint pain being positive. When these features are present, as in this patient, we recommend proceeding with diagnostic MBB once the patient has failed attempts at conservative management.

 

Lumbar Medial Branch Block
Lumbar refers to the area of the back that is situated between the lowest ribs and the pelvis (L1-L5).

What is a Medial Branch? Facet joints are innervated, or “supplied,” by nerves called “medial branches.” These nerves carry the pain signals to the spinal cord and the signals eventually reach the brain, where the pain is noticed.

What is the purpose of it? If the nerves are “blocked” or “numbed”, they will not be able to carry pain sensation to the spinal cord. It is like temporarily cutting the “wires”. Therefore, if the pain is due to facet joint arthritis, you should have relief from pain and stiffness.

Once it is determined that the pain is indeed due to facet joint disease, we can use a procedure called “Radio-Frequency Lesioning” and prevent the conduction of pain information for several weeks to months. So, in a way, medial branch block is a temporary and diagnostic procedure.

How long does the injection take? The actual injection takes only a few minutes. The more nerves that need to be blocked, the more time it takes.

What is actually injected? The injection consists of a local anesthetic (like lidocaine or bupivacaine).

Will the injection hurt? The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”). Therefore, there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle before inserting the needle into the joint.

Will I be “put out” for this procedure? No. This procedure is done under local anesthesia. The amount of sedation given generally depends upon the patient’s tolerance.

How is the injection performed? It is done either with the patient lying on the stomach for the upper and low back pain, or for the cervical (neck area) injections – lying on the back, under x-ray control. The patients are monitored with EKG, blood pressure cuff and blood oxygen-monitoring device. The skin on the back is cleaned with antiseptic solution and then the injection is carried out.

What should I expect after the injection? Immediately after the injection, you may feel that your pain may be less, or gone. This is due to the local anesthetic injected. This may last only for a few hours. Your pain will return and you may have a “sore back or neck” for a day or two. This is due to the mechanical process of needle insertion. It is very important for you to keep a track of your pain and stiffness for the next 2 to 12 hours following injections. Your response to the injections will determine if the facets are the cause of your pain or not.

What should I do after the procedure? You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. You may want to apply ice to the affected area. Perform your usual activities as tolerated.

Can I go to work to work the next day? Unless there are complications, you should be able to return to your work the next day. The most common thing you may feel is sore back.

How long does the effect of the medication last? The immediate effect is from the local anesthetic injected. Depending upon the medication injected, it can last from 1 hour to 8 hours. Of course, if the facet joints are not the source of your pain, you may not have much relief.

How many injections do I need to have? Usually one session is enough to determine if the facet joints are the most likely source of your pain or not. However, the “placebo response” can be as high as 30 to 40 % and a second, repeat, diagnostic injection is done to reduce the rate of “false positives” significantly, and so making the more long term procedure (radiofrequency lesioning) more likely to be successful.

Will the procedure help me? If the pain is originating mostly from the facet joints, you should benefit from this procedure on a temporary basis. Some do get a “placebo response” and others may get a “False-Positive” response. Please remember that these are diagnostic injections only and last only for a few hours. These are done to determine if the pain is coming from the facet joints or not, and if the pain is coming from the facet joints, we will recommend “Radio-Frequency Lesioning” – which can “numb” the same nerves for many months to one year or more.

What are the risks and side effects? Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain – which is temporary. The other risks involve, infection, bleeding, worsening of symptoms, spinal block, epidural block etc. Fortunately, the serious side effects and complications are uncommon.

Who should not have this injection? If you are allergic to any of the medications to be injected, if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid), or if you have an active infection going on near the injection site, you should not have the injection.

 

Lumbar Radio Frequency Lesioning
Lumbar refers to the area of the back that is situated between the lowest ribs and the pelvis (L1-L5). After a patient has undergone the proper diagnostic tests (nerve block injections), our doctors educate our patients about radio frequency lesioning—a procedure that typically results in 6-18 months of pain relief (on average a year or more). Using high-frequency radio waves and heat, our physicians pulse the pain generating nerve. Through this process, the pain sensory on the nerve is de-activated. The nerve is still functioning, but there is no more pain. Most insurance companies will cover this treatment at least once a year. “Many conditions can be treated by simply targeting the painful nerve and treating it with our radio frequency procedures. Thanks to these medical advances, we can offer effective treatments without the risk and recovery time of surgery,’” says Dr. Richard Rosenthal, the medical director of Nexus Paincare.

 

Lumbar Degenerative Disc Disease
Lumbar refers to the area of the back that is situated between the lowest ribs and the pelvis (L1-L5). The disc is the structure in the spinal column that supports weight and allows flexibility of the spine. Over time, the discs can wear out. This places stress on associated structures like the facet joints and nerve roots at the level of wear. Oftentimes, patients with degenerative disc disease complain of pain in the back, hip, and groin that gets worse with twisting or bending backwards. They may also experience a burning pain in the legs that gets worse with walking. This occurs when the nerve at the degenerative level gets pinched.

Degenerative disc disease, sometimes called spondylosis, results in the wearing down of individual discs in the spine. This disease is caused by trauma, infection, or the natural process of aging. As the disease progresses, most patients feel back and/or leg pain.

 

Lumbar Disc Disruption Syndrome
Lumbar refers to the area of the back that is situated between the lowest ribs and the pelvis (L1-L5).

The lumbar intervertebral disc is known to contain nociceptors (pain receptors) which are most numerous in the posterolateral portion of the disc. With age and wear, the disc develops radial fissures and annular tears extending into the outer third of the annulus fibrosis. The nociceptive fibers within the disc and the surrounding structures (such as the posterior longitudinal ligament) respond to both mechanical and chemical stimuli by sending pain impulses into the spinal cord via the dorsal root ganglion. This leads to chronic stimulation of the dorsal root ganglion causing chronic low back pain. Clinically, the pain is characterized as a constant aching sensation, which increases with sitting. Patients often report a sitting tolerance of less than thirty minutes. Standing in one place can also be painful, but walking usually is not. The pain may radiate onto the buttocks, hips, legs, and usually above the knee. The patient will not have radicular symptoms unless the disc has ruptured with nuclear material spilling out onto the associated nerve root. Therefore, the pain of internal disc disruption is, by definition, non-dermatomal. The prevalence of the syndrome is thought to be about 40% of patients with chronic low back pain. A small portion of these patients will improve with conservative measures. For the remainder, no definitive treatment has been clearly established within the medical literature, though precutaneous disc decompression and IDET are being used as minimally invasive techniques to avert surgery.

 

Lumbar Internal Disc Disruption
Lumbar refers to the area of the back that is situated between the lowest ribs and the pelvis (L1-L5). Internal Disc Disruption (IDD) is a condition that occurs when a spinal disc is ripped or torn, exposing nerve endings. This causes a disruption of the internal structure of the disc and usually results in back and lower limb pain. X-rays and MRIs typically show a “normal” spine. Only after proper testing, is this condition diagnosed. The specialists at Nexus Paincare have many treatment options for patients who suffer from IDD.

 

Discogram or Discography
What is Discography? Discography is a diagnostic procedure in which x-ray dye (x-ray contrast) is injected into the discs of the spine. After the x-ray dye is injected, an x-ray (called a “discogram”) is taken of the discs. The discogram may be normal or may show tears (fissures) in the lining of the disc. The results of discography are used to plan surgery or IDET (intradiscal electrothermal ) treatment.

What is the purpose of Discography? Discography is done to answer the questions “Is my back pain or neck pain from a degenerated disc?” and “Which discs -if any- are causing my pain?”

How do I know if my pain is from a damaged disc? With age or from an injury, the wall of the spinal discs can get cracks or tears (fissures). This condition is call Internal Disc Disruption or Degenerative Disc Disease. Also, the wall of the disc can weaken and bulge out (a herniated disc). When the disc causes pain, the pain is usually felt as a deep, aching pain in the back and sometimes in the buttocks and into the thigh. However, pain from facet joints in the back and from the sacroiliac joints (SI joints) can be in the same location and feel the same. The best way to tell if the pain is from a damaged disc is with discography.

How is Discography performed? The procedure is done in the Operating Room with fluoroscopic (x-ray) guidance. For lumbar discography (discs in the low back), it is done with you lying on your stomach. For cervical discography (discs in the neck), it is usually done with you lying on your back.There will be an anesthesiologist or a nurse present during the procedure to monitor you and administer intravenous sedation to help you be comfortable and relaxed. You are watched closely with an EKG monitor, blood pressure cuff and blood oxygen-monitoring device. The skin over the injection site(s) is cleaned with an antiseptic solution and then the injections are carried out. After the injection, you are placed on your back or on your side.

What will I feel during the injection? When a normal disc is injected, you will feel a sense of pressure, but not pain. When an abnormal disc is injected, you will feel pain. It is important to try to tell if the pain you are feeling is your usual pain or different. With each disc injected, you will be asked if it is painful, where you feel the pain and whether it is in the same area as your usual pain.

