ECPC Holly Springs Interventional Pain and Spine

A bursal sac is filled with fluid that provides a cushion between muscles/tendons and bones to decrease friction and irritation. There are bursal sacs around most of the body's joints. When a bursal sac gets infected or inflamed, it can lead to a painful condition called "bursitis." Although often caused by repetitive movement or overuse of a joint during sports or intense physical activity, bursitis can also result from injury, or arthritis of a joint. The most common symptoms of bursitis are pain, stiffness, swelling and tenderness, usually in the joints of the elbow, shoulder, hip, knee or ankle. The heel and Achilles tendon can also be affected. Pain, which can develop gradually or be sudden and severe, may be accompanied by decreased mobility of the joint. If conservative treatment methods are unsuccessful in treating the pain and discomfort caused by bursitis, bursal sac injections can be an effective way of reducing inflammation and diminishing pain. Anti-inflammatory steroid medication is injected directly into the bursal sac; as inflammation decreases, pain and discomfort subside, often for a few weeks or months. In some cases, one injection may be sufficient to alleviate symptoms.

A celiac plexus block is an injection performed to relieve severe abdominal pain by blocking signals from the celiac plexus, a nerve bundle that supplies organs in the abdomen, including the stomach, intestines, liver, pancreas, adrenal glands and other organs around the midsection. The injection contains a local anesthetic or concentrated alcohol to produce immediate pain relief, as well as a medication such as a corticosteroid to provide longer-term respite from pain. Pain remedied by a celiac plexus block may be caused by conditions such as chronic pancreatis and cancer in other organs of the abdomen. The Celiac Plexus Block Procedure A celiac plexus block is generally conducted with the patient lying on his or her stomach. The skin surrounding the affected area will be cleaned and numbed with a local anesthetic. The patient may also receive a mild sedative through an intravenous line if needed. With the assistance of an X-ray and contrast dye, the needle is inserted. Once the needle is situated properly, the medicine is injected. The procedure typically lasts for 30 minutes. The pain the patient has been experiencing should be reduced almost immediately, but the length of time this relief lasts varies from patient to patient. Recovery From a Celiac Plexus Block The patient should arrange for a ride home after the procedure. In most cases, if there are no complications, the patient may go to work and resume most normal activities after a day or two. Some patients may be able to start physical therapy immediately, depending on individual recovery. Risks From a Celiac Plexus Block A celiac plexus block is relatively safe for most patients, but there may be soreness or bruising at the injection site. Low blood pressure or diarrhea may also occur. More serious complications, although uncommon, may include: Nerve damage Bleeding Pneumothorax (collapsed lung) Infection Bloody urine The patient's abdominal wall or leg may feel weak or numb, but that feeling typically disappears in a day or two.

A cervical selective-nerve-root block is an epidural steroid injection used for treating shoulder, upper back, neck and arm pain. It is also used to determine whether pain is being caused by disc problems or nerve-root inflammation. Although MRI scans and other imaging tests are often helpful in locating the source of pain, they may not be able to identify torn or leaking discs. The Cervical Selective-Nerve-Root-Block Procedure A cervical selective-nerve-root-block procedure is performed with a local anesthetic. In some cases, a mild sedative is administered through an intravenous line. Once a patient's skin is numb from the local anesthetic, a small needle is inserted into the epidural space, which is the sac of fluid that protects the spinal cord and its nerves. Fluoroscopy or other imaging techniques may be used to verify that the needle is positioned properly. Once the needle is in the correct place, an anesthetic and a steroid are injected into the epidural space. Recovery from a Cervical Selective-Nerve-Root Block A patient usually returns home on the day of the cervical selective-nerve-root-block procedure, and is usually able to return to work the next day. Immediately after the procedure, a patient often experiences relief from pain, although pain can then worsen for a day or two (this is completely normal). In most cases, the patient experiences full pain relief within a week. Complications of a Cervical Selective-Nerve-Root Block Although complications from a cervical selective-nerve-root block are uncommon, they do exist, and include the following: Pain at the injection site Infection Elevated blood sugar The steroid medication can also cause insomnia, fluid retention and changes in blood pressure. Results of a Cervical Selective-Nerve-Root Block The effectiveness of a cervical selective-nerve-root block varies. Some patients only experience pain relief for a few months, while others enjoy long-term relief.

