Pacific Pain Medicine Consultants

An epidural steroid injection is an injection performed to treat pain due to irritation of a spinal nerve(s) in the spine. The injection typically contains numbing medicine (lidocaine) and anti-inflammatory medicine (steroid) that are injected into the epidural space of the spine, around the affected nerve(s), with the goal of reducing inflammation of the nerve(s) and therefore the symptoms. The epidural steroid injection will be given according to the site where suspected nerve irritation occurs in your spine. These injections are typically performed when the patient has trialed conservative (non-surgical) treatments that have failed in the past and as an attempt to reduce pain and avoid surgery if possible. The administration of such injections can also allow time for healing to occur in the damaged area. If the symptoms (pain, tingling, and weakness) are no longer present, further injections are not indicated. These injections are performed under fluoroscopic guidance (x-ray) to ensure safe delivery of medication to the intended site.

Onabotulinumtoxin A (BOTOX®) is FDA approved for the treatment of chronic migraines, spasticity and cervical dystonia in adults. It is a medicine that is injected into the affected muscle(s). BOTOX® is the most common neurotoxin derived from the toxin Clostridium botulinum, the same bacterium that causes food poisoning. While this bacterium may be fatal in large doses, in small, medically regulated doses, it has been found to be an effective therapeutic tool in relieving chronic pain. In regards to chronic migraine headaches, eligible patients must have 15 or more days each month with headache, lasting 4 or more hours each day. BOTOX has been studied to reduce headache days every month, preventing up to 9 headache days a month (PREEMPT trial). The positive effects of BOTOX injections may be felt for several months, but they are not permanent. When these injections are helpful, it is usually recommended that they are repeated every 3 or 4 months for continuous relief of symptoms. Physical therapy is often recommended after injections to restore flexibility and muscle function. BURSA INJECTIONS Bursa Injections are used to deliver medications to inflamed, painful bursas, for the treatment of bursitis. These injections are used to reduce inflammation & swelling, and may, in turn, reduce pain.

If facet joints of the spine are a suspected source of pain, a diagnostic or “test” injection is performed to determine/diagnose if the facet joints in the spine are a significant reason for your pain. This is called a medial branch block, an injection where the medial branches are numbed to “block” the nerve transmission from the targeted facet joint(s). This test only provides temporary information, if the facet joints are a significant source of your pain or not. If the medial branch block provides significant, yet transient relief, you may be a candidate for a procedure that may provide long term relief of facet joint pain. Radiofrequency neurotomy treatment is indicated for patients who receive at least a 50% reduction of the pain in question- typically for a couple of hours.

Intradiscal Electrothermal Therapy (IDET) is a minimally invasive treatment for spinal disc related chronic low back pain. This type of persistent disc pain is thought to be caused by nerve fibers that have grown from their normal location in the outer layers (annulus), or from an injury to the disc, causing the material in the middle of the disc (nucleus pulposus) to move into the outer layers of the disc (annulus) where nerves are, causing pain. Under x-ray guidance a thin flexible catheter is introduced into the problematic disc, and heats up. The proposed mechanism is that the heat causes contraction of the collagen fibers that may seal up painful tears and destruction of the painful nerve fibers, and stimulation of new collagen formation.

Intrathecal Drug Delivery/pain pump delivers pain medication directly to the fluid around the spinal cord, providing pain relief with reduced medication compared to the amount required when taken orally. This may lead to fewer or more tolerable drug side effects compared to oral medications. The system consists of a pump and catheter that are surgically placed under the skin. The pump is a round device that stores and delivers pain medication. The catheter is connected to the pump and inserted into your spine to allow for the delivery of the medication. Prior to an implant of a pain pump, a patient would be required to perform a trial to determine candidacy.

JOINT INJECTIONS Osteoarthritis (OA) is one of the most common forms of arthritis; joint pain and stiffness impacting ones function. When conservative measures don't provide adequate relief, corticosteroid injections directly into the aching joint may be effective. Corticosteroids are medications that mimic the effects of the hormone- cortisol, which is produced naturally in the body, by the adrenal glands. Corticosteroids work to decrease inflammation. The goal of a corticosteroid injection into a painful arthritic joint is to reduce the irritation of bone interacting with bone which is what happens when the smooth, cartilage surface wears away. Another injection option for certain joints affected by OA that have failed conservative therapy is hyaluronic acid. In a healthy joint, a thick substance called synovial fluid provides lubrication and acts as a shock absorber. In joints with OA a critical substance in the synovial fluid known as hyaluronic acid breaks down. Loss of hyaluronic acid appears to contribute to joint pain and stiffness.