How many discs will be injected? Based on your symptoms and your MRI, we will identify which discs we suspect are causing your pain. These discs will be injected. In addition, we inject a normal disc to serve as a reference point.

How long does Discography take? Discography takes about 30 minutes, depending on how many levels are injected.

What is actually injected? The injection consists of x-ray dye (x-ray contrast). It is usually mixed with some antibiotics to prevent infection.

Will the injections hurt? The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”), so there is some discomfort involved. However, your doctor will numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the needle into the disc. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easy to tolerate.

You may have a flare-up of your back pain after the injection, but this gets better in a day or two and can usually be managed with ice packs and oral pain medication.

Will I be “put out” for this procedure? No. This procedure is done under local anesthesia. Injection of a medicine like Novocaine-Lidocaine is performed to numb the skin. Most of the patients also receive intravenous sedation and analgesia, to help them relax and make the procedure easier to tolerate. The amount of sedation given depends upon the patient. You can be sleepy while the needles are placed, but during the discogram injections, you need to be awake enough to tell the doctor what you are feeling.

Will my pain be better after the injection? No. Discography does not treat your condition. It is a diagnostic test that allows your doctors to plan your therapy.

What should I do after the procedure? You will a ride home. We advise the patients to take it easy for a day or so after the procedure. You may need to apply ice to the affected area for 20-30 minutes at a time for the next day. Perform the activities as tolerated by you. Can I go to work to work the next day? We usually recommend taking 2-3 days off work after the injection.

What are the risks and side effects of discography? Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain , which is temporary. Sometimes, the discogram needle brushes past a nerve root and the nerve root is irritated. This pain almost always gets better quickly. The other risks involve infection, bleeding, and worsening of symptoms. Fortunately, the serious side effects and complications are uncommon. Who should not have this procedure? If you are allergic to any of the medications to be injected, if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid), or if you have an active infection going on, you should not have the procedure. You should not have discography if you have not tried simpler treatments such as activity restriction and anti-inflammatory medications.

 

Sacroiliac (SI) Joint Dysfunction
The sacroiliac joint lies next to the spine and connects the lower portion of the spine with the pelvis. A dysfunction in the SI joint can result in low-back, hip and leg pain. SI joint discomfort is very common and can be easily diagnosed and treated with a simple injection.

 

Sacroiliac (SI) Joint Injection
What is a Sacro-Iliac Joint Injection? Sacro-Iliac Joint Injection is an injection of long lasting steroid (“cortisone”) in the Sacro-Iliac joints – which are located in the low back area.

What is the purpose of it? The steroid injected reduces the inflammation and/or swelling of tissue in the joint space. This may in turn reduce pain, and other symptoms caused by inflammation / irritation of the joint and surrounding structures.

How long does the injection take? The actual injection takes only a few minutes.

What is actually injected? The injection consists of a mixture of local anesthetic (like lidocaine or bupivacaine) and the steroid medication (Betamethasone – Dexamethasone – Depo-medrol).

Will the injection hurt? The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”). So, there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the needle into the joint.

Will I be “put out” for this procedure? No. This procedure is done under local anesthesia. The amount of sedation given generally depends upon the patient tolerance.

How is the injection performed? It is done with the patient lying on the stomach, under x-ray control. The patients are monitored with EKG, blood pressure cuff and blood oxygen-monitoring device. The skin in the back is cleaned with antiseptic solution and then the injection is carried out. After the injection, you are brought to a sitting position.

What should I expect after the injection? Immediately after the injection, you may feel that your pain may be gone or quite less. This is due to the local anesthetic injected. This will last only for a few hours. Your pain will return and you may have a “sore back” for a day or two. This is due to the mechanical process of needle insertion as well as initial irritation form the steroid itself. You should start noticing pain relief starting the 5th day or so.

What should I do after the procedure? You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. You may want to apply ice to the affected area. Perform the activities as tolerated by you.

Can I go to work to work the next day? Unless there are complications, you should be able to return to your work the next day. The most common thing you may feel is a sore back.

How long will the effect of the medication last? The immediate effect is usually from the local anesthetic injected. This wears off in a few hours. The cortisone starts working in about 5 to 7 days and its effect can last for several days to months.

How many injections do I need to have? If the first injection does not relieve your symptoms in about a week to two weeks, you may be recommended to have one more injection. If you respond to the injections and still have residual pain, you may be recommended for a third injection

Can I have more than three injections? In a six-month period, we generally do not perform more than three injections. This is because the medication injected lasts for about six months. If three injections have not helped you much, it is very unlikely that you will get any further benefit from more injections. Also, giving more injections will increase the likelihood of side effects from cortisone.

Will the Sacro-Iliac Joint Injection help me? It is very difficult to predict if the injection will indeed help you or not. Generally speaking, the patients who have recent onset of pain may respond much better than the ones with a long standing pain.

What are the risks and side effects? Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain – which is temporary. The other risks involve, infection, bleeding, worsening of symptoms etc. The other risks are related to the side effects of cortisone: These include weight gain, increase in blood sugar (mainly in diabetics), water retention, suppression of body’s own natural production of cortisone etc. Fortunately, the serious side effects and complications are uncommon.

Who should not have this injection? If you are allergic to any of the medications to be injected, if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid), or if you have an active infection going on near the injection site, you should not have the injection.

 

Sacroiliac (SI) Joint Syndrome
The sacroiliac joint lies next to the spine and connects the lower portion of the spine with the pelvis. This term refers to a constellation of symptoms in a low back pain patient including pain in the back, buttock, groin and lower extremity. Accurate diagnosis requires anesthetizing the target joint and determining if the patient has concordant relief of pain. SI joint syndrome is easily treatable.

 

Sacroiliac (SI) Joint Radio Frequency Lesioning 
The sacroiliac joint lies next to the spine and connects the lower portion of the spine with the pelvis.

After a patient has undergone the proper diagnostic tests (nerve block injections), our doctors educate our patients about radio frequency lesioning—a procedure that typically results in 12-24 months of pain relief.

Using high-frequency radio waves and heat, our physicians pulse the pain generating nerve. Through this process, the pain sensory on the nerve is de-activated. The nerve is still functioning, but there is no more pain. Most insurance companies will cover this treatment at least once a year.

“Many conditions can be treated by simply targeting the painful nerve and treating it with our radio frequency procedures. Thanks to these medical advances, we can offer effective treatments without the risk and recovery time of surgery,’” says Dr. Richard Rosenthal, the medical director of Nexus Paincare.

Once the procedure has been completed, our physicians usually recommend a course of physical therapy to prevent recurrence of the condition.

Capsaicin Cream
Capsaicin is the active ingredient in chili peppers that produces heat. In its purified form it is a crystalline alkaloid that is a key ingredient in medicinal cream. Capsaicin cream has proven effective in treating chronic pain. It appears to interfere with chemicals that facilitate pain messages to the brain. Capsaicin has a hyperemic effect, which means that it increases blood flow similar to when an area is inflamed. When applied to the skin in cream form, the area becomes red, warm, and may become slightly swollen. Many individuals experience a localized burning sensation when a cream containing capsaicin is applied to the skin. However, with repeated use, the burning sensation usually disappears, and pain relief is noted. The burning or stinging sensation may last a few weeks for some. Capsaicin appears to work through a mechanism that initially causes a hypersensitivity to pain, and then ends in pain relief.

Postherpetic Neuralgia
Post herpetic neuralgia is pain that persists after a patient has had shingles and the rash has gone away. This continued burning sensation can linger for quite some time, making life extremely uncomfortable. There are several treatments that the doctor can perform to help reduce or eliminate this painful condition. Without treatment, the burning pain may be life-long.

Shingles
Shingles is a disorder caused by the herpes zoster virus, (the same virus that causes chickenpox during childhood). Shingles is onset when this virus comes out of dormancy. Anyone who has had chickenpox is susceptible to shingles, but particularly older people and those who are under physiological stress.

Shingles causes a burning pain that is likely a result from the destruction of the nerve fibers and reduced blood flow to the nerves.

Most of the time, patients with shingles are given medication to make the pain more tolerable. Medications often cause dizziness and loss of balance, which can result in falls for older people.

There are other options besides medication. Nerve blocks can effectively reduce the pain from shingles. A nerve block injection helps to re-establish the normal blood flow to the nerves. The normal blood flow helps control the pain and helps the rash to heal faster. Nerve blocks also aid in preventing the development of postherpetic neuralgia—a condition in which the burning pain continues after the rash has healed.

Receiving nerve block treatments can help shingles patients heal faster and have a higher level of comfort.

Ligament Injection
Both tendons and ligaments have a nerve supply and can be a source of pain. A ligament injection is used to diagnose and sometimes treat painful conditions that arise from a ligament.