By reducing inflammation, epidural steroid injections (ESIs) are used to temporarily relieve lumbar (lower back), cervical (neck), thoracic (mid-spine) and sciatic-nerve pain. ESIs contain cortisone and an anesthetic, and are delivered directly to the epidural space, which is the area between the spinal cord and the outer membrane that covers the brain and spinal cord (the dura). As a result, they provide more effective and faster pain relief than oral medications. Candidates for Epidural Steroid Injections Candidates for epidural steroid injections have back pain, and/or pain radiating down the arms and legs. Pain relieved by ESIs can be the result of many conditions, including the following: Lumbar-disc herniation Degenerative disc disease Lumbar spinal stenosis Vertebral compression fractures Cysts in a facet joint or nerve root Annular tears Epidural steroid injections can be used alone to provide pain relief, or given as part of a rehabilitation program to help a patient perform physical therapy exercises with less discomfort. Relief from a single injection can last from 1 week up to 1 year; a typical positive response lasts for 1 month. If helpful, injections can be repeated at 2-week intervals, but usually no more than 3 or 4 times per year. ESIs can also be of diagnostic value in pinpointing the source of the pain and determining its severity, which can assist a physician in developing an appropriate treatment plan. The Epidural-Steroid-Injection Procedure Epidural steroid injections are administered by many types of physicians, including anesthesiologists, orthopedists, physiatrists, pain-management specialists and neurologists. Typically, they are administered in an outpatient facility, under the guidance of fluoroscopy, to verify that the medication is reaching the inflamed nerve root. Because the injection contains a local anesthetic as well as a corticosteroid, the injection is not usually painful, although a patient may feel pressure at the injection site. The injection procedure takes only a few minutes. In most cases, the patient experiences immediate pain relief due to the anesthetic, but the relief is temporary and wears off in a few hours. During the next day or two, however, as the corticosteroid works to reduce inflammation, the patient should feel a significant, if not total, alleviation of pain. The patient can usually resume normal activities the day after the procedure. Risks of Epidural Steroid Injections Epidural steroid injections are a safe form of treatment, although, in rare instances, they can cause headaches, bleeding, infections, nausea or vomiting, allergic reactions or nerve damage. Patients who are pregnant, have infections, or suffer from chronic bleeding disorders are not candidates for epidural steroid injections. ESIs can temporarily elevate blood pressure and blood sugar, and cause mood swings, so patients with hypertension, diabetes or mood disorders should be monitored before, during and after treatment.

Facet-joint injections are both a minimally invasive treatment for back pain caused by inflamed facet joints, and a diagnostic tool for determining whether facet-joint inflammation is a source of pain. Four facet joints connect each vertebra to the vertebra above and below it. A facet-joint injection, administered into either the joint capsule or its surrounding tissue, combines a long-lasting steroid and a local anesthetic. Although the anesthetic provides only temporary pain relief, the steroid reduces inflammation, and can relieve pain for anywhere from a few days to a few years. Lasting pain relief is diagnostically significant because it confirms that the pain originated in the joint that received the injection. Facet-joint injections can be repeated up to 3 times a year for those who have successful but short-term pain relief. Candidates for Facet-Joint Injections Patients with back pain (or pain thought to originate in the back) are candidates for facet-joint injections. Facet-joint pain can be the result of injury, spinal stenosis, sciatica or osteoarthritis. Although pain typically appears in the lumbar region, it can occur anywhere in the spine. When facet joints are inflamed, depending on the location of the inflammation, pain can be experienced in the following regions: Groin Buttocks Hips Shoulders or neck Legs or arms Facet-joint injections are often recommended after anti-inflammatory medication, a back brace or other conservative methods have failed to alleviate symptoms. A patient who is pregnant, has an infection, or suffers from a chronic bleeding disorder is not a candidate for facet-joint injections. The Facet-Joint-Injection Procedure During the procedure, the injection site is first numbed with an anesthetic. The needle is then inserted directly into the facet joint through the back; fluoroscopy, an imaging technique, is used to ensure precise placement. Once the needle is correctly positioned, a combination of anesthetic and cortisone is injected into the targeted joint. The procedure takes less than 30 minutes to perform. There is immediate pain relief from the anesthetic used in the injection, but it takes several days to determine whether the cortisone has had an effect. There may be mild pain at the injection site; it can be managed by taking Tylenol and applying ice. Recovery from Facet-Joint Injections A patient can return home shortly after receiving an injection(s), and can resume regular activities the next day. A follow-up visit to the doctor takes place in about a week; an evaluation is made of how effective the injection has been in lessening symptoms. Results of Facet-Joint Injections Results of facet-joint injections vary widely. Some patients experience long-term, even permanent, pain relief after one injection, whereas others may need additional treatment within a few weeks or months. Risks of Facet-Joint Injections Although considered safe, there are risks involved with facet-joint injections. In rare cases, they can cause infection, allergic reaction, bleeding or nerve damage.

