The intervertebral disc, the primary weight bearing structure of the spine is recognized as a common source of low back pain. Initially, chronic low back pain was thought to be caused by nerve root compression. However, MRI scans fail to show compression of nerves even in the presence of sciatica. Such sensitivity has been documented by eliciting pain by pressing on the back wall of the disc (annulus) during lumbar surgery in an awake patient. Such sensitivity has also been documented during pressure controlled discography, leading to the identification of a low pressure sensitive disc.

At times, MRI scans can show tears in the outer wall of the disc, called high intensity zones (HIZ). This may indicate a greater potential of a pain sensitized disc. Many studies have shown the presence of irritating chemical substances within the outer wall of the disc that could cause sensitization of the disc to mechanical weight bearing. It has been demonstrated that nerves supplying the outer disc wall can grow into disc tears or areas of injury causing the disc to become sensitive and painful. (Nerve in growth)

The discogram procedure begins when the skin is anesthetized using a local anesthetic such as novicaine or lidocaine. A needle introducer is advanced under fluoroscopy (x-ray) guidance into the center of the disc. A solution of dye is injected very slowly into the disc and pressures are measured. During the injection phase the patient is asked to inform the doctor of any discomfort. Several of the discs are usually tested, including one disc that appears to be normal that is used as a control, or comparison level. It is anticipated the patient will not be aware of any feeling when the dye is injected into a normal disc.

If the disc is abnormal the patient will begin to feel some discomfort. Based on the patient’s response and the internal pressure of the disc recorded during the procedure, a diagnosis can be made. Once discomfort is felt, the test of that disc is stopped. The concept is to identify an abnormal disc, not to measure pain tolerance. After a brief time of observation, the patient is released from the center. The procedure is considered minimally invasive and done on an out-patient basis. In patients with dye allergies, normal salt solution (saline) can be substituted for the dye.

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Percutaneous epidural adhesiololysis (removal of scar tissue) is used to treat patients with refractory low back pain due to scarring. Epidural scarring can occur as the result of a previous tear in the disc which inflamed the nerves, the inflammation may resolve, but scarring may persist without prior surgery.

Hematoma (blood clot formation) may occur in the epidural space during to the post op period. After spine surgery, fibrous tissue (scar) may adhere to the nerve roots. Perineural fibrosis (scar around the nerve) can inhibit nutrients from reaching the nerves causing hypersensitivity. Mechanical compression can also occur. The scar tissue is formed in the epidural space. The space is a potential space located in between the spinal cord and spinal canal.

The procedure is performed under fluoroscopy (x-ray) guidance. After local anesthesia is administered to the skin, a needle is advanced to the proper anatomical location. A specialized catheter is advanced through the needle. Contrast dye is administered to outline the scar tissue. There have been numerous alternatives to the next sequences of the treatment forms. Initially hypertonic saline was infu22qsed daily for 3 days to “break up” the scar tissue. Initial studies were promising, but unfortunately could not be reproduced. Dangerous side effects were seen and the technique was abandoned. A special medication hyalurunidase was then used to break down the scar. This procedure was also questioned with conflicting outcomes. Now the catheter is manipulated through the scar when possible, and subsequent steroids are administered to decrease inflammation around the area of scar disruption. The patient is returned to the recovery room and observed for a short period, and discharged home the same day.

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Epidural steroid injection offers the potential of pain relief to people with neck, mid-back and lower back pain with or without arm or leg pain. Two different routes of administration are available for steroid placement within the epidural space: transforaminal (area of exiting nerve from the spinal cord) and interlaminar (area behind the spinal canal). In the cervical (neck) spine, interlaminar injection is generally considered safe with reports of minor complication rate of less than one percent. The transforaminal approach has been associated with rare but devastating complications. In the lumbar (lower back) area, both procedures are considered safe with the most effective being transforaminal under fluoroscopy.

