EPIDURAL INJECTIONS
EPIDURAL INJECTIONS TREAT THE INFLAMMATION, CHEMICAL IRRITATION, AND OTHER PATHOLOGY ASSOCIATED WITH DISC RUPTURE AND DISC BULGE CAUSING BACK AND NECK PAIN AT THE SPINAL NERVE LEVEL.
CLINICAL EXPERIENCE SHOWS THAT MANY PATIENTS HAVE DRAMATIC RESPONSES.
A RECENT STUDY (LUTZ ET.AL) DEMONSTRATED PAIN RELIEF FOR MORE THAN 2 YEARS IN 78% OF 200 CONSECUTIVE PATIENTS.
A RETROSPECTIVE STUDY (SAAL ET.AL) COMBINING COMPREHENSIVE REHAB WITH EPIDURAL STEROID INJECTIONS YIELDED A 90% GOOD TO EXCELLENT OUTCOME WITH A 92% RETURN TO WORK RATE.
FOR PATIENTS IN BOTH STUDIES, THE ALTERNATIVE WOULD HAVE BEEN A MAJOR SURGICAL PROCEDURE.
RELATIVE TO SURGERY, EPIDURAL INJECTIONS ARE SAFE AND INEXPENSIVE. THEY ARE DONE ON AN OUTPATIENT BASIS WITH LITTLE OR NO DOWN TIME AND DO NOT HAVE THE MORBIDITY OR MORTALITY RATES ASSOCIATED WITH SURGERY AND GENERAL ANESTHESIA.
WITH ALL EPIDURAL INJECTIONS, X-RAY GUIDANCE (FLUOROSCOPY) SHOULD BE USED TO ASSURE CORRECT PLACEMENT OF THE NEEDLE AND MEDICATION. WITHOUT X-RAY GUIDANCE, A 30% ERROR RATE HAS BEEN DOCUMENTED EVEN IN THE MOST EXPERIENCED HANDS.
CANCER PAIN
CANCER PAIN VARIES WITH THE TYPE OF CANCER AND STAGE OF DISEASE.
THE MOST SPECIFIC TREATMENT FOR THE TYPE OF PAIN PRESENT SHOULD BE ADMINISTERED.
THIS MAY BE THE SAME TREATMENT USED FOR THE NON-CANCER PATIENT.
EPIDURAL BLOCKADE, FOR EXAMPLE, IS DONE THE SAME WAY FOR THE CANCER PATIENT AS FOR THE BACK PAIN PATIENT WITH A HERNIATED DISC.
CERTAINLY, THE TERMINALLY- ILL PATIENT WITH SEVERE PAIN CAN BE TREATED MORE AGGRESSIVELY BUT SIDE EFFECTS MUST BE REVIEWED. KNOWLEDGE OF THE ORIGIN AND PATTERN OF CANCER PAIN IS ESSENTIAL IN DEVELOPING A TREATMENT PROGRAM.
FOR EXAMPLE: INTERMITTENT VISCERAL OR ABDOMINAL PAIN RESPONDS POORLY TO SPINAL OPIOIDS (NARCOTICS).
CENTRAL PAIN IN THE CANCER PATIENT IS ROUTINELY NOT RESPONSIVE ON A PROLONGED BASIS TO NEURAL BLOCKADE, BUT OFTEN RESPONDS TO STIMULATION TECHNIQUES.
EACH CANCER PATIENT, THEREFORE, MUST BE EVALUATED INDIVIDUALLY TO DETERMINE THE BEST MANAGEMENT TECHNIQUES.
HEADACHE
MIGRAINE VS TENSION HEADACHE
MIGRAINE HEADACHE TENDS TO BE UNILATERAL WHILE TENSION HEADACHE IS BILATERAL
MIGRAINE PAIN IS THROBBING OR PULSATILE WHILE TENSION HEADACHE IS A STEADY ACHE OR SQUEEZING, PRESSURE-TYPE SENSATION.
MIGRAINE PAIN IS NORMALLY MODERATE TO SEVERE WHILE TENSION HEADACHE IS MILD TO MODERATE.
MIGRAINE IS AGGRAVATED BY ROUTINE PHYSICAL ACTIVITY, LIKE CLIMBING STAIRS, WHILE TENSION HEADACHE IS NOT.
TENSION HEADACHE ROUTINELY LACKS THE MIGRAINE-DEFINING SYMPTOMS OF AURA, NAUSEA/VOMITING, AND INABILITY TO TOLERATE LIGHT AND SOUND.
