Pain Management Procedures

Epidural Steroid Injections

Many patients have heard about epidural injections (commonly known as epidurals) because they, their friends, or their spouses have had epidurals for labor delivery. Epidurals are currently the standard pain management for labor delivery in the U.S. and most developed countries.

So what are epidurals?

The human spinal cord is an organ controlling sensation, movement, vascular construction, sweating, and hormone production. Similar to the brain, the spinal cord is well protected with spinal fluid, which is contained by a few layers of membranes. The outside layer of the membranes is the thickest and strongest layer, named dura. In the spinal canal, there is a loose space between the dura and surrounding bone structures called the epidural space, where spinal nerve roots exit the spinal cord and spinal canal to reach every part of the body. Epidural injections mean delivery of medications to the epidural space.

Epidural steroid injections are used to reduce inflammatory response of the spinal nerves or discs, caused by a variety of reasons. Selective nerve blocks are also called transforaminal epidural steroid injections. The medications are selectively delivered to particular spinal nerve roots through neuroforamina, which are canals that the spinal nerves use to exit the spinal column. If the pain is relieved by selective nerve blocks, it suggests the pain generators are related to inflammation in those particular nerve roots. Therefore selective nerve blocks are not only therapeutic but are frequently used for diagnostic purposes.

Epidural steroid injections are very simple and safe procedures. They are done under x-ray guidance and with light sedation. Patients are normally released after 1-2 hours and can return to their normal work and activities the next day if sedation is used.

Radiofrequency Lesioning

Radiofrequency nerve ablation (neurotomy) has a long history in the treatment of spine facet joints. Clinically, pain from facet joints are located along the spine and do not travel to distal extremities. This technique is an emerging therapy for sacroiliac joint pain. At the sacroiliac joint level, the procedures are more complex due to the area's nerve supply variability.

Radiofrequency nerve ablation of facet joints is performed in an operative setting using mild sedation and local anesthetics. Fluoroscopic x-ray guidance allows the physician to accurately position the radiofrequency probe adjacent to the medial branch nerves to be treated. The nerve is then heated to 80C using a radiofrequency generator.

Nerve functions usually recover within 12 months. It has been demonstrated that muscles innervated by these medial branches undergo atrophy following successful denervation. However, patients never complain of weakness or instability following procedure.

A number of studies have been performed on the efficacy of radiofrequency nerve ablation. For example, it has been shown that lumbar radiofrequency nerve ablation is effective for facet joint pain. Medical literatures demonstrated that at 12 months, 60% of patients had 90% relief, and 90% had 60% relief.

Side effects of radiofrequency nerve ablation potentially include:

• Rare, but possible, allergic reaction to local anesthetic.
• Bleeding and bruising; the effects are minimal and should disappear within days.
• Infection, though unlikely.
• Post procedure soreness is extremely variable and dissipates within a few days

Spinal Cord Stimulator

Nerve modulation techniques have been used for a few decades. A spinal cord stimulator is one of the nerve modulation techniques for spinal pain. It is considered the last resort of pain management. It does not address the causes of the pain, but serves as a very effective pain killer. The electrical wires are inserted into the spinal canal, stimulating the spinal cord, which is the center for pain transmission. The wires are connected to a programmable pulse generator, which is buried under the skin. The artificial electric pulses are felt as a comfortable buzzing in the pain area and the usual pain in these areas abate considerably.

A spinal cord stimulator is typically given to people who have failed previous spine surgeries, pain due to nerves, diabetic neuropathy, and pain from peripheral vascular diseases. It is also wildly used for intractable angina in European countries, but not in the US.

Atlantic Spinal Care can help you if you have persistent lower back and neck pain even if you have failed surgeries or other intractable pain syndromes.