Myofascial Pain Syndrome
Myofascial pain syndrome (MPS) is a chronic pain sensation in the head and face area—originating in muscles, similar to fibromyalgia. MPS is sometimes the result of an injury In order to arrive at this diagnosis, the patient must exhibit the following criteria: 1) The complaint must be regional in nature. 2) The pain or altered sense of sensation must follow the expected distribution of referred pain from the myofascial trigger point. 3) Tight band palpable in the affected musculature. 4) Presence of exquisite point tenderness at one point along the length of the taut muscular band. 5) Restricted ROM to the affected area. 6) The patient’s pain must be reproducible by applying pressure to the trigger point. 7) Presence of the jump sign by transverse snapping palpation or insertion of a needle into the trigger point. 8) Alleviation of pain with stretching or injecting into the trigger point.

Trigger Point Injection
Trigger points are commonly seen in “Myofascial Pain Syndrome.” Trigger points are “knotty” areas or bands in muscle tissue. Trigger Point Injections (TPI) are sometimes given for neck pain, headaches, and low back to treat muscle spasm and other soft tissue problems. Typically a low dose of anesthetic medication is injected into the trigger point(s) after careful examination. This is a simple “in office procedure” and can give excellent relief for headaches of myofascial origin and soft tissue damage. A mixture of lidocaine and marcaine is injected into the muscle trigger point, which helps to relieve muscle spasms. Trigger Point Injections are not painful, and may be repeated on an occasional basis.

ASTYM
ASTYM is a physical therapy technique used to help in the remodeling of new collagen at the local inflammation site to increase stretching, strengthening and functional activities. This has been demonstrated to be of benefit in many inflammatory conditions such as patellar tendonitis, plantar fasciitis, lateral epicondylitis, tibial fasciitis. ASTYM can cause bruising or discolorations which can be tender to the touch following treatment and may require multiple applications. Anticipated response may require 2-3 treatments. Usually, the pain associated with ASTYM will decrease over time. However, the pain may increase before it gets better and it is very important to keep stretching to the point of pull but not pain, as directed by the physical therapist.

Fibromyalgia
Fibromyalgia is a syndrome characterized by chronic pain in the muscles and soft tissues surrounding joints, fatigue, and tenderness at specific sites in the body. Also called fibromyalgia syndrome, fibromyositis, fibrositis.

Intraarticular Hip Injection
Pain in the hip that is associated with wear of the joint can sometimes be helped by injection of an anti-inflammatory into the joint capsule.

Intraarticular Knee Injection
Pain in the knee that is associated with wear of the joint can sometimes be helped by an injection of an anti-inflammatory medication into the joint capsule. Our physicians will usually inject a steroid into the knee. If good results are noticed, a follow-up injection series of Synvisc will be considered. Synvisc typically provides longer term pain relief. This medication acts as an artificial cartilage—it helps to lubricate the joint.

Intraarticular Shoulder Injection
Pain in the shoulder that is associated with wear of the joint can sometimes be helped by injection of an anti inflammatory in the joint capsule

Subacromial Bursa Injection
This is an injection used to treat shoulder pain. A bursa is fluid filled bag that protects tendons from getting rubbed at the point where they slide across the bone. Sometimes they get inflamed and cause pain.

Synvisc Injection
Synvisc is a medication that is injected into joints (most commonly into the knees). It acts as lubricant for the joint. This simple procedure is done in a series of three injections. Synvisc typically provides patients with months of pain relief.

Iliohypogastric Nerve Block
A nerve block is a diagnosing tool that helps our doctors to know exactly which nerves are causing our patients to feel pain.  Our doctors use a live x-ray-type machine (flouroscopy) to see the patients’ bone structures.  They are often able to tell, based on the patients’ description, the general area where the pain is being generated.  Our physicians select the nerve that is likely the cause of the pain.  That nerve is temporarily numbed with lidocaine (the same numbing medication dentists use).

If the patient feels relief for a few hours before the lidocaine effects wear off, then the doctor can likely conclude that the pain generating nerve has been correctly identified.  This process is repeated another time, just to assure that the pain relief was not a placebo effect.  After two successful nerve blocks, our physicians educate our patients and move on to a more permanent treatment that will likely produce pain relief for 12-24 months—radio frequency lesioning.

Ilioinguinal Nerve Neurolysis
Neurolysis refers to the breaking down or destruction of nerve tissue—especially as the result of a disease. The ilioinguinal nerve is a branch of the first lumbar nerve that is distributed to the muscles of the anterolateral wall of the abdomen, to the skin of the proximal and medial part of the thigh, and to the base of the penis and the scrotum in the male or the mons veneris and labia majora in the female. Thus Ilioinguinal nerve nuerolysis is the destruction of such nerve via chemical (via phenol) or electromagnetic (radiofrequency) means to alleviate pain in such area.

Ilioinguinal Nerve Phenol Injection
The ilioinguinal nerve is a branch of the first lumbar nerve that is distributed to the muscles of the anterolateral wall of the abdomen, to the skin of the proximal and medial part of the thigh, and to the base of the penis and the scrotum in the male or the mons veneris and labia majora in the female.

Sometimes, after hernia surgery, patients can develop a burning pain in the distribution of this nerve that is constant and does not heal.  This injection is then used to treat the pain.

Ilioinguinal Nerve Radio Frequency
The ilioinguinal nerve is a branch of the first lumbar nerve that is distributed to the muscles of the anterolateral wall of the abdomen, to the skin of the proximal and medial part of the thigh, and to the base of the penis and the scrotum in the male or the mons veneris and labia majora in the female.

After a patient has undergone the proper diagnostic tests (nerve block injections), our doctors educate our patients about radio frequency lesioning—a procedure that typically results in 12-24 months of pain relief.

Using high-frequency radio waves and heat, our physicians pulse the pain generating nerve. Through this process, the pain sensory on the nerve is de-activated. The nerve is still functioning, but there is no more pain. Most insurance companies will cover this treatment at least once a year.

“Many conditions can be treated by simply targeting the painful nerve and treating it with our radio frequency procedures. Thanks to these medical advances, we can offer effective treatments without the risk and recovery time of surgery,’” says Dr. Richard Rosenthal, the medical director of Nexus Paincare.

Ilioinguinal Neuralgia
The ilioinguinal nerve is a branch of the first lumbar nerve that is distributed to the muscles of the anterolateral wall of the abdomen, to the skin of the proximal and medial part of the thigh, and to the base of the penis and the scrotum in the male or the mons veneris and labia majora in the female.

Neuralgia is a painful sensation that extends along the course of one or more nerves.

Meralgia Paresthetica
Meralgia paresthetica refers to the entrapment or pinching of the nerve that supplies feeling to the upper outer part of the thigh. This can be caused by trauma or direct pressure. Patients typically complain of a burning sensation or numbness in the lateral thigh. Oftentimes, this condition simply goes away with time.

Meralgia Paresthetica, was first described in 1878. This condition is considered to be due to either compression or injury to the lateral femoral cutaneous nerve near the anterior superior iliac spine as it passes through or under the ilioinguinal ligament. It is thought that the erect human posture, combined with the course of the lateral femoral cutaneous nerve causes tension, mechanical friction, and irritation of the nerve. These factors contribute to the development of pseudoganglion which is thought to play a role in the pathogenesis of Meralgia Paresthetica.

Lat Fem Cut Nerve Block
This injection helps diagnose and sometimes treat a condition in which a nerve gets pinched in the front of the hip. Patients with thie condition complain of burning pain on the outside of the thigh.

Paresthesias (burning pain) or hypesthesias (numbness and tingling) over the upper outer thigh is the classic presentation of meralgia paresthetica (MP). Often, discomfort can be exacerbated by valsalva maneuvers, or any other activity that increases intra-abdominal pressure. Neurologic symptoms are restricted to sensory changes since the lateral femoral cutaneous nerve does not contain motor fibers. Sensory loss is quite discrete, and it is often possible to clearly demarcate the area of numbness. The patient often rubs the outer thigh when describing the symptoms

For classic MP, conservative therapy may be initiated without the necessity for invasive procedures. The diagnosis can be verified by injecting a small quantity of lidocaine at the point of their intersection or at the point of tenderness. The discomfort should resolve transiently. Nerve conduction studies also help diagnose the condition.

MP is treated with conservative therapy, such as physical therapy, weight reduction to reduce abdominal girth, heat application, and analgesics. Patients should avoid wearing constrictive garments, belts, or braces that impart excessive focal pressure at the inguinal ligament. Patients failing conservative measures are referred to a surgeon for consideration of surgical decompression of the LFCN.

Occipital Neuralgia
Occipital neuralgia is described as a chronic pain in the occipital nerve—located at the back of the head near the base of the skull. This is often the result of an injury. The diagnosis and/or treatment for this condition is an occipital nerve block.