MIGRAINE IS VIEWED AS A DISEASE OF THE BRAIN: CHANGES IN THE BLOOD VESSELS OF THE BRAIN ARE FELT TO PRODUCE MIGRAINE PAIN.
THE MECHANISM OF PAIN IN TENSION HEADACHE REMAINS UNCLEAR ALTHOUGH SOME RECENT THINKING SUGGESTS THE TWO MAY BE RELATED.
BRAIN TUMOR HEADACHE
THE CLASSIC BRAIN TUMOR HEADACHE IS A MORNING HEADACHE THAT CAN AWAKEN THE PATIENT FROM SLEEP.
IT IMPROVES AS THE DAY GOES ON AND ROUTINELY RESPONDS TO ASPIRIN AND STEROIDS.
THE CLASSIC HEADACHE SYNDROME OCCURS IN ONLY 17-20% OF BRAIN TUMOR PATIENTS.
INCREASED INTRACRANIAL PRESSURE MAY OCCUR WITH SLEEP OR LYING DOWN, THEREBY INCREASING PAIN FROM BRAIN TUMORS.
MILD CO2 RETENTION DURING SLEEP DILATES BLOOD VESSELS CAUSING INCREASED PRESSURE.
WITH AWAKENING OR AMBULATION, CO2 DROPS INCREASING VENOUS RETURN OF BLOOD AND HEADACHE IMPROVES AS THE DAY PROGRESSES.
HEADACHE FOLLOWING CAR ACCIDENTS
UP TO 75% OF HEADACHES AFTER WHIPLASH INJURIES ARE DUE EITHER TO OCCIPITAL NERVE TRAUMA (OCCIPITAL NEURALGIA) OR TO FACET JOINT ARTHROPATHY (INJURY TO THE JOINTS OF THE NECK THE ALLOW MOTION TO OCCUR).
TYPICALLY THERE IS PAIN ON ONE OR BOTH SIDES THAT RADIATES TO THE AREA ABOVE THE EAR OR BEHIND THE EYE.
TRAUMA TO THE OCCIPITAL NERVE OR ITS PARENT NERVE (C2) IS SUSPECTED. IT ROUTINELY RESPONDS TO TREATMENT AT THE C2 LEVEL.
FATIGUE
FATIGUE IS AN OVERWHELMING LACK OF ENERGY.
THE PATIENT FEELS WEAK AND LOSES INTEREST IN PEOPLE AND ACTIVITIES THEY NORMALLY ENJOY
IT IS NOT RELATED TO EXERTION AND IS NOT RELIEVED BY SLEEP.
IT CAN RESULT FROM PAIN, STRESS, CANCER, MEDICATION, DEPRESSION, AND OTHER MEDICAL CONDITIONS.
DON’T HIDE IT! THERE MAY BE A MEDICAL CAUSE THAT CAN BE TREATED. SOME COMMON TREATABLE CONDITIONS INCLUDE:
1. MOST TYPES OF PAIN
2. ANEMIA WHICH IS A LOW NUMBER OF RED BLOOD CELLS.
3. HYPOTHYROIDISM
4. DEPRESSION
PAIN ITSELF MAKES ACTIVITY MORE DIFFICULT BOTH MENTALLY AND PHYSICALLY.
FATIGUE RELATED TO PAIN REQUIRES EVALUATION BY A QUALIFIED PHYSICIAN AND REST WHEN YOU NEED IT.
KEEP A REGULAR DAILY ROUTINE. ACTIVITY IS THERAPEUTIC.
START AN EXERCISE PROGRAM SUPERVISED BY YOUR DOCTOR.
EAT WELL, DRINK LOTS OF WATER, AND AVOID CAFFEINE IN THE EVENING.
DELEGATE CHORES THAT ARE PAINFUL AND GET A HANDLE ON STRESS.
NON-SURGICAL DISK DECOMPRESSION
THERE ARE SEVERAL GOOD ALTERNATIVES TO SURGERY FOR SYMPTOMATIC DISC BULGES AND CONTAINED DISC HERNIATIONS.
THEY SHOULD BE CONSIDERED AFTER DISCOGRAPHY SHOWS WHICH DISC IS THE PAIN GENERATOR AND OUTLINES THE DISC DEFECT. (SEE DISCOGRAPHY)
LASER DISC DECOMPRESSION, NUCLEOPLASTY AND "DEKOMPRESSOR" ARE ALL EFFECTIVE TREATMENT METHODS.
