→ Lumbar Transforaminal epidural injection
→ Epidural steroid injections for disc prolapse
→ Disc procedures – Ozone Nucleolysis
→ Facet joint and Medial Branch nerve injections
→ Sacro-iliac Joint Injection
→ PIriformis block
→ Percutaneous Vertebroplasty
→ Radiofrequency Neuroablation
→ Sympathetic plexus blockade - Lumbar sympathetic block,
→ Lumbar Provocative Discography
→ Suprascapular block for frozen shoulder
→ Stellate ganglion Block,
→ Peripheral nerve blocks
→ Intra-articular Injections
Epidural glucocorticoid injections are commonly given to patients with leg and/or back pain to relieve such pain and improve mobility without surgery. These steroid injections buy time to allow healing to occur and/or as an attempt to avoid surgery after other conservative (non-surgical) treatment approaches have failed.
During a transforaminal injection, a small-gauge blunt needle is inserted into the epidural space through the bony opening of the exiting nerve root (See Figure 1, Neuroforamen).
Figure 1. Spinal nerve structures; nerve root and neuroforamen
The needle is smaller in size than that used during a conventional epidural approach. The procedure is performed with the patient lying on their belly using fluoroscopic (real-time x-ray) guidance, which helps to prevent damage to the nerve root. A radiopaque dye is injected to enhance the fluoroscopic images and to confirm that the needle is properly placed (See Figure 2). This technique allows the glucocorticoid medicine to be placed closer to the irritated nerve root than using conventional interlaminar epidural approach. The exposure to radiation is minimal.
Figure 2. Transforaminal spread of the radiopaque
dye to confirm correct needle placement.
Spinal Conditions Treated and Outcomes
Indications include large disc herniations, foraminal stenosis, and lateral disc herniations. Patients with disc herniations and leg pain in most of the studies attained maximal improvement in 6 weeks. Interestingly, long-term success rates for transforaminal epidural glucocorticoid injections ranged from 71% to 84%.
Is More than One Injection Necessary?
As a rule, patients who obtained little relief from the first injection got little benefit from a second or third injection. Those patients with degenerative lumbar canal stenosis and patients who failed previous therapies may significantly improve standing and walking tolerance following transforaminal lumbar steroid injections. However, only about 15% to 61% of interventional pain management physicians perform transforaminal epidural injections. Interestingly, almost every single interventional pain management physician uses the conventional, interlaminar epidural injection.
Epidural Steroid (cortisone) Injection
Epidural gluco-corticoid injections are commonly given to patients with leg and/or back pain to relieve such pain and improve mobility without surgery. These steroid injections buy time to allow healing to occur and/or as an attempt to avoid surgery after other conservative (non-surgical) treatment approaches have failed.
During a trans-foraminal injection, a thin needle is inserted into the epidural space through the bony opening of vertebral column from where a nerve root exits. (See Figure 1, Neuroforamen). The drug is delivered exactly in the area where disc is compressing nerve and causing inflammation.
The procedure is performed with the patient lying on their belly using fluoroscopic (real-time x-ray) guidance, which helps to prevent damage to the nerve root. A radio-opaque dye is injected to enhance the fluoroscopic images and to confirm that the needle is properly placed (See Figure 2). This technique allows the cortisone medicine to be placed closer to the irritated nerve root. The exposure to radiation is minimal.
Indications include disc herniations, Lumbar canal stenosis, vertebral fractures, Cancer tumor compressing epidural space, Herpes zoster pain etc.
Patients with disc herniations and leg pain attains maximal improvement in 6 weeks. Interestingly, long-term success rates for trans-foraminal epidural glucocorticoid injections ranged from 71% to 84%.
Therapeutic Rationale – why steroids?
→ Structures (pain generators) like nerves/discs are accessible to neural blockade.
→ Surgery of these structures may fail to cure and may worsen painful spinal conditions.
→ Degenerative processes of the spine and the origin of spinal pain is complex.
→ The effectiveness of a large variety of therapeutic interventions used to manage chronic spinal pain has not been demonstrated conclusively.
→ There is increasing evidence supporting the use of interventional techniques in managing spinal pain
Injection of ozone gas into the knee and other joints has clinically proven to reduce pain and inflammation
Ozone Injections deliver active oxygen (mixture of oxygen and ozone – O3) directly into the problem area. This, minimally invasive, treatment delivers regenerative and anti-inflammatory power of medial ozone directly into the inflamed tissue. Ozone can provide pain relief and start regenerate the tissue, even for patients with severe damage to their joints, by activating your own Stem Cells, which has a power to repair and rebuild your damaged cells. Ozone also activate your natural anti-oxidant system that takes control over free radical invasion, the true culprits of cell damage resulted from chronic inflammation that also causes pain. Ozone injections increase circulation and encourage a synthesis of collagen and cartilage. Ozone addresses the key issues in almost all disease conditions: oxygen delivery, circulation, and immune system function.
→ Medial branch nerves are small nerves that feed out from the facet joints in the spine and carry pain signals from the facet joints to the brain.