By International Headache Society criteria, occipital neuralgia is relieved by local anesthetic blockade of the involved occipital nerve; thus, the principle indication for occipital block is diagnosis. Another indication is the treatment of chronic occipital neuralgia, often with a series of therapeutic blocks combined with depot corticosteroids. Due to the preservatives included in the steroid, it is believed that a mild degree of neurolysis may result and contribute to the prolongation of pain relief. One must remember that the potential interneuron connections with the upper spinal cord may allow occipital nerve (C2) pain to be referred to the trigeminal distribution; this is due to the proximity of the C2 root to the trigeminal spinal nucleus. Thus, occipital block may relieve pain outside of the typical C2 distribution but within the trigeminal distribution.

Occipital Nerve Block
This treatment is used to provide patients with relief from chronic migraine headache pain that originates in the back of the head. The occipital nerve is located at the back of the head near the base of the skull.

A nerve block is a diagnosing tool that helps our doctors to know exactly which nerves are causing our patients to feel pain. Our doctors use a live x-ray-type machine (flouroscopy) to see the patients’ bone structures. They are often able to tell, based on the patients’ description, the general area where the pain is being generated. Our physicians select the nerve that is likely the cause of the pain. That nerve is temporarily numbed with lidocaine (the same numbing medication dentists use).

If the patient feels relief for a few hours before the lidocaine effects wear off, then the doctor can likely conclude that the pain generating nerve has been correctly identified. This process is repeated another time, just to assure that the pain relief was not a placebo effect. After two successful nerve blocks, our physicians educate our patients and move on to a more permanent treatment that will likely produce pain relief for 12-24 months—radio frequency lesioning.

Auriculotemporal Neuralgia
Neuralgia is a painful sensation that extends along the course of one or more nerves.

The auriculotemporal nerve is part of the mandibular nerve. It passes through the parotid gland and ends in the skin of the temple/scalp. There are communicating branches of the auriculotemporal nerve that send messages to the facial nerves. Headaches and facial related pain may originate in the auriculotemporal nerve.

Therefore, auriculotemporal neuralgia is pain that originates in the auriculotemporal area—headache, face, or jaw pain.

Auriculotemporal Nerve Block
The auriculotemporal nerve is part of the mandibular nerve. It passes through the parotid gland and ends in the skin of the temple/scalp. There are communicating branches of the auriculotemporal nerve that send messages to the facial nerves. Headaches and facial related pain at the temples may originate in the auriculotemporal nerve.

A nerve block is a diagnosing tool that helps our doctors to know exactly which nerves are causing our patients to feel pain. Our doctors use a live x-ray-type machine (flouroscopy) to see the patients’ bone structures. They are often able to tell, based on the patients’ description, the general area where the pain is being generated. Our physicians select the nerve that is likely the cause of the pain. That nerve is temporarily numbed with lidocaine (the same numbing medication dentists use).

If the patient feels relief for a few hours before the lidocaine effects wear off, then the doctor can likely conclude that the pain generating nerve has been correctly identified. This process is repeated another time, just to assure that the pain relief was not a placebo effect. After two successful nerve blocks, our physicians educate our patients and move on to a more permanent treatment that will likely produce pain relief for 12-24 months—radio frequency lesioning.

Auriculotemporal Radio Frequency
The auriculotemporal nerve is part of the mandibular nerve. It passes through the parotid gland and ends in the skin of the temple/scalp. There are communicating branches of the auriculotemporal nerve that send messages to the facial nerves. Headaches and facial related pain may originate in the auriculotemporal nerve.

After a patient has undergone the proper diagnostic tests (nerve block injections), our doctors educate our patients about radio frequency lesioning—a procedure that typically results in 12-24 months of pain relief.

Using high-frequency pulsed radio waves, our physicians pulse the pain generating nerve. Through this process, the chronic pain sensory nerve fibers on the nerve is de-activated. The nerve is still functioning, but there is no more pain. Most insurance companies will cover this treatment at least once a year.

“Many conditions can be treated by simply targeting the painful nerve and treating it with our radio frequency procedures. Thanks to these medical advances, we can offer effective treatments without the risk and recovery time of surgery,’” says Dr. Richard Rosenthal, the medical director of Nexus Paincare.

Suprascapular Nerve Block
Suprascapular refers to the nerve located above the scapula, or shoulder blade. By turning off this nerve, pain from a rotator cuff tear can be eliminated.

A nerve block is a diagnosing tool that helps our doctors to know exactly which nerves are causing our patients to feel pain. Our doctors use a live x-ray-type machine (flouroscopy) to see the patients’ bone structures. They are often able to tell, based on the patients’ description, the general area where the pain is being generated. Our physicians select the nerve that is likely the cause of the pain. That nerve is temporarily numbed with lidocaine (the same numbing medication dentists use).

If the patient feels relief for a few hours before the lidocaine effects wear off, then the doctor can likely conclude that the pain generating nerve has been correctly identified. This process is repeated another time, just to assure that the pain relief was not a placebo effect. After two successful nerve blocks, our physicians educate our patients and move on to a more permanent treatment that will likely produce pain relief for 12-24 months—radio frequency lesioning.

Tibial Neuralgia
The tibial nerve provides sensation to parts of the foot. It can sometimes get damaged and cause a constant burning pain Neuralgia is a painful sensation that extends along the course of one or more nerves.

Ulnar Neuralgia
The ulnar nerve provides sensation to parts of the foot. It can sometimes get damaged and cause a constant burning pain Neuralgia is a painful sensation that extends along the course of one or more nerves.

Electrodiagnostic testing (EMG and nerve conduction studies) 
What are EMG and nerve conduction studies?
This testing is used to record the electrical activity of nerves and muscles. The test is done to evaluate how your nerves and muscles are functioning.

This testing can be used to detect abnormal nerve or muscle electrical activity that can occur in many diseases and conditions including muscular dystrophy, inflammation of muscles, pinched nerves, peripheral nerve damage (damage to nerves in the arms and legs), amyotrophic lateral sclerosis (ALS) (also known as Lou Gehrig disease), as well as many other conditions.

Why is an electrodiagnostic test done?
This testing is most often performed when patients have unexplained muscle weakness, numbness, or pain. The testing helps to distinguish between various nerve or muscle disorders that you may have.

Are there any risks or side effects associated with this test?
There may be some mild temporary soreness or bruising but typically this is minimal.

How do I prepare for the test?

Do not use lotions on the hands or feet that are being tested on the day of the testing.  If testing is being done on hands, please remove jewelry if possible. You may eat before the test. You may continue to take medications as usual.

What happens before the test?
There is usually a brief physical exam before the test

How long does it take?
This varies depending on the situation but the testing typically takes about an hour to complete.

How is it done?
It is done by different techniques. Small electrical stimuli are administered to different nerves and their response is analysed. To test muscle function, a very small disposable needle (an electrode) is inserted in your muscles, and electrical activity is recorded. These data are analysed by the doctor doing your test.

What will I feel?
The electrical stimulation feels like an electrical shock.  You may experience some discomfort when the needle is inserted into each of the muscles to be tested.

Will I be “put out” for the procedure?
No this procedure is done with your participation, there are no medications used to put you to sleep. You will be fully awake through out the procedure.  Though many people undergo testing without any medication, your doctor (at your request) may prescribe medication for pain to be taken at the time of testing or medication for anxiety to be taken at the time of testing.                                                                                                                                                  
Will the procedure help me? How?
Yes. In order to better treat you, your doctor needs to know what is causing your symptoms. The test information allows your doctor to better choose an appropriate treatment more specific to you and your needs.

How many EMGs do I need to have?

Usually just one. However there are occasional exceptions when a second EMG may be required.

Can I go to work the same day? The next day?
Typically you should be able to immediately return to your work. If prior to the testing , you were given a prescription for medication to be taken at the time of testing, then returning to work may be difficult because of that medication.  As stated above, taking medication during the testing is optional.

Who should not have this test done?
The most common reasons not to have the test done are concurrent infection, a bleeding disorder or if you are taking a blood thinning medication, such as, coumadin, lovenox, etc.

Will I be able to drive myself home following this test?
Typically you should be able to drive following the testing.  However, if you have elected to have medications for anxiety or pain in conjunction with the testing, then you should not drive and will need to have a driver come with you to the testing.

Is anything injected into my body?
No. Nothing is injected into your body.  .

What happens after the test?
You may return home unless given other instructions.

How will I receive the results of my test? 
The doctor who ordered your test will explain the results at your following visit. (please allow a few days for them to receive the results)

Epidural Blood Patch
Epidural blood patches are done to relieve headache pain that may rarely occur after spinal injections.  In an epidural blood patch procedure, the doctor will inject some of the patients’ own blood into the epidural space.  The epidural space refers to a potential space between layers of the covering of the spinal cord.

Epidural Steroid Injection

What is an Epidural Steroid Injection?
ESI – The epidural steroid injection is the placement of cortisone, a powerful anti-inflammatory agent, into the epidural space to relieve pain caused by irritated nerves and discs.