DEKOMPRESSOR AND NUCLEOPLASTY ARE PREFERRED IN OUR CLINIC BECAUSE THEY ARE SIMPLER PROCEDURES WITH MINIMAL SIDE EFFECTS AND MINIMAL DOWN TIME.
THEY REMOVE APPROXIMATELY ONE TO ONE AND ONE HALF CUBIC CENTIMETERS OF DISC MATERIAL FROM THE AREA OF BULGE OR HERNIATION THEREBY REDUCING THE DEGREE OF DISC PATHOLOGY AND DISCOGENIC PAIN.
THEY ARE 20 MINUTE OUTPATIENT PROCEDURES DONE UNDER LOCAL ANESTHESIA WITH MILD SEDATION AND X-RAY GUIDANCE.
AS OPPOSED TO THE LASER METHOD THERE IS LESS DISCOMFORT BOTH DURING AND AFTER TREATMENT.
THEY ARE RELATIVELY NEW TECHNIQUES WHICH HAVE GAINED RAPID AND WIDE-SPREAD ACCEPTANCE IN THE MEDICAL COMMUNITY BECAUSE OF THEIR SAFETY AND HIGH SUCCESS RATE.
SACROILIAC JOINT PAIN
SACROILIAC JOINT PAIN MAY BE THE MOST UNDER-DIAGNOSED LOW BACK PAIN CONDITION.
UP TO 30% OF ALL LOW BACK PAIN COMING TO THE ATTENTION OF A PHYSICIAN IS ESTIMATED TO ORIGINATE IN THE SACROILIAC JOINT.
PAIN IS LOCALIZED TO THE BUTTOCK AREAS BUT MAY SPREAD INTO THE SACRUM, HIP AND LEGS. IT IS THERFORE COMMONLY MISDIAGNOSED AS NERVE ROOT PAIN.
SACROILIAC JOINT PAIN DOES NOT EXTEND ABOVE THE 5TH LUMBAR LEVEL.
THE DIAGNOSIS IS MADE ON THE PHYSICAL EXAMINATION.
THE X-RAY AND MRI APPEARANCE OF THE JOINT HAVE LITTLE RELATION TO THE DEGREE OF PAIN.
PAIN FROM A DEGENERATED LOW BACK DISC, USUALLY L5-S1, CAN MIMIC SACROILIAC JOINT PAIN BUT IS FAR LESS COMMON.
DIAGNOSTIC INJECTIONS REMAIN THE GOLD STANDARD FOR ESTABLISHING THE DIAGNOSIS.
IF THE DIAGNOSTIC INJECTION RELIEVES PAIN FOR THE DURATION OF THE LOCAL ANESTHETIC, A THERAPEUTIC RADIOFREQUENCY DENERVATION PROCEDURE SHOULD PROVIDE PROLONGED PAIN RELIEF.
RADIOFREQUENCY DENERVATION WARMS THE SMALL UNINSULATED PAIN FIBERS TO 90 DEGREES CENTIGRADE AND SELECTIVELY BLOCKS THE FLOW OF PAIN FROM THE JOINT TO THE BRAIN.
NO LOSS OF STRENGTH OR SENSATION OCCURS WHEN TREATMENT IS PROPERLY ADMINISTERED.
THE PROCEDURE IS SAFE AND EFFECTIVE AND IS DONE ON AN OUTPATIENT BASIS WITH LITTLE OR NO DOWN TIME .
COMPREHENSIVE PAIN MANAGEMENT
THE 3 ESSENTIAL ASPECTS OF PAIN MANAGEMENT ARE:
1. AN ACCURATE DIAGNOSIS IS MANDATORY. IF AN ADEQUATE MEDICATION TRIAL HAS NOT BEEN ADMINISTERED, IT SHOULD PRECEDE AN INTERVENTIONAL PROCEDURE. ONCE THE DIAGNOSIS IS ESTABLISHED, A THERAPEUTIC OR DIAGNOSTIC PROCEDURE SHOULD BE PROVIDED WITH GENTLENESS AND PRECISION, KEEPING PATIENT COMFORT AND SAFETY IN MIND. FLUOROSCOPIC (X-RAY) GUIDANCE IS ESSENTIAL FOR SAFETY AND PRECISION.
2. THE SECOND ASPECT IS PSYCHOLOGICAL SUPPORT.
DEPRESSION, ANXIETY, INSOMNIA, AND EMOTIONAL DISTRESS ARE COUNTERPRODUCTIVE AND SHOULD BE ADDRESSED BY THE PHYSICIAN.
