Pain Management

Sacroiliac Joint Block | Epidural Steroid Injection | Facet Joint Block | Radio Frequency AblationEMG | Nerve Conduction Study | Intrathecal Pump Implant | Spinal Cord Stimulation | Fluoroscopic Guided Hip Injection | Fluoroscopic Guided Steroid Injection - Knee Pain | Joint Injection: Hip | Ultrasound-Guided Injection for Knee Pain | Trigger Point Injections | Ultrasound-Guided Injection for Shoulder Pain

 

Parshotam Gupta, M.D.     Sanjay Kumar, D.O.     Charles Choi, M.D.

Joanne Holiday, M.D.     Sunjay Mathur, M.D.

 

 

Sacroiliac Joint Block

Sacroiliac (SI) joint blocks are injections that are primarily used for diagnosing and treating the low back pain associated with sacroiliac joint dysfunction. The SI joint lies next to the spine and connects the sacrum (bottom of the spine) with the pelvis (hip).

In an SI joint block injection approach, a physician uses fluoroscopic guidance (live x-ray) and inserts a needle into the sacroiliac joint to inject lidocaine (a numbing agent) and a steroid (an anti-inflammatory medication). It takes a highly skilled and experienced physician to be able to insert a needle into the sacroiliac joint.

An SI joint block injection may be repeated up to four times per year. For the treatment to be successful, the injection should be followed by physical therapy and/or chiropractic manipulations to provide mobilization and range of motion exercises.


 


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Epidural Steroid Injection

How an epidural steroid injection works

The most commonly performed injection is an epidural steroid injection. In this approach, a steroid is injected directly around the dura, the sac around the nerve roots that contains cerebrospinal fluid (the fluid that the nerve roots are bathed in). Prior to the injection, the skin is anesthetized by using a small needle to numb the area in the low back (a local anesthetic).

Epidural injections help reduce inflammation

Injecting around the dura sac with steroid can markedly decrease inflammation associated with common conditions such as spinal stenosis, disc herniation or degenerative disc disease. It is thought that there is also a flushing effect from the injection that helps remove or "flush out" inflammatory proteins from around structures that may cause pain.

Epidural steroid injection success rates

An epidural steroid injection is generally successful in relieving lower back and leg pain for a majority of patients depending on their condition. While the effects of the injection tend to be temporary (one week to one year), an epidural can be very beneficial in providing relief for patients during an episode of severe back pain and allows patients to progress in their rehabilitation.

Frequency for epidural steroid injections

There is no definitive research to dictate the frequency of the epidural steroid injections; however, a limit of three injections per year is generally considered reasonable. There is also no general consensus in the medical community as to whether or not a series of three injections need always be performed. If one or two injections resolve the patient’s low back pain, some physicians prefer to save the one or two additional injections for any potential recurrent low back pain.

Generally, there are few risks associated with epidural injections. The risks are remote and include:

  • A wet tap may occur, which means that the needle has penetrated the dural sac into the cerebral spinal fluid (CSF).
  • A wet tap may result in a CSF leak and a spinal headache.
  • Infection into the epidural space is also a remote risk.

While there is no risk of paralysis (since the spinal cord ends at a higher level in the spine), there is a remote risk of damage to a nerve root.


 



 



 


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Facet Joint Block

In cases where the facet joint itself is the pain generator, a facet block injection can be performed to alleviate the pain. Similar to SNRB’s, facet block injections are a diagnostic tool used to isolate and confirm the specific source of back pain for the patient. Additionally, facet blocks have a therapeutic effect as they numb the source of pain and soothe the inflammation for the patient.

The facet joints are paired joints in the back that have opposing surfaces of cartilage (cushioning tissue between the bones) and a surrounding capsule. Twisting injuries can cause damage to one or both facet joints, and cartilage degeneration associated with aging may also cause pain.

In a facet block procedure, a physician uses fluoroscopy (live x-ray) to guide the needle into the facet joint capsule to inject lidocaine (a numbing agent) and/or a steroid (an anti-inflammatory medication). If the patient’s pain goes away after the injection, it can be inferred that the pain generator is the specific facet joint capsule that has just been injected.

If the facet block procedure is effective in alleviating the patient's low back pain, it is often considered reasonable for the procedure to be done up to four times per year. There are very few risks associated with this technique.


 


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Radio Frequency Ablation

What is radio-frequency ablation?

Radio-frequency ablation involves the destruction of small nerves that supply the facet joints. The radio-frequency unit allows heat to be generated in nerve tissue sufficient to either destroy or deactivate the nerve.

How is the procedure performed?

The procedure is performed under local anesthesia. Fluoroscopic control (x-ray guidance) is used to help ensure safe and correct placement. In addition, stimulation of the nerves is also used to identify the location of the needle tip. When patients feel stimulation locally and x-ray position is acceptable, lesioning is then performed.

Is the procedure painful?

Because the procedure is performed while the patient is awake, you may feel some uncomfortable sensations at times. Post procedure, patients may also have some injection site tenderness for up to two weeks. It can take up to 2-4 weeks to feel relief from the procedure, some patients will respond much sooner.

How long does pain relief last following the procedure?

Only small peripheral sensory nerves are lesioned with this procedure. These nerves do have the capacity to grow back. Patients may require repeat lesioning as early at 6 months but some may also have long-term relief as well.


 


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Electromyography (EMG) Studies

Electromyography is a form of electrodiagnostic testing that is used to study nerve and muscle function.  Dr. Kumar  and Dr. Eid perform this test in our office. This test can give specific information about the extent of nerve and/or muscle injury and can also determine the exact location of injury and give some indication whether the damage is irreversible.

There are two parts to EMG testing: a nerve conduction study and a needle exam for muscle testing. Both may result in some discomfort but are usually well tolerated without the need for medication beforehand.


 


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Nerve Conduction Study(NCS)

 

 


 

 

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Intrathecal Pump Implant (Medtronic)

 

 


 

 

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Spinal Cord Stimulation (Medtronic)

 

 


 

 

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Fluoroscopic Guided Hip Injection

 

 


 

 

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Fluoroscopic Guided Steroid Injection - Knee Pain

 

 


 

 

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Joint Injection: Hip

 

 


 

 

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Ultrasound-Guided Injection for Knee Pain

 

 


 

 

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Trigger Point Injections

 

 


 

 

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Ultrasound-Guided Injection for Shoulder Pain

 

 


 

 

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