How long does the injection take?
The actual injection takes only a few minutes.

What is actually injected?
The injection consists of a mixture of local anesthetic (like lidocaine or bupivacaine) and the steroid medication (triamcinolone – Aristocortor methylprednisolone – Depo-medrol).

Will the injection hurt?

The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”). So, there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the Epidural needle. Also, the tissues in the midline have less nerve supply, so usually you feel strong pressure and not much pain.

Will I be “put out” for this procedure?
No. This procedure is done under local anesthesia.

How is the injection performed?
It is done either with the patient sitting up or on the side, or on your stomach. The skin in the back is cleaned with antiseptic solution and then the injection is carried out.

What should I expect after the injection?
Immediately after the injection, you may feel that your legs are slightly heavy and may be numb. Also, you may notice that your pain may be gone or quite less. This is due to the local anesthetic injected. This will last only for a few hours. Your pain will return and you may have a “sore back” for a day or two. This is due to the mechanical process of needle insertion as well as initial irritation form the steroid itself. You should start noticing pain relief starting the 3rd or 5th day or so.

What should I do after the procedure?
You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. Perform the activities as tolerated by you.

Can I go back to work the next day?
You should be able to unless the procedure was complicated. Usually you will feel some back pain or have a “sore back” only.

How long does the effect of the medication last?
The immediate effect is usually from the local anesthetic injected. This wears off in a few hours. The cortisone starts working in about 3 to 5 days and its effect can last for several days to a few months.

How many injections do I need to have?
If the first injection does not relieve your symptoms in about a week to two weeks, we may  recommend that you have one more injection. Similarly If the second injection does not relieve your symptoms in about a week to two weeks, you may be recommended to have a third injection.

Can I have more than three injections?
In a six month period, we generally do not perform more than three injections. This is because the medication injected lasts for about six months. If three injections have not helped you much, it is very unlikely that you will get any further benefit from more injections. Also, giving more injections will increase the likelihood of side effects from cortisone.

Will the Epidural Steroid Injection help me?
It is very difficult to predict if the injection will indeed help you or not. Generally speaking, the patients who have “radicular symptoms” (like sciatica) respond better to the injections than the patients who have only back pain. Similarly, the patients with a recent onset of pain may respond much better than the ones with a long standing pain. Also, the patients with back pain mainly due to bony abnormality may not respond adequately.

What are the risks and side effects?
Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain – which is temporary. The other risk involve spinal puncture with headaches, infection, bleeding, etc. The other risks are related to the side effects of cortisone. These include weight gain, increase in blood sugar (mainly in diabetics), water retention, suppression of body`s own natural production of cortisone etc.

Who should not have this injection?
If you are allergic to any of the medications to be injected, if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid), or if you have an active infection going on near the injection site, you should not have the injection.    Facet Joint
The cervical facet joints (or zygapophysial joints) are located in pairs in the back of the spine.  These nerves are roughly the size of a fingernail.  They help with motion and provide stability.  If these joints became aggravated, they can cause pain in several different areas—head, neck, shoulders, and arms.     Facet Joint Arthritis
This diagnosis is given to patients whose pain arises from the z- joints (zygapophysial joints), small joints located in the back of the spine.  These nerves are roughly the size of a fingernail.  They help with motion and provide stability.  If these joints became aggravated, they can cause pain in several different areas—head, neck, shoulders, and arms.

Arthritis is acute or chronic inflammation of a joint, often accompanied by pain and structural changes and having diverse causes, such as infection, crystal deposition, or injury.     Facet Joint Syndrome
This diagnosis is given to some patients who have an irritation of one or more joints in the spinal area.  Facet joints are pairs of joints (about the size of a finger nail) that are located on the back side of the spine at each disc level.  These joints add stability and help the spine from moving too far.  There are nerve endings both on the outside and inside of each of these joints.

Normal wear and tear, auto accidents, or other neck/back injuries can damage the facet joints, also known as zygapophysial joints.  When damaged, facet joints can result in headache, neck, and/or back pain.

Nexus Paincare has many different treatment options—depending on which area of the spine is causing pain.     Facet Joint Injection

What is a Facet Joint Injection?
Facet Joint Injection is an injection of long lasting steroid (“cortisone”) in the Facet joints – which are located in the back area, as a part of the bony structure.

What is the purpose of it?
The steroid injected reduces the inflammation and/or swelling of tissue in the joint space. This may in turn reduce pain, and other symptoms caused by inflammation / irritation of the joint and surrounding structures.

How long does the injection take?
The actual injection takes only a few minutes.

What is actually injected?

The injection consists of a mixture of local anesthetic (like lidocaine or bupivacaine) and the steroid medication (celestone or betamethasone or dexamethasone)

Will the injection(s) hurt?
The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”). So, there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the needle into the joint.

Will I be “put out” for this procedure?
No. This procedure is done under local anesthesia.

How is the injection performed?
It is done either with the patient lying on the stomach.  The entire procedure is done under live X-ray.   After the injection, you are placed on your back or on your side.

What should I expect after the injection?
Immediately after the injection, you may feel that your pain may be gone or quite less. This is due to the local anesthetic injected. This will last only for a few hours. Your pain will return and you may have a “sore back” for a day or two. This is due to the mechanical process of needle insertion as well as initial irritation form the steroid itself. You should start noticing pain relief starting the 5th day or so.

What should I do after the procedure?
You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. You may want to apply ice to the affected area. Perform the activities as tolerated by you.

Can I go to work to work the next day?
Unless there are complications, you should be able to return to your work the next day. The most common thing you may feel is sore back.

How long the effect of the medication lasts?

The immediate effect is usually from the local anesthetic injected. This wears off in a few hours. The cortisone starts working in about 5 to 7 days and its effect can last for several days to a few months.

How many injections do I need to have?
If the first injection does not relieve your symptoms in about a week to two weeks, you may be recommended to have one more injection. If you respond to the injections and still have residual pain, you may be recommended for a third injection.

Can I have more than three injections?
In a six-month period, we generally do not perform more than three injections. This is because the medication injected lasts for about six months. If three injections have not helped you much, it is very unlikely that you will get any further benefit from more injections. Also, giving more injections will increase the likelihood of side effects from cortisone.

Will the Facet Joint Injection help me?
It is very difficult to predict if the injection will indeed help you or not. Generally speaking, the patients who have recent onset of pain may respond much better than the ones with long standing pain.

What are the risks and side effects?

Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain – which is temporary. The other risks involve, infection, bleeding, worsening of symptoms, spinal block, Epidural block etc. The other risks are related to the side effects of cortisone: These include weight gain, increase in blood sugar (mainly in diabetics), water retention, suppression of body`s own natural production of cortisone etc. Fortunately, the serious side effects and complications are uncommon.

Who should not have this injection?
If you are allergic to any of the medications to be injected, if you are on a blood thinning medication (e.g. Coumadin), or if you have an active infection going on, you should not have the injection.

Failed Back Surgery Syndrome
This generalized term describes patients who have had back surgeries are and still feeling pain.  Some patients claim their back pain is worse after having back surgery, while others claim it is the same.  Depending on what type of back surgery a patient has previously had, our doctors can help create individualized treatment plans that will effectively provide our patients with pain relief.  Our physicians specialize in minimally invasive procedures—no operations.

 

Intrathecal Pump Implant (“Spinal Morphine Pump”)

What is an Intrathecal Pump Implant (“Spinal Morphine Pump”)?
An Intrathecal Pump is a specialized device, which delivers concentrated amounts of medication(s) into spinal cord area via a small catheter (tubing).

Am I a candidate for Intrathecal Pump Implant (“Spinal Morphine Pump”)?
The Intrathecal Pump is offered to patients with; Chronic and severe pain, who have not adequately responded to any other treatment modalities. Some of the examples may be failed back syndrome, cancer pain, RSD. However other options may still exist for these conditions that may be safer.

What is the purpose of it?
This device delivers concentrated amounts of medication into spinal cord area allowing the patient to decrease or eliminate the need for oral medications. It delivers medication around the clock, thus eliminating or minimizing breakthrough pain and/or other symptoms.

How long does the procedure take? 
It is done in two stages. In the first stage, a single injection is made to assess effectiveness and screen for unwanted side effects. If this trial is successful in relieving symptoms, then the permanent device is placed under the skin by a surgeon that you would be referred to. The patients have to meet certain other screening criteria before implanting the pump.

Will the procedure hurt?

The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”). So, there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the injection needle. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easier to tolerate.

Will I be “put out” for this procedure?
The placement of the tubing is done under local anesthesia with patients mildly sedated. The amount of sedation given generally depends upon the individual patient tolerance.

How is the procedure performed?
It is usually done with the patient lying on their side. Sometimes the tubing is placed with the patient sitting up. The patients are monitored with EKG, blood pressure cuff and blood oxygen-monitoring devices. The skin is cleaned with antiseptic solution and then the procedure is carried out. X-ray (fluoroscopy) is used to guide the needle for inserting the tubing.