3. THE THIRD ASPECT IS PHYSICAL REHABILITATION TO RESTORE THE PATIENTS ABILITY TO FUNCTION NORMALLY ON A DAILY BASIS.
INTERVENTIONAL PAIN PROCEDURES ARE DONE TO ALLOW THE PATIENT TO PARTICIPATE IN REHABILITATION THERAPY AND TO PURSUE NORMAL DAILY ACTIVITIES.
MRI SCANS
MRI SCANS, CT SCANS, X-RAYS, AND ELECTRODIAGNOSTIC STUDIES ARE DONE TO CLARIFY FINDINGS ON THE PHYSICAL EXAM.
WITHOUT A METICULOUS PHYSICAL AND NEUROLOGICAL EXAM, THESE STUDIES HAVE NO SIGNIFICANT DIAGNOSTIC VALUE IN EVALUATING PAIN.
WHEN YOU LIE ON YOUR BACK THERE MAY BE VERY LITTLE DISC BULGE. HOWEVER, WHEN YOU ARISE OR BEND OVER THERE MAY BE A LARGE BULGE OR EVEN DISC HERNIATION.
MOREOVER, CHEMICAL AND INFLAMMATORY CHANGES ASSOCIATED WITH DISC HERNIATION MAY CAUSE SEVERE PAIN, WEAKNESS AND NUMBNESS WITHOUT MAJOR MRI CHANGES.
THE PHYSICAL AND NEUROLOGICAL EXAMINATION, THEREFORE, SHOULD ALWAYS BE THE BASIS FOR DEVELOPING THE CARE PLAN.
THE EXAMINATION MUST BE REPEATED AT EVERY CLINIC VISIT TO OBJECTIVELY ASSESS PROGRESS AND INTERIM CHANGES.
PHANTOM LIMB PAIN
THE INCIDENCE OF PHANTOM LIMB PAIN IN AMPUTEES IS AT LEAST 10%.
A SENSATION THAT THE LEG IS STILL THERE AFTER AMPUTATION IS NORMAL AND USUALLY DOES NOT INVOLVE PAIN.
50-60% OF ALL AMPUTEES WILL HAVE THIS PAINLESS SENSATION ONE YEAR AFTER AMPUTATION. IT GENERALLY GOES AWAY AFTER 2-3 YEARS IF THERE IS NO PAIN.
THERE ARE MANY DIFFERENT TYPES OF PHANTOM LIMB PAIN, ALL OF WHICH ARE DIFFICULT TO TREAT.
IF A PROSTHETIC LIMB IS USED, PROPER FIT OF THE PROSTHESIS MUST BE DOCUMENTED BEFORE OTHER TREATMENT MEASURES ARE CONSIDERED.
TREATMENT THEN SHOULD BE TAILORED TO THE TYPE OF PAIN PRESENT.
SEVERE, REFRACTORY PAIN MAY REQUIRE A SPINAL CORD STIMULATOR.
SPINAL STENOSIS
SPINAL STENOSIS IS COMPRESSION OF THE SPINAL CORD FROM NARROWING OF THE BONY SPINAL CANAL.
THE MORE COMMON FORM OCCURS IN THE ELDERLY FROM VERTEBRAL COLLAPSE, ARTHRITIS, AND CHRONIC MALALIGNMENT OF THE FACET JOINTS WHICH IS WHERE SPINAL MOTION OCCURS.
ALL 3 CONDITIONS ARE ASSOCIATED WITH INFLAMMATORY AND CHEMICAL MEDIATORS. THE BENEFIT OF EPIDURAL INJECTIONS LIES IN ITS DEMONSTRATED EFFECT IN REDUCING THE INFLAMMATORY RESPONSE.
THE PERIOD OF PAIN RELIEF FROM EPIDURAL INJECTIONS RANGES FROM 4 TO 10 MONTHS.