A number of different types of medications may be used to reduce pain in various parts of the body. Any of the medications described below may be helpful in relieving pain, depending on the medical condition of the patient and the severity of the pain being experienced. Over-the-Counter Medications Over-the-counter medications are frequently helpful in relieving symptomatic pain that is mild to moderate. Such medications may include analgesics such as acetaminophen and non-steroidal anti-inflammatory drugs, or NSAIDS, such as ibuprofen and naproxen. It is important for patients to consult with their physicians regarding appropriate dosages and to avoid possible interactions with prescribed medications or over-the-counter preparations they may be already taking. Opioids For severe or post-operative pain, opioids, sometimes known as narcotics, may be necessary. These may include codeine, propoxyphene (Darvocet), hydrocodone (Vicodin) and oxycodone (Percocet, Oxycontin). While these drugs can be extremely effective against pain, they tend to be addictive. Ultram (Tramadol), a prescribed medication called an opioid analgesic, is somewhere between an over-the-counter medication and a narcotic and may be habit-forming. Muscle Relaxants Muscle relaxants can also help to relieve symptoms of pain, particularly when such symptoms are associated with muscle spasms. Examples of commonly used muscle relaxants are cyclobenzaprine (Flexeril), carisoprodol (Soma) and diazepam (Valium).

Platelet-rich-plasma (PRP) injections use components of the body's own blood to stimulate healing. Platelets, which are usually associated with coagulation (clotting), are also, according to recent research, able to assist in mending and strengthening damaged tissue by increasing certain growth factors. During the normal healing process, the body uses platelets to promote new-tissue growth and repair injuries. By supplementing platelet content, the healing process is accelerated. There is ongoing research on the efficacy of PRP injections, and some medical professionals remain skeptical about their value. Conditions Treated with Platelet-Rich-Plasma Injections Platelet-rich-plasma injections can be used to treat a wide range of orthopedic conditions, including the following: Arthritis Tendonitis Bursitis Joint pain Ligament sprains or tears Nerve inflammation Postsurgical healing from tendon or ligament repair PRP therapy is also used to promote rapid healing after nonorthopedic surgeries, including cosmetic ones. Benefits of Platelet-Rich-Plasma Injections There are several benefits to PRP therapy. They include the fact that the platelet-rich plasma being injected is autologous (comes from the patient), so there is no risk of cross-reactivity, immune reaction or disease transmission. It is also minimally invasive (unlike surgery), and facilitates healing (unlike corticosteroids). The Platelet-Rich-Plasma-Injection Procedure During the PRP-injection procedure, which usually incorporates ultrasound imaging, a small amount of blood is withdrawn from the patient. This blood is processed in a centrifuge to separate its various elements, and concentrate the platelets. The resulting plasma is up to five times more concentrated with platelets than "natural" blood. Once concentrated, the platelets are loaded, along with some of the patient's whole blood, into a sterile syringe, and injected into the patient. The procedure is usually performed under local anesthetic in a physician's office. A typical patient experiences little or no discomfort from the injection, but the injection site is usually inflamed and sore for about 48 hours. Taking pain medication and applying ice are recommended. Most patients require one to three PRP injections, about 4 to 6 weeks apart, in order to achieve optimal results. Occasionally, a fourth injection is necessary. Typically, by the fifth day after an injection, the patient has a significant reduction in pain, and can begin physical therapy. Risks of Platelet-Rich-Plasma Injections Although PRP injections are generally safe and effective, sterilization is of great importance. There is a slight chance of infection or blood clots, and the remote possibility of allergic reaction.