Where is the tubing inserted? Where is the pump placed?
Tubing is inserted in the midline of the lower back. The pump is then placed on the side of the abdomen.

What should I expect after the procedure?
If the procedure is successful, you may feel that your pain may be controlled or at least better controlled. The pump is adjusted electronically to deliver an adequate amount of medication to optimize the pain control as safely as possible.

What should I do after the procedure?
This procedure is normally a day-surgery procedure and patients are kept overnight for observation and pump adjustment.

How long will the pumps last?
The medication contained within the pump will last about 1 to 3 months depending upon the concentration and amount infused. It is then refilled via a small needle inserted into the pump chamber. This is done in the office or at your home and it takes only a few minutes.The batteries in the pump may last 3 to 5 years depending upon the usage. The batteries can not be replaced or recharged. The pump is replaced at that time.
Will the Intrathecal Pump Implant (“Spinal Morphine Pump”) help me?
It is very difficult to predict if the procedure will help you or not. For that reason a trial is carried out to determine if a permanent device (pump) will be effective to relieve your pain or not.

What are the risks and side effects?
Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The pump itself has risks as well – Including, but not limited to; cessation of therapy due to end of device service life or component failure, change in flow performance due to component failure, inability to program the device due to programmer failure, CAP component failure; inaccessible refill port due to inverted pump, pocket seroma, hematoma, erosion, infection, post-lumbar puncture (spinal headache), CSF leak, radiculitis, arachnoiditis, bleeding, spinal cord damage, meningitis (intrathecal applications), anesthesia complications, damage to the pump, catheter and catheter access system due to improper handling and filling before, during, or after implantation; change in catheter performance due to catheter kinking, disconnection, leakage (which can result in overdose and death), breakage, occlusion, dislodgement, migration, or catheter fibrosis; body rejection phenomena, surgical replacement of pump or catheter due to complications; local and systemic drug toxicity and related side effects, complications due to use of unapproved drugs and/or not using drugs in accordance with drug labeling, or inflammatory mass at the tip of the catheter in patients receiving intraspinal morphine or other opioid drugs.

Who should not have this procedure?
When infection is present; when the pump cannot be implanted 2.5 cm or less from the surface of the skin; when body size is not sufficient to accept pump bulk and weight; when contraindications exist relating to the drug, such as an allergy, or if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid). Patients also have to meet certain other screening criteria before implanting the pump.

Where can I get additional information?
More detailed information is available from the manufacturer of this device. At the time of consultation you will receive a SynchromedInfusion System Patient Education Booklet. Additional information is also available at the MedtronicsWeb Site @ http://www.medtronics.com/neuro/apt/faq.html.

 

Medial Branch Block

What is a Medial Branch? 
Facet Joints are innervated or “supplied” by nerves called “medial branches”. These nerves carry the pain signals to the spinal cord and the signals eventually reach the brain, where the pain is noticed.

What is the purpose of it? 
If the nerves are “blocked” or “numbed”, they will not be able to carry pain sensation to the spinal cord. It is like temporarily cutting off “wires”. Therefore, if the pain is due to facet joint arthritis, you should have relief from pain and stiffness.
Once it is determined that the pain is indeed due to facet joint disease, we can use a procedure called “Radio-Frequency Lesioning” and prevent the conduction of pain information for several weeks to months.
So, in a way, medial branch block is a temporary and diagnostic procedure.

How long does the injection take? 
The actual injection takes only a few minutes. More nerves to be blocked, more time it takes.

What is actually injected? 
The injection consists of a local anesthetic (like lidocaine or bupivacaine).

Will the injection hurt? 
The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”). Therefore, there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle before inserting the needle into the joint.
Will I be “put out” for this procedure?
No. This procedure is done under local anesthesia. The amount of sedation given generally depends upon the patient’s tolerance.

How is the injection performed? 
It is done either with the patient lying on the stomach for the upper and low back pain, or for the cervical (neck area) injections – lying on the back, under x-ray control. The patients are monitored with EKG, blood pressure cuff and blood oxygen-monitoring device. The skin in the back is cleaned with antiseptic solution and then the injection is carried out.

What should I expect after the injection?
Immediately after the injection, you may feel that your pain may be gone or quite less. This is due to the local anesthetic injected. This may last only for a few hours. Your pain will return and you may have a “sore back or neck” for a day or two. This is due to the mechanical process of needle insertion. It is very important for you to keep a track of your pain and stiffness for the next 2 to 12 hours following injections. Your response to the injections will determine if the facets are the cause of your pain or not.

What should I do after the procedure?
You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. You may want to apply ice to the affected area. Perform your usual activities as tolerated.

Can I go to work to work the next day? 
Unless there are complications, you should be able to return to your work the next day. The most common thing you may feel is sore back.

How long does the effect of the medication last? 
The immediate effect is from the local anesthetic injected. Depending upon the medication injected, it can last from 2 hours to 8 hours. Of course, if the facet joints are not the source of your pain, you may not have much relief.

How many injections do I need to have? 
Usually one session is enough to determine if the facet joints are the most likely source of your pain or not. However, the “placebo response” can be as high as 30 to 40 % and some patients may be recommended to have repeated diagnostic injections. In addition, “False Positive” responses can occur.

Will the procedure help me? 

If the pain is originating mostly from the facet joints, you should benefit from this procedure on a temporary basis. Some do get a “placebo response” and others may get a “False-Positive” response. Please remember that these are diagnostic injections only and last only for a few hours. These are done to determine if the pain is coming from the facet joints or not, and if the pain is coming from the facet joints, we will recommend “Radio-Frequency Lesioning” – which will “numb” the same nerves for many weeks to months.

What are the risks and side effects? 
Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain – which is temporary. The other risks involve, infection, bleeding, worsening of symptoms, spinal block, epidural block etc. Fortunately, the serious side effects and complications are uncommon.

Who should not have this injection?
If you are allergic to any of the medications to be injected, if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid), or if you have an active infection going on near the injection site, you should not have the injection.    

Radio Frequency Lesioning

What is a Radio Frequency Lesioning?
Radio Frequency Lesioning is a procedure using a specialized machine to interrupt nerve transmission originating from a painful structure within the spine.  The procedure usually relieves the pain for 9-14 months after which a second procedure can be performed.  The procedure takes only 15-20 minutes and will again work for a period of 9-14 months.

Am I a candidate for Radio Frequency Lesioning?

Patients are first screened with a local anesthetic injection to determine what structure is generating the pain.  If this gives good but temporary relief, a radiofrequency procedure can be expected to procedure the same amount of relief on a long term basis

What are the benefits of Radio Frequency Lesioning?

The procedure disrupts nerve conduction (such as conduction of pain signals), and it may in turn reduce pain, and other related symptoms. Approximately 70-80% of patients will get good relief of the intended nerve. This should help relieve that part of the pain that the blocked nerve controls. Sometimes after a nerve is blocked, it becomes clear that there is pain from the other areas as well.

How long does the procedure take? 

Depending upon the areas to be treated, the procedure can take from about twenty minutes to a couple of hours when we include preparation and observation following the procedure.

Where is the procedure performed? 
The procedure is usually performed in an operating room, sometimes in a fluoroscopy (x-ray) room.

How is it actually performed?
Since nerves cannot be seen on x-ray, the needles are positioned using bony landmarks that indicate where the nerves usually are. Fluoroscopy (x-ray) is used to identify those bony landmarks. A local anesthetic (like Lidocaine) is injected to confirm proper placement. After confirmation of the needle tip position, a special needle tip is inserted.
When the needle is in good position, as confirmed by x-ray, electrical stimulation is done before any lesioning. This stimulation may produce a buzzing or tingling sensation or may be like hitting your “funny bone”. You may also feel your muscles jump. You need to be awake during this part of the procedure so you can report what you’re feeling. The tissues surrounding the needle tip are then heated when electronic current is passed using the Radio Frequency machine, for a few seconds. This “numbs” the nerves semi-permanently.

Will the procedure hurt?

Nerves are protected by layers of muscle and soft tissues. The procedure involves inserting a needle through skin and those layers of muscle and soft tissues, so there is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the needle.

Will I be “put out” for this procedure?
No. This procedure is done under local anesthesia. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easier to tolerate. The amount of sedation given generally depends upon the patient tolerance. It is necessary for you to be awake enough to communicate easily during the procedure.

How is the procedure performed?

It is done either with the patient lying on the stomach when working on the facet joints, low back for lumbar sympathetic nerves, and the back when lesioning the cervical (neck) area (e.g. Stellate Ganglion). The patients are monitored with EKG, blood pressure cuff, and blood oxygen-monitoring device. The skin on the back is cleaned with antiseptic solution and then the procedure is carried out. X-ray (fluoroscopy) is used to guide the needles.