Blinded epidurals (those done without fluoroscopic guidance) have shown the greatest risk and less positive outcomes than epidurals done using fluoroscopy. Blinded epidurals are done with the assumption the injected steroids will spread to the sites of pathology. Studies of epidural steroid injections without x-ray guidance show the injected medications fail to reach the target site at a significant rate with a consequent lack of benefit. There was also an increased risk and a potential increased incidence of surgery. For these reasons, the physicians at the Pain Relief Centers complete epidurals procedures with the benefit of fluoroscopic guidance.

Epidural steroid injections (ESI’s) are primarily used to relieve pain from a mechanical irritation or inflammation that affects the nerves leaving the spinal cord to the arms and legs. This target specific administration of steroids helps suppress the inflammation caused by discs which have herniated, protruded, torn or have been disrupted by other causes. Other indications for epidural steroid injections include pain from herpetic neuralgia and a multitude of arthritic changes, such as spinal stenosis.

Epidural steroids injections may be repeated if partial improvement occurs. Repeated injections are not recommended if there was either no relief or full relief after the procedure.

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The facet joint is formed by the attachment of one vertebra (back bone segment) to the vertebra above and the vertebra below. This forms the protective back wall of the spinal column. The joint is a true joint containing hyaline cartilage, a synovial membrane/sac, a fibrous capsule and nocioceptive fibers (pain nerves). The nerves can transmit painful signals to the brain. The pattern of pain appears to overlap considerably with the presentation of pain due to other causes. Under normal biomechanics the joint limits motion between vertebras and assists in weight bearing. Following injury, osteoarthritis and a multitude of other spine related disorders the joints can become painful as a result of increased weight bearing. There is no correlation between facet joint pain, x-rays, MRIs or CT scans. The diagnosis and treatment is determined by facet joint block or blocking the nerve to the joint under x-ray guidance (fluoroscopy).

The joint approach (facet joint injection) entails placing dye, local anesthetic and steroid into the synovial sac of the joint. If the pain is improved for the duration of the local anesthetic on the day of injection, this is considered diagnostic. If severity and duration of relief is determined diagnostic the steroid may help reduce the pain in 2-5 days.

The nerve approach (diagnostic facet nerve block, diagnostic medial branch block) involves placing a local anesthetic agent on to the nerve under fluoroscopy guidance. Patient response is evaluated by duration and amount of pain reduction. If diagnostic, a confirmatory block is then performed. Ultimately the nerve signal may be disrupted using radiofrequency waves. (See radiofrequency rhizotomy).

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Many patients with neck pain or back pain, with or without arm or leg pain, are treated with narcotic(opiod) medication. These patients can develop a tolerance, requiring constant increases in the strength of the opiod. In spite of these changes some patients still fail to get adequate pain relief. Others may begin to have significant and intolerable side effects to large doses required to control their pain. Side effects include nausea/vomiting, confusion, sedation, respiratory depression, constipation, urinary retention and itching. These patients may benefit from an implanted pain pump.

This technology has been available since the 1970's. The procedure involves placing a catheter into the cerebrosperal fluid (intrathecal). This supplies central nervous system with pain medication to decrease the patients pain. This involves a trial (test) to determine if the patients pain can be controlled by this approach. Also the trial allows the interventional pain managemant doctor to determine which medication regimen to place through the catheter. The trial is typically done in a hospital setting from 1-3 days. This allows the patient to be monitored closer for side effects of intrathecal opiod placement. The trial involves placing a catheter which extends from the spinal fluid to a pump outside the body.

If the trial is successful then a catheter is placed inside the spinal fluid and tunneled under the skin to a pump which is under the skin. The pump is programmed to deliver a certain amount of medication continously. It can also be programmed to give bolus doses of medication for breakthrough pain. The pump is refilled (approximately every 2-4 months) by placing a needle through the skin over the reservoir and injecting a certain volume of medication.

Several meds have been used successful including, Morphine, Hydromorphone,(Dilaudid), Fentanyl, Methadone, or Meperidine (Demerol). Other medications to control pain have been added to the opiate solution. These include Baclofen, Tizanidine, Clonidine, Bupivicaine, Ropivicaine, Ketamine, Ziconotide, Octrectide, Gabapentin, or Midazolam.