Prolotherapy (proliferative therapy) is a treatment for patients with chronic joint and muscle pain; it is offered as an alternative to over-the-counter pain relievers (NSAIDs), corticosteroids and, in some cases, surgery. Prolotherapy is based on the premise that the injection of a mild irritant, usually dextrose, into a joint, ligament or tendon triggers a localized inflammatory response, thereby stimulating an increase in blood supply to damaged tissue. With this increased blood flow comes an increased supply of immune cells and collagen to assist in repairing the damage, and stimulating the formation of new, healthy connective tissue. Uses of Prolotherapy Prolotherapy is used to treat a variety of musculoskeletal conditions. Although its effectiveness has not been proven, proponents point out that it has seemingly successfully treated a wide variety of conditions, including the following: Osteoarthritis Fibromyalgia Connective-tissue damage Partially torn tendons or ligaments Sacroiliac and sciatic problems Chronic tendonitis Degenerative disc disease Whiplash Myofascial pain Although why it seems to work has not been established, there is anecdotal evidence that prolotherapy warrants further investigation and, as long as it seems to be helping patients, should continue to be used. In some documented cases, the tissue treated with prolotherapy appears to be stronger and thicker than the original. There is also evidence that prolotherapy repairs connective-tissue damage, even years after the original injury occurred. The Prolotherapy Procedure Prolotherapy solution is injected into the ligament or tendon at the site of the injury or damage. The precision with which the injection is placed ensures that the resulting inflammation is only to the damaged tissue. The body reacts by increasing the flow of blood and nutrients to the damaged area, helping tissue in the region to regenerate. Treatment with prolotherapy depends on the nature and extent of the damage within the joint, as well as how quickly a person heals. For some people, treatment may consist of only a few sessions, whereas others may require more than 10. For most injuries, the average number of treatment sessions is between four and six. Treatments may be administered every 2, 4 or 6 weeks. Risks of Prolotherapy Possible side effects, which can last between 2 and 4 days after treatment, include swelling at the injection site, fatigue, headache and nausea. More common side effects are soreness and some stiffness at the treatment site for 1 to 2 days post-procedure. The most serious risk, though rare, is that the injection, if incorrectly administered, will cause nerve damage.

Radiofrequency neurotomy is a treatment designed to provide relief from severe pain in the back or neck. It uses the heat generated by radiofrequency waves to interfere with the nerves' ability to send out pain signals. The heat generated by these waves is delivered to targeted nerve areas through special needles that are inserted, just above the spinal area, through the skin. Radiofrequency neurotomy does not usually provide permanent pain relief; its goal is to significantly decrease neck or back pain. Patients who have been previously unresponsive to more conservative methods of treatment, such as physical therapy or pain medication, are often candidates for this procedure. Candidates for Radiofrequency Neurotomy People experiencing chronic back or neck pain are considered good candidates for radiofrequency neurotomy. Patients who are taking blood-thinning medications are generally not good candidates because blood thinners can cause adverse reactions when mixed with the medication that is administered during radiofrequency neurotomy. A series of diagnostic tests are performed to determine whether radiofrequency neurotomy will be beneficial for the patient. The diagnostic testing process begins with the injection of a small amount of numbing medication into the area where the pain is located. The areas of the body that have been numbed by the medication are the locations where the radiofrequency needles are placed. Once the needles have been inserted, the patient's pain level is tested. If the pain gradually lessens, the patient is a good candidate for radiofrequency neurotomy. The Radiofrequency Neurotomy Procedure Radiofrequency neurotomy is performed as an outpatient procedure in a doctor's office, and is usually completed within an hour. The procedure begins with the placement of an intravenous (IV) line into the patient's arm or hand. The IV is used to administer medication that keeps the patient comfortable and relaxed during treatment. A specialized X-ray machine, known as a fluoroscope, provides information that allows for the most accurate positioning of the radiofrequency needles. This ensures that only the targeted nerve tissues are affected, and that the healthy surrounding nerve tissues remain undamaged. Risks of Radiofrequency Neurotomy The risks of radiofrequency neurotomy vary. Some patients experience mild and temporary discomfort/reactions, while other patients experience serious and long-term pain or discomfort. Complications include the following: Temporary pain/numbness where the needles were placed Persistent numbness that cannot be resolved with medication Paralysis Another possible complication of radiofrequency neurotomy is bowel or bladder incontinence. Recovery from Radiofrequency Neurotomy Patients can return home immediately following radiofrequency neurotomy. The recovery process varies from patient to patient, though most patients need only a few days to recover. One of the most commonly reported side effects of the procedure is mild, temporary soreness throughout the body; it is typically treated with rest, or over-the-counter pain medication. Results of Radiofrequency Neurotomy Radiofrequency neurotomy is more successful in some patients than others. The relief the procedure provides is only temporary, and lasts anywhere from just a few months to up to 2 years. Radiofrequency neurotomy can be repeated if pain recurs.