What should I expect after the procedure?
Initially there will be muscle soreness for up to a week afterward. Ice packs will usually control this discomfort. After that first week is over, your pain may be gone or quite less.

What should I do after the procedure?
You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. You may want to apply ice to the affected area. Perform the activities as tolerated by you.

Can I go to work the next day?
You should be able to return to your work the next day. Sometimes soreness at the injection site causes you to be off work for a day or two.

How long will the effects of the procedure last?
If successful, the effects of the procedure can last from 3-18 months, usually 6-9 months.

How many procedures do I need to have?
If the first procedure does not relieve your symptoms completely, you may be recommended to have a repeat procedure after re-evaluation. Because these are not permanent procedures, they may need to be repeated when the numbness wears off (often 6-12 months).

Will the Radio Frequency Lesioning help me?
It is very difficult to predict if the procedure will indeed help you or not. Generally speaking, the patients who have responded to repeated local anesthetic blocks will have better results.

What are the risks and side effects?
Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and the possibility of complications. The risks and complications are dependent upon the sites that are lesioned. Any time there is an injection through the skin, there is a risk of infection. This is why sterile conditions are used for these blocks. The needles have to go through skin and soft tissues, which will cause soreness. The nerves to be lesioned may be near blood vessels or other nerves which can be potentially damaged. Great care is taken when placing the radio frequency needles, but sometimes complications occur. Please discuss your specific concerns with your physician.

Who should not have this procedure?

If you are allergic to any of the medications to be injected, if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid), or if you have an active infection going on near the injection site, you should not have the procedure.

If you have not responded to local anesthetic blocks, you may not be a candidate for this procedure.

Reflex Sympathetic Dystrophy (RSD)
RSD is a condition which involves burning pain, swelling and limited movement of an extremity that is associated with an injury such as a broken limb. In patients with RSD, these symptoms can linger for months, years or a lifetime unless treatment is sought.

Rotator Cuff Syndrome
Sometimes, after surgery on the rotator cuff (a group of muscles that hold the shoulder in place), the patient can still have pain. This pain is typically called rotator cuff syndrome.

Cervical Radiculopathy

Cervical radicular pain refers to pain that is originating in the nerve roots of the neck. Patients often describe radicular pain as radiating, sharp, shooting, and/or electric-type pain. It is often associated with numbness or weakness in the upper extremity.

Cervical Epidural Steroid Injection (ESI)

The word cervical means of or related to the neck.

Epidural steroid injections (ESIs) are a common treatment option for some types of cervical, thoracic, arm, low back and/or leg pain. ESIs have been used for low back pain since the 1950s and are still an important part of the non-surgical management of low back pain and sciatica.

The goal of an ESI is to provide the patient with pain relief.  Sometimes the injection alone provides the patient with great relief, but oftentimes our doctors use a combination of rehabilitation services to help the patient gain better function and mobility—physical therapy, chiropractics, and massage therapy are all effective tools once the pain has been resolved.

Cervical Transforaminal Epidural Steroid Injection (ESI)

During a cervical transforaminal ESI, a small amount of steroids are injected into a specific nerve in the neck.  The procedure helps the inflamed nerve to return to normal, providing the patient with pain relief.  Once the pain is under control, patients are then able to more comfortably participate in rehabilitative services such as physical therapy, massage therapy and/or chiropractics.     Cervical Dorsal Root Ganglion Radio Frequency

The word cervical means of or related to the neck.  Dorsal root ganglion refers to a group of sensory nerve cell bodies. These nerves pass sensory information to neurons in the spinal cord so it can be analyzed by the brain.  Therefore, cervical dorsal root ganglion refers to nerves in the neck that transmit information to the brain.

After a patient has undergone the proper diagnostic tests (nerve block injections), our doctors educate our patients about radio frequency lesioning—a procedure that typically results in 12-24 months of pain relief.

Using high-frequency pulsed radio waves, our physicians pulse the pain generating nerve.  Through this process, the chronic pain sensory fibers on the nerve are de-activated.  The nerve is still functioning, but there is no more pain.  Most insurance companies will cover this treatment at least once a year.

“Many conditions can be treated by simply targeting the painful nerve and treating it with our radio frequency procedures.  Thanks to these medical advances, we can offer effective treatments without the risk and recovery time of surgery,’” says Dr. Richard Rosenthal, the medical director of Nexus Paincare.

Sciatica is a layman’s term for pain that shoots into the arm or leg. It is usually caused by a prolapsed
intervertebral disk. It can be diagnosed by an epidural steroid injection and treated with a dorsal root
radiofrequency procedure.

Botox®
Botox® is most commonly recognized as a cosmetic agent to help reduce wrinkles.  But recent studies indicate that Botox® is also helpful in alleviating headache pain.

A 2003 study presented at the American Headache Society 45th Annual Scientific Meeting produced results indicating that 80 percent of patients treated with Botox® for headache pain claimed to have less frequent pain, less intense pain or both after the injections.  Of the 271 patients who received Botox® injections for the study, 60 percent reported good to excellent pain relief, 20 percent reported some pain relief and 20 percent reported no relief.

Three-quarters of the 271 patients had tried other therapies in seeking pain relief.  Half of them had been over-using medication in an effort to find relief.
At Nexus Paincare, we treated a series of 50 patients suffering from tension headaches with Botox® injections.  There was only one patient who wasn’t completely satisfied.

Many patients who receive relief from Botox® injections are able to reduce their medication dosages or stop taking pain medications all together.

For millions of Americans, chronic daily headaches have become a way of life.  People who live with daily headache pain may find the key to lasting relief through Botox®.  There are also several other treatments that successfully provide headache pain relief.

Cervicogenic Headache
Headaches that involve pain that begins in the neck, frequently secondary to cervical facet syndrome, are called cervicogenic headaches.  Proper diagnostic tests (nerve blocks) must be performed to determine that the neck is, in fact, the source of the pain.

Chronic Daily Headache
Chronic daily headaches probably represent a fusion of both migraine and tension headaches.

Chronic daily headache is a general term representing at least five different clinical entities:

1.  Chronic Tension-type Headaches—the patient must have headache pain at least 15 days per month for at least six months.  The average duration of headache must be more than four hours per day.  The pain must have two of the following characteristics: pressing/tightening quality, mild or moderate severity, bilateral location, no aggravation by walking stairs or similar physical exertion.  The patient should have a previous history of episodic or occasional tension type headaches.  The headaches must have gradually increased in frequency over a three-month period; the patient must deny vomiting and have no more than one of the following symptoms: nausea, photophobia, phonophobia.

2.  Transformed Migraine—the patient must have headache pain at least 15 days per month for more than one month.  The average duration of headache must be more than four hours per day.  The patient must have a history of previous episodic migraine and the current headaches must meet the IHS criteria for migraine other than duration.  These patients typically have a non-descript headache between migraine episodes.

3.  New Daily Persistent Headaches—the patient must have headache pain at least 15 days per month for greater than one month.  The average headache duration must be more than four hours per day.  The patient has no previous history of migraine or tension type headache.  The onset of headache should be abrupt, occurring over less than three days.  It has been suggested that this headache is related to a viral or post viral infection.
4.  Hemicrania Continual Headaches—the patient must have persistent headache for at least one month.  The headache should be strictly unilateral in location.  The headache must be completely treated with indomethacin.  The pain has all three of the following present: continuous but fluctuating character, moderate severity, lack of precipitating mechanisms.
5.  Analgesic Rebound Headaches—this term refers to the inappropriate over-use of abortive analgesic medications for the treatment of chronic daily headaches.

The consequences of daily headache are myriad.  These include:
1.  Pain, nausea, vomiting, and dehydration.
2.  Sleep disturbance.  Very often patients will have difficulty falling or staying asleep as a result of headache pain.  They may wake up several times during the night with a headache.
3.  Curtailment of social and recreational activities.  When you don’t feel good, you’re not going to participate in activities that you previously enjoyed.
4.  Depression.  Over time, loss of function and stress of dealing with headache pain leads to depression and lowering of self-esteem.
5.  Disability.  If the behavior remains unchecked, eventually patients become totally disabled by headache.

Cluster Headaches
Cluster headaches involve pain that is usually just on one side of the face or head that lasts for minutes or hours, recurring several times throughout the day.  These headaches typically happen several days in a row followed by a remission time of a few days before the headache pain returns. Spenopalatine blocks provide must cluster headache patients with immediate pain relief.

Sphenopalatine Block
This procedure is used to treat cluster headaches (pain that is usually just on one side of the face or head that lasts for minutes or hours, recurring several times throughout the day.  These headaches typically happen several days in a row followed by a remission time of a few days before the headache pain returns).  It is also used to treat burning pain in the face as described above.  This pain sometimes occurs after spinal surgery.

A spenopalatine block is a process of numbing the sphenopalatine ganglion.  Most patients feel immediate relief of the pain associated with cluster headaches after receiving this treatment.