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Symptomatic disc protrusion causing back pain and referred extremity pain (arm or leg), are thought to be due to combined chemical and mechanical forces. PPD is one of several new minimally invasive procedures intended for the treatment of radicular pain (arm or leg pain) due to a contained herniated disc. It is claimed that the procedure is extremely safe and does not advance the degeneration of the disc beyond what might be typically expected from natural history alone.

The procedure involves anesthetizing the skin, and placing a needle into the damaged disc. Once properly placed, a coil, or “wand,” is advanced into the disc’s center (nucleus pulposus). The “wand” is activated which causes a plasma field that vaporizes tissue. Small channels are produced. The pressure inside the disc is decreased, which in turn relieves pressure between the disc and the nerve. This should improve spine pain and extremity pain.

As with all procedures, the best outcomes are a result of proper clinical evaluation to identify patients with conditions best suited for each type of care (inclusion criteria).

The procedure is an outpatient procedure performed in our specialized ambulatory surgery center.

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The prevalence of chronic lumbar joint pain ranges from 15% in younger patients to as high as 40% in elderly patients. The prevalence of cervical (neck) facet joint pain ranges from 25-66%. The only proven treatment for facet pain is radiofrequency rhizotomy.

The procedure involves placing a electrode (small needle) through the anesthetized skin to rest parallel to the target nerve under fluoroscopy (x-ray guidance). A group of muscles, called the mulitifidus muscle is stimulated causing a mild contracting sensation at the target site. Painless muscle contraction and fluoroscopic guidance is used to confirm proper placement of the electrode. Once confirmed, the nerve is (put to sleep) anesthetized, and a radiofrequency lesion is performed. This stops the nerve from sending pain signals from the joint to the brain.

Since the joint’s role is to limit motion by anatomical barriers, the radiofrequency treatment does not stop the joint from protecting the spine or potential harm by movement without pain signals. Pain relief is usually appreciated within 6 weeks in the majority of the patients

The duration of effectiveness is 6 months to 2 years in the general population. The majority of patients appreciate pain relief lasting 1 year. With careful selection of patients, 60% of patients can expect at least 90% reduction in pain lasting 12 months.

Neck and back pain can be caused by multiple pain generators (sources). The greater the role one specific pain source is, the better response to a specific therapy can be expected. Patients benefit greatly, and experience the best outcomes when receiving treatment in a practice capable using multiple modalities to treat the different sources of pain.

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Lumbar disc, facet joints and sacroiliac joints are 3 major sources of lower back pain. Theses structures can result in pain in the lower back, buttocks, leg, groin, hip or even the abdomen.

The Sacroiliac joint is a large synovial (fluid filled) joint formed by the junction of the sacrum and ileum. The joint allows a small amount of rotation and forward and backward movement. The greatest amount of movement occurs when individuals rise from a sitting or lying position to standing position. In middle age and beyond, fibrous adhesions (scar tissue) and degenerative changes result in gradual obliteration of (loss of) the synovial cavity which occurs in both sexes. This occurs earlier in men, and after menopause in women. The joint can dysfunction as a result of injury, abnormal weight bearing, leg length discrepancies, fractures, changes in walking patterns, pregnancy, and a host of other arthritic disorders. Pain can also be referred to the area by the lumbar discs.

To diagnosis pain from the sacroiliac joint, physical exam can be helpful, but it is not always reliable. Imaging studies such as x-rays, CT scan and MRI can be normal in patients who have problems from this area. Therefore, diagnosis of the offending joint requires intra-articular diagnostic block of the sacroiliac joint under fluoroscopy. The older, “blind” injection technique was completed without fluoroscopy (x-ray guidance), anesthetized only the interosseous sacroiliac ligament (band connecting two bones) and did not produce reliable results or pain relief. In some patients, the sacroiliac pain may also be diagnosed by blocking the nerves to the joint under fluoroscopic guidance.