Sacroiliac-joint steroid injections help to diagnose and relieve lower-back pain caused by problems with one or both of the sacroiliac joints, which connect the spine's base (sacrum) to the pelvis's ilium bones. If one or both of the sacroiliac joints is inflamed (sacroiliac-joint dysfunction), a patient can experience pain in the buttocks and lower back that worsens when running or standing. Sacroiliac-joint dysfunction can be caused by osteoarthritis, traumatic injury, pregnancy, inflammatory joint disease, or underlying structural abnormalities. Reasons for Sacroiliac-Joint Steroid Injections A sacroiliac-joint steroid injection is used to confirm a diagnosis of sacroiliac-joint dysfunction. If the injection provides pain relief, it establishes the joint as the pain's source, and, at the same time, acts as a treatment. Corticosteroids, along with a local anesthetic and saline solution, are injected directly into the sacroiliac joint, reducing swelling and pain for, possibly, several months. As with other spinal blocks, a sacroiliac-joint injection can be repeated up to 3 times a year. Spinal injections only provide temporary relief from pain; they are not a cure. For that, surgery may be necessary. The Sacroiliac-Joint-Steroid-Injection Procedure To make sure the injection is placed in the correct spot, the procedure, which takes less than half an hour, is performed using imaging guidance and a contrast dye. The patient lies facedown on a surgical table, and the skin on the lower back is cleansed with an antiseptic solution. A local anesthetic is given to reduce discomfort from the injection, which contains steroid medication, saline solution and anesthetic. When the procedure is complete, the injection site is covered with a small bandage. The anesthetic in the injection provides immediate pain relief, and the steroid medication reduces inflammation within 24 to 48 hours. Recovery from Sacroiliac-Joint Steroid Injections In some cases, a patient's legs are affected by the anesthetic, causing numbness or weakness that can make walking difficult until the anesthetic wears off. Injection-site tenderness and swelling can occur, but they are usually mild, and can be minimized by applying ice. Normal activities can be resumed the next day. Only moderate exercise is allowed, but it can be increased in duration and intensity during the following 1 to 2 weeks. Risks of Sacroiliac-Joint Steroid Injections Although sacroiliac-joint steroid injections are considered safe, there are risks; they include infection, excessive bleeding, adverse reaction to medication, and damage to adjacent tissue. Post-injection, a diabetic patient may have temporary spike in blood sugar levels, and a patient with bipolar disorder may have a manic episode, making careful monitoring essential in these instances.

The sympathetic nervous system is responsible for regulating involuntary body functions, including blood flow, heart rate, digestion and perspiration. Sympathetic nerves spread outward from the spine, and, when compromised, can cause pain in various parts of the body. A sympathetic-nerve block is an injection of medication into whichever of these nerves is causing the pain. It works by numbing the nerve, which interrupts the pain signals the nerve is sending to the brain. It is used both to diagnose damage of and treat pain caused by the sympathetic nerves. Uses for Sympathetic-Nerve Blocks There are a number of uses for sympathetic nerve blocks; two of the most common are therapeutic and diagnostic. A therapeutic nerve block is used to treat pain; it typically contains a local anesthetic. Nerve blocks used to treat chronic pain can work for up to 6 to 12 months, and can be repeated as needed. A diagnostic nerve block is designed to determine the cause of pain; an anesthetic is injected only for the amount of time it takes to pinpoint the area causing the issue. Sympathetic-Nerve-Block Treatment Areas Injections of sympathetic nerve blocks are given near various areas of the spine. Types of blocks include stellate blocks, which target the upper spine's sympathetic nerves, including those that run to the chest, arms, neck and head; lumbar blocks, which target the lower spine's sympathetic nerves, including those that run to the legs and feet; and thoracic-region blocks, which target the mid-spine's sympathetic nerves, including those that run to the abdomen.