Sphenopalatine Ganglion Neuralgia
Sphenopalatine ganglion neuralgia, also known as Sluder’s Syndrome, is characterized by neuralgia (an intense burning or stabbing pain caused by irritation of or damage to a nerve) of the sphenopalatine ganglion, which is a mass of nerve tissue located in the maxillary region of the head.  Neuralgia in the sphenopalatine ganglia results in headaches, nasal pressure, and/or facial tenderness.  This disorder is easily treated with a sphenopalatine block procedure.

Sluder’s Syndrome
Sluder’s syndrome, also known as sphenopalatine ganglion neuralgia, is characterized by neuralgia (an intense burning or stabbing pain caused by irritation of or damage to a nerve) of the sphenopalatine ganglion, which is a mass of nerve tissue located in the maxillary region of the head.  Neuralgia in the sphenopalatine ganglia results in headaches, nasal pressure, and/or facial tenderness. This disorder is easily treated with a sphenopalatine block procedure.

Supraorbital Block
Supraorbital refers to the area above the orbit of the eye.  Some headache pain originates in this area of the head.  Nerve block injections are helpful in diagnosing the pain generator.

A nerve block is a diagnosing tool that helps our doctors to know exactly which nerves are causing our patients to feel pain.  Our doctors use a live x-ray-type machine (flouroscopy) to see the patients’ bone structures.  They are often able to tell, based on the patients’ description, the general area where the pain is being generated.  Our physicians select the nerve that is likely the cause of the pain.  That nerve is temporarily numbed with lidocaine (the same numbing medication dentists use).

If the patient feels relief for a few hours before the lidocaine effects wear off, then the doctor can likely conclude that the pain generating nerve has been correctly identified.  This process is repeated another time, just to assure that the pain relief was not a placebo effect.  After two successful nerve blocks, our physicians educate our patients and move on to a more permanent treatment that will likely produce pain relief for 12-24 months—radio frequency lesioning.

Ankylosing Spondylitis

Anklyosing spondylitis is a chronic, usually progressive rheumatologic condition in which inflammatory changes and new bone formations occur at the attachment of tendons and ligaments to bone (enthesopathy). This frequently occurs along the spine, causing a progressive “hunching over” effect and a condition known as “bamboo spine”.

Sacroiliac joint involvement is the hallmark of ankylosing spondylitis with variable degrees of spinal involvement. However, 20-30% of patients also have larger peripheral joint involvement.

Arthritis

Arthritis is acute or chronic inflammation of a joint, often accompanied by pain and structural changes and having diverse causes, such as infection, crystal deposition, or injury.

Patients who suffer from Arthritis are most commonly treated by rheumatologists.

Osteoarthritis

Osteoarthritis, also known as degenerative arthritis, is a degenerative joint disease caused by gradual loss of cartilage.  This disease usually results in the formation of bone spurs and cysts.  Many sufferers of osteoarthritis experience disabling pain that keeps them from participating in routine activities.

What is Spinal Cord Stimulator?

The Spinal Cord Stimulator is a specialized device which stimulates nerves by tiny electrical impulses via small electrical wires placed on the spinal cord. Spinal cord simulation has been most commonly used in the United States in the treatment of neuropathic pain syndromes including: failed back surgery syndrome, RSD, post-herpetic neuralgia and other painful conditions. The most common use is in failed laminectomy syndrome. This condition occurs in 20-40% of the more than 200,000 patients who undergo lumbar spine surgery each year. Other conditions we commonly use the technology for include: limb pain, occipital neuralgia, and postherniopathy pain. It is most commonly used when further reparative surgery is not an option.

The therapy is based on sending an electric signal into a targeted portion of the spinal cord or a peripheral nerve to block incoming pain signals. When the device is activated, the patient feels a warm, tingling sensation known as a stimulation paresthesia. Because it is impossible to feel this sensation and pain at the same time, when the patient feels a stimulation paresthesia, they are not able to perceive their pain. The device has been in commercial use for greater than 30 years.

Am I a candidate for Spinal Cord Stimulator?

Currently, the Spinal Cord Stimulator is offered to patients with chronic and severe neuropathic pain who have not responded to other treatment modalities. (Neuropathic pain being pain due to damaged nerve tissue.)

What is the purpose of it?

This device interrupts nerve conduction (such as conduction of pain signals) to brain.

How long does the procedure take?

It is done in two stages. In the first stage (called a “trial”), temporary wires are placed and an external device is used by the patients to generate electrical current. If this trial is successful in relieving pain, then the permanent device is placed under the skin. Each procedure can take up to 3 hours.

How is it actually performed?

The wires are placed under x-ray guidance and a local anesthetic like Novocain is used to numb the skin and deeper tissues. The procedure is performed in the operating room to maintain sterility.

Will the procedure hurt?

The procedure involves inserting a needle through skin and deeper tissues (like a “tetanus shot”).  There is some discomfort involved. However, we numb the skin and deeper tissues with a local anesthetic using a very thin needle prior to inserting the needle.

Will I be “put out” for this procedure?

The placement of the wires is done under local anesthesia with patients mildly sedated. This is necessary to ensure proper placement of the wires. The amount of sedation given generally depends upon the patient tolerance. For the generator placement, patients are given stronger intravenous sedation.

How is the procedure performed?

It is done with the patient lying on the stomach when placing the wires. For the insertion of the generator, patients are placed on their back or on the side. The patients are monitored with EKG, blood pressure cuff and blood oxygen-monitoring device. The skin is cleaned with antiseptic solution and then the procedure is carried out. X-ray (fluoroscopy) is used to guide the needle for wire placement.

Where are the wires inserted? Where is the generator placed?

For the pain involving lower back and lower extremities, the wires are inserted in the midline at the lower back. The generator is then placed on the side of the abdomen.

For the pain involving upper extremities, the wires are inserted in the midline at the upper back. The generator is then placed on the side of the chest.

What should I expect after the procedure?

If the procedure is successful, you may feel that your pain may be gone or quite less. You will experience a fairly constant sensation of stimulation. You may have soreness due to the needles used for a day or two.

What should I do after the procedure?

This procedure is normally a day-procedure. Some patients may be kept overnight for observation. You should have a ride home. We advise the patients to take it easy for a day or so after the procedure. Perform the activities as tolerated by you.

How long will the generators last?

The battery in the stimulator lasts about five years. This device needs to be charged one to three times per month. This is simple to do. A representative educates all stimulator patients on how to charge the battery.

Will the Spinal Cord Stimulator help me?

It is very difficult to predict if the procedure will indeed help you or not. For that reason temporary wires are placed during the trial to determine if this device will be effective to relieve your pain or not. Typically, patients will have a 50 to 70 % reduction in their pain.

What are the risks and side effects?

Generally speaking, this procedure is safe. However, with any procedure there are risks, side effects, and possibility of complications. Please discuss your concerns with your physician.

Who should not have this procedure?

If you are allergic to any of the medications to be injected, if you are on blood thinning medications (e.g. Coumadin, Plavix, Ticlid), or if you have an active infection going on, you should not have the procedure.

Where can I get additional information?

More detailed information is available from the manufacturer of this device. At the time of consultation you will receive a Spinal Cord Stimulation Patient Education Booklet. Additional information is also available at www.controlyourpain.com, www.nevro.com or www.raceagainstpain.com.

 

 

A dorsal root ganglion (DRG), also known as spinal ganglia, is a lump containing nerve cell bodies on the dorsal or sensory root of each spinal nerve. In other words, all of the fibers capable of generating pain in the arm or the leg pass through this structure. When inflamed, it is capable of generating severe arm or leg pain. Using radiofrequency electricity to treat the pain is a specialized technique that has been perfected at Nexus Pain Specialists. It is a practice that is not commonly performed by other pain physicians due to the specialized training required to correctly perform the procedure. Nexus Pain Specialists is one of the few facilities that perform this procedure in the area. Dr. Rosenthal has published articles in scientific journals on to teach other physicians about this procedure.

After a patient has undergone the proper diagnostic tests (nerve block injections), our doctors educate our patients about radiofrequency lesioning—a procedure that typically results in 12-24 months of pain relief.

Using high-frequency radio waves and heat, our physicians pulse the pain generating nerve. Through this process, the pain sensory on the nerve is deactivated. The nerve is still functioning, but there is no more pain. Most insurance companies will cover this treatment at least once a year.

“Many conditions can be treated by simply targeting the painful nerve and treating it with our radiofrequency procedures. Thanks to these medical advances, we can offer effective treatments without the risk and recovery time of surgery,’” says Dr. Richard Rosenthal, the medical director of Nexus Pain Specialists.

 

Nexus Pain Specialists


3585 N University Ave,  Suite 150, Provo, UT 84604 • Phone: 801-356-6100 • Fax: 801-356-2113
1575 West 7000 South, West Jordan, UT 84084 • Phone: 801-833-6569