The minimally invasive lumbar decompression (MILD) procedure is indicated for patients with lumbar spinal stenosis experiencing pain and reduced mobility related to their lumbar spinal stenosis. It is an outpatient procedure performed through a hole about the size of a baby aspirin. With the assistance of imaging guidance, specialized tools remove small pieces of bone and excess ligament through the small hole. Removing these elements is meant to decompress your spinal stenosis, restore the space in your spinal canal and reduce pain and increase mobility.

Occipital Nerve Stimulation (ONS) is implantable technology for the treatment of chronic, intractable pain located in the head. It works by delivering electrical impulses, and provides relief by altering the pain signals before they reach the brain. Instead of feeling the pain, you feel a tingling sensation. You are able to adjust the strength and area of stimulation using a remote control. When ONS is successful, it should provide significant long term relief, reduce the need for pain medications, and improve function. To determine if the patient is a good candidate for ONS therapy and permanent implantation, a ONS trial will be performed first. The trial is temporary lasting up to a week, where the patient will learn and decide if this is the right treatment for them.

Radio frequency neurotomy works by means of radio waves (heat) that are sent through a needle to disrupt small sensory nerve endings of your medial branch nerves and interrupt pain signals from the facet joint(s). This procedure is considered quite effective and typically patients report pain relief between 6-24 months after the procedure. It can take between 1-4 weeks for the results to be fully noticed. The nerve endings do regenerate; therefore the return of familiar pain is likely. Fortunately, the procedure may be repeated if necessary and appropriate. You should recall that you have had the “test injections” called Medial Branch Blocks that determined that the radio frequency neurotomy is an appropriate treatment for this pain complaint.

Spinal Cord Stimulation (SCS) is implantable technology for the treatment of chronic, intractable pain. It works by delivering electrical impulses, and provides relief by altering the pain signals before they reach the brain. Instead of feeling the pain, you feel a tingling sensation. You are able to adjust the strength and area of stimulation using a remote control. When SCS is successful, it should provide significant long term relief, reduce the need for pain medications, and improve function. To determine if the patient is a good candidate for SCS therapy and permanent implantation, a SCS trial will be performed first. The trial is temporary lasting up to a week, where the patient will learn and decide if this is the right treatment for them.

The Sacroiliac Joint injection is an injection administered to diagnose and treat low back/buttocks pain caused by injury or disease to the sacroiliac joint (SI joint) which are located in the lower back area and buttocks where the pelvis joins with the spine. If the SI joints are damaged by injury or disease, these joints can cause pain in the lower back, buttocks and sometimes legs. This is due to the inflammation and swelling within the joint space.

The Sympathetic Block, or injection, is a diagnostic & potentially therapeutic injection of numbing medicine administered in order to block or decrease a certain type of pain located in the head, neck, chest, arm, or leg- known as sympathetic maintained pain. This type of injection is administered to a group of nerves located in the neck or lower back that are part of the sympathetic nervous system. If an illness or an injury affects the sympathetic nervous system, it may not function optimally and cause pain. This type of injection can often help diagnose, and possibly treat sympathetically maintained pain. One of the conditions considered for this type of procedure is complex regional pain syndrome (CRPS) also called reflex sympathetic dystrophy (RSD).

Trigger Point Injections (TPI) are injections that are given directly into an active trigger point for the management of pain. Trigger points are discrete, focal, hyperirritable spots located in a taut band of skeletal muscle. Trigger points produce pain locally and in a referred pattern and often accompany chronic musculoskeletal disorders. The goal is to reduce the inflammation and associated pain to allow a patient increased range of motion, and to participate in physical activity.

A comprehensive medical history, physical exam and routine imaging are the essential foundations for which interventional medicine relies upon to deliver safe and effective injections. For many musculoskeletal pain generators, we are able to provide the addition of ultra sound guidance to accurately deliver medicine under real time visualization allows for the greatest opportunity to provide pain reduction without radiation exposure.