Spinal cord stimulation (SCS) typically involves implanting an electronic device in the body to help relieve chronic back and leg pain. The device, called a "spinal cord stimulator" or "dorsal column stimulator," sends electrical impulses through wires/electrodes placed near the spinal cord; the impulses block pain signals from reaching the brain. SCS does not cure chronic pain, but usually lessens it by 50 percent and more by replacing a patient's feeling of pain with a tingling sensation. Before implantation, a patient is asked to go through a trial period with an external device; this allows pain levels to be evaluated, and determine whether they decrease when the device is used. Candidates for Spinal Cord Stimulation Not everyone is a candidate for SCS. It is an option only for those who have tried, but been unsuccessful with, conservative treatments; will likely not be helped by surgery; are not addicted to drugs; have been psychologically evaluated; do not have pacemakers; and have undergone trials with an external spinal-cord stimulator. The Spinal-Cord-Stimulation Implantation Process Implantation of a spinal cord stimulator is a two-step process that involves first implanting the stimulator, and then a pulse generator to power it. To implant the stimulator, an incision is made in the patient's back; the wires with electrodes on the end are fed through and positioned on the spinal cord. Exact placement depends on the area of pain. To implant the pulse generator, an incision is made in the buttocks or abdomen, and the generator is placed between layers of skin and muscle. An extension wire is run from the spine to whichever area the generator is placed in. Incisions are closed with either staples or sutures. The procedure takes 3 or 4 hours, and the patient usually goes home on the same day. Recovery from the Spinal-Cord-Stimulation Implantation Process Pain from SCS implantation is treated with prescription medication and/or over-the-counter painkillers. A patient should refrain from lifting, bending, twisting and stretching during the healing process, which can take 6 to 8 weeks. Risks and Complications of Spinal Cord Stimulation In addition to the risks associated with any surgical procedure, those related to SCS include spinal-fluid leakage and paralysis. Complications related specifically to the stimulator include the following: Device works only intermittently or stops Device causes over-stimulation, or unpleasant sensations Stimulation occurs in the wrong place Device causes an allergic reaction It is also possible that the device's wires could shift or become damaged, which might require surgical intervention. The pulse generator's battery, if it is a standard one, needs to be surgically replaced every 2 to 5 years, although there are generators that run on rechargeable batteries that can last up to 10.

Trigger-point injections treat pain in areas that have developed trigger points, which are knots of muscle that form when muscles contract and but cannot relax. Trigger points are caused by injury to or overuse of the affected muscle; they can also be caused by stress and anxiety. They can irritate the nerves around them, which causes pain in other areas of the body. The chronic pain brought on by trigger points can also decrease the affected muscle's range of motion. Candidates for Trigger-Point Injections Trigger-point injections are typically used to treat pain in the neck, lower back, arms and legs. They can also be effective for tension headaches, temporomandibular joint (TMJ) pain or fibromyalgia, and for myofascial pain syndrome, a chronic pain condition in which trigger points develop in certain muscles, and cause pain when touched. Patients with this condition often experience deep, aching pain in the affected muscle that worsens over time, as well as muscle and joint stiffness, and difficulty sleeping. Symptoms can significantly affect a person's quality of life, and should be addressed if they do not subside. Over time, patients with untreated myofascial pain syndrome can develop muscle weakness or fibromyalgia. The Trigger-Point Injection Procedure A needle containing a local anesthetic, and, sometimes, a corticosteroid to reduce inflammation, is inserted into the trigger point to make it inactive and, therefore, alleviate the pain. The procedure typically takes between 15 and 20 minutes, and is done in a doctor's office. If necessary, multiple sites can receive trigger point injections in one appointment. Risks of Trigger-Point Injections Trigger-point injections are considered safe, and have few side effects. The patient may feel sore around the injection site for up to 2 days, but applying ice usually helps. In most cases, normal activities can be resumed the next day. Trigger-point injections not only relieve pain, they loosen the muscles that are responsible for the pain, which facilitates the rehabilitation process.