The procedure is begun by numbing the skin with a local anesthetic. A needle is then placed under fluoroscopic guidance into the sacroiliac joint. A numbing medicine, such as novocaine is placed into the joint. This will help the physician identify the joint as the source of pain. Typically cortisone is also injected into the joint for the inflammation as well as to provide extended pain relief.

Once the pain is controlled, a trial of physical therapy or manual therapy is prescribed to correct the underlying mechanical problems.

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Spinal Cord Stimulation therapy has been used since the 1960’s. It is a technology which sends gentle electrical stimulation to the spinal cord to stop the nerves in painful areas, from sending the pain signals through the spinal cord and to the brain. The pain signal is replaced with a gentle vibration sensation (stimulation- evoked paresthesias ) in the painful areas, such as the arms, legs, neck, or back. This technology has been used to successfully treat Post- Laminectomy Syndrome, Failed Back Syndrome, cervical/ lumbar radiculopathy, neuropathic pain syndromes (CRPS/RSD, causalgia, and diabetic peripheral neuropathy), and vascular disorders (angina and peripheral ischemia). Most patients, who may be candidates for this therapy, have unsuccessfully been treated with conservative measures. These include medications, spinal injections, and physical therapy. Also, further surgical interventions have been ruled out.

Initially a “test” or “trial” is done, in which an electrode is placed into the epidural space, under fluoroscopic (x-ray) guidance. The electrode extends out side of the body and is connected to a remote. The patient can increase or decrease the level of stimulation according to his/her pain level. The “trial” can last between 3- 7 days, depending on the preference of the physician. The patient is told to conduct his/her normal activities in order to get the best assessment of their pain relief. If the trial is successful then a completely enclosed system is implanted, permanently. As with the trial, the electrode is placed into the epidural space, however, now the opposite end is tunneled to a generator which is under the skin. There is still a remote that is used to adjust the level of stimulation based on the pain level. Both the trial and implant are typically done on an out- patient basis. In addition, the patient is instructed to take several days of antibiotics, which decreases the chance for an infection.

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The sympathetic nervous system is a collection of nerves that control multiple functions throughout the body. It originates from the spinal cord and generally helps control temperature, blood flow and sensitivity. In addition, branches of those nerves combined with other nerves form the spinal cord that play a role in pain perception and transmission (sympathetically mediated pain).

The most classic entity associated with the sympathetic nervous system is the pain from RSD (reflex sympathetic dystrophy). The most current state is known as complex regional pain syndrome. The pain is usually described as a burning in quality and usually involving the distal portions of the extremities (arms, hands, legs, knees, ankles or feet). However other pain descriptions such as deep, aching, throbbing or stabbing pain are common. Mechanical allodynia (pain with light touch), or pain with exposure to cool temperatures that are usually not painful may occur.

Autonomic changes, such as changes in skin color, temperature or sweating are frequently seen. Muscle disorders such as tremors, weakness and decreased coordination can develop if the disease becomes progressive. The symptoms may spread beyond the region of initial discomfort.

RSD/CRPS and sympathetic pain may occur following a traumatic injury, most commonly following ankle, knee and wrist injuries. The initial event may be mild to a severe trauma. It is thought that the initiating trauma may also be so slight it may go unnoticed and initiate the onset of the syndrome.

A sympathetic block may be used to help diagnosis the entity, improve the symptoms or even stop the over activity of the sympathetic system.

The sympathetic block is completed under x-ray guidance (fluoroscopy). The skin is anesthetized for the lumbar sympathetic block. The needle is advanced through the back to the anatomical location of the sympathetic chain at the L2-L3 vertebral level. Multiple views of the needle placement under fluoroscopy are obtained. After confirmation with contrast dye, a local anesthetic is applied through the needle. Following the procedure, the patient is taken to the recovery room and observed briefly. They are then discharged home the same day.

For upper extremity blocks a very small needle is advanced to the area on cervical vertebrae (neck) where the sympathetic nerves are located. Confirmation is obtained with fluoroscopy and contrast dye. A local anesthetic solution is injected through the needle to the target area. The patient is taken to the recovery room for a short course of observation and discharged home the same day.

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