IT IS A SIMPLE OUTPATIENT PROCEDURE THAT MAY ELIMINATE THE NEED FOR MAJOR SURGERY AND/OR PROVIDE A SAFE AND EFFECTIVE OPTION FOR OLDER PATIENTS WHO ARE NOT SURGICAL CANDIDATES
DISCOGRAPHY
THE PURPOSE OF PROVOCATIVE DISCOGRAPHY IS TO IDENTIFY A PAINFUL INTERVERTEBRAL DISC. THE PROCEDURE INVOLVES STRESSING THE DISC BY INJECTING DYE INTO THE DISC CENTER USING X-RAY GUIDANCE FOR ACCURACY AND A MANOMETER TO MEASURE PRESSURE. IF A PARTICULAR DISC IS THE CAUSE OF PAIN THEN STRESSING IT SHOULD REPRODUCE THE NORMALLY EXPERIENCED PAIN. IF THE DISC IS NOT THE SOURCE OF PAIN THEN STRESSING IT SHOULD EITHER NOT BE PAINFUL OR SHOULD PRODUCE A PAIN THAT IS UNLIKE THE PATIENT'S NORMALLY EXPERIENCED PAIN. WHEN NECESSARY, DISCOGRAPHY IS SUPPLEMENTED BY POST-DISCOGRAPHY CT SCANNING WHICH HAS THE ABILITY
TO SHOW DETAILS OF DISC DISRUPTION. THE CT INFORMATION THEN GUIDES THE INJECTIONIST OR SURGEON IN PROPERLY TREATING THE PAINFUL DISC.
ARACHNOIDITIS
SPINAL ADHESIVE ARACHNODITIS IS AN INFLAMMATORY CONDITION THAT MAY FOLLOW TRAUMA, TUMOR, INFECTIONS, BLEEDING, OR ADMINISTRATION OF VARIOUS COMPOUNDS INTO THE SPINAL FLUID. THESE COMPOUNDS INCLUDE SOME MYELOGRAM DYES, POTASSIUM, THIOPENTAL SODIUM, AND EVEN STEROIDS AND BETADINE. ARACHNOIDITIS LEADS TO CLUMPING AND THICKENING OF THE NERVE ROOTS AND PROGRESSIVE SCARRING OR ADHESIONS. UNFORTUNATELY, THERE IS NO TREATMENT FOR THIS CONDITION UNLESS AN ANTIBIOTIC-SENSITIVE INFECTION IS IDENTIFIED AS THE CAUSE. ONE OF THE REASONS WE STRONGLY ADVOCATE XRAY VISUALIZATION OF ALL SPINAL PROCEDURES IS TO AVOID INADVERTANT INJECTION OF ANYTHING INTO THE SPINAL CANAL. THE CONSEQUENCES OF ARACHNOIDITIS INCLUDE NECK AND BACK PAIN, RADIATING PAIN IN THE DISTRIBUTION OF THE INVOLVED NERVES, SENSORY LOSS IN THE GENITAL AREA, OCCASIONALLY LEG WEAKNESS OR PARALYSIS AND LOSS OF THE BOWEL AND BLADDER CONTROL.
VERTEBROPLASTY
VERTEBAL COMPRESSION FRACTURES ARE FRACTURES OF THE BACKBONES (VERTEBRAE).
THEY ARE COMMON IN POST-MENOPAUSAL WOMEN WITH OSTEOPOROSIS AND IN PATIENTS WITH TUMOR INFILTRATING THE BACKBONE.
THEY ARE OFTEN THE CAUSE OF BACK PAIN.
VERTEBROPLASTY IS A SAFE AND EFFECTIVE MEANS OF TREATING THESE AREAS OF COMPRESSION OR FRACTURE.
THE PROCEDURE INVOLVES INJECTING ACRYLIC CEMENT, WHICH IS USED AS A BONE FILLER, INTO THE AREA OF FRACTURE OR COMPRESSION OF THE VERTEBRAL BONE.
VERTEBROPLASTY OFFERS RAPID RELIEF OF THE PAIN ASSOCIATED WITH VERTEBRAL COMPRESSION FRACTURE AND IS EVOLVING AS THE ACCEPTED INTERVENTIONAL STANDARD OF CARE FOR THE CONDITION.
PATIENT SELECTION IS CRITICAL AND REQUIRES A HIGH LIKLIHOOD THAT THE COMPRESSION FRACTURE IS THE CAUSE OF PAIN.
AN MRI SCAN AND METICULOUS PHYSICAL EXAMINATION ARE MANDATORY TO RULE OUT OTHER CAUSES.
HIGH QUALITY FLUOROSCOPY (MOVABLE X-RAY) IS ESSENTIAL TO ENSURE SAFETY.
THE CEMENT MUST BE OBSERVED DURING INJECTION TO PREVENT IT FROM GOING ANYWHERE BUT TO THE INTENDED SITE.
WHEN PROPERLY ADMINISTERED, IT IS A SIMPLE, SAFE AND EFFECTIVE, OUTPATIENT PROCEDURE THAT CAN RAPIDLY RELIEVE PAIN AND IMPROVE QUALITY OF LIFE.
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