Facet joint injections involve an injection of anti-inflammatory steroid solution directly into the joint. If such an injection confirms the facet joint as the likely source of the patient's pain, but this injection - along with other treatments (such as physical therapy, manual manipulation, and medications) have not resulted in long term pain relief, then a medial branch block may be recommended.
→ As evidence evolves on the efficacy of facet joint injections, a medial branch block may also be considered instead of a facet joint injection. A medial branch block might also be considered first if for any reason the patient cannot tolerate the steroid and/or an injection directly into the facet joint.
→ Role of a Medial Branch Radiofrequency Neurotomy (Ablation)
In cases where a medial branch nerve block has confirmed that a patient's pain originates from a facet joint, a radiofrequency neurotomy can be considered for longer term pain relief.
→ A radiofrequency neurotomy is a type of injection procedure in which a heat lesion is created on the nerve that transmits the pain signal to the brain. The goal of a radiofrequency neurotomy is to interrupt the pain signal to the brain, while preserving other functions, such as normal sensation and muscle strength.
Facet joint injections usually have two goals: to help diagnose the cause and location of pain and also to provide pain relief:
→ Diagnostic goals: By placing numbing medicine into the facet joint, the amount of immediate pain relief experienced by the patient will help determine if the facet joint is a source of pain. If complete pain relief is achieved while the facet joint is numb, it means that joint is likely a source of pain.
→ Pain relief goals: Along with the numbing medication, a facet joint injection also includes injecting time-release steroid (cortisone) into the facet joint to reduce inflammation, which can sometimes provide longer-term pain relief.
The injection procedure may also be called a facet block, as its purpose is to block the pain.
→ A sacroiliac injection places a pain-numbing medicine and steroid directly into the sacroiliac (SI) joint. The benefit of this procedure is to reduce inflammation, help confirm the SI joint as the source of pain, and better allow a physical therapist to treat the joint.
→ If successful in relieving pain, repeated injection every few months gap can be done to maintain pain free status.
strengthen your muscles. You may have injections every three months. Phenol or alcohol injections into your peripheral nerve near the spastic muscles may reduce your muscle spasms.
→ Piriformis block
→ Piriformis steroid injection is made in piriformis muscle belly with the help of C-arm or ultrasound
Vertebroplasty is a minimally invasive procedures for the treatment of painful vertebral compression fractures (VCF), which are fractures in the spine.
When a vertebral body fractures, the usual rectangular shape of the bone becomes compressed, causing pain. These compression fractures may involve the collapse of one or more vertebrae in the spine and are a common result of osteoporosis. Osteoporosis is a disease that results in a loss of normal bone density, mass and strength, leading to a condition in which bones are increasingly porous, and vulnerable to breaking. Vertebrae may also become weakened by cancer.
You are an ideal candidate for vertebroplasty if you:
→ are elderly or frail and will likely have impaired bone healing after a fracture
→ have vertebral compression due to a malignant tumor
→ suffer from osteoporosis due to long-term steroid treatment or a metabolic disorder
In vertebroplasty, pain physicians use image guidance to inject a cement mixture into the fractured bone through a hollow needle. Shortly after the cement has hardened, the patient is free to leave the pain clinic and can go home the same day. If the patient needs further observation after the procedure, is particularly frail, or will not have assistance at home, a short stay in the pain clinic may be recommended.
For the first 24 hours after vertebroplasty, bedrest is usually recommended. Activities may be increased gradually and most regular medications can be resumed. There may be some soreness for a few days at the puncture site which may be relieved with an ice pack.
Many patients undergoing percutaneous vertebroplasty experience 90 percent or better reduction in pain within 24-48 hours and increased ability to perform daily activities shortly thereafter. Recent research has demonstrated that percutaneous vertebroplasty can relieve pain from vertebral compression fractures for up to nearly three years following the procedure.
Vertebroplasty has several benefits:
Return to normal activity: Many people with compression fractures are unable to do everyday tasks because of the pain. Vertebroplasty stabilizes the fracture, allowing most people to resume previous levels of activity within a few days.
Reduced pain medication: Vertebroplasty reduces and sometimes eliminates the need for pain medication.
Prevention of further fractures: The cement fills the spaces in bone weakened by osteoporosis. The treated bone is less likely to crack or fracture again.
Radiofrequency ablation (or RFA) is a procedure used to reduce pain. An electrical current produced by a radio wave is used to heat up a small area of nerve tissue, thereby decreasing pain signals from that specific area. RFA can be used to help patients with chronic (long-lasting) low-back pain. RFA has proven to be a safe and effective way to treat some forms of pain. It also is generally well-tolerated, with very few associated complications.
Radiofrequency waves are electromagnetic waves which travel at the speed of light, or 300,000 km/s. Radiofrequency Energy is a type of heat energy that is created by a special generator at very high or super high frequencies. With the use of this specialized generator, heat energy is created and delivered with precision to target nerves that carry pain impulses. The resulting “lesion”involves a spherical area of tissue destruction at the tip of the RF needle that can include pain-carrying nerves.
Radiofrequency ablation/lesioning is a procedure used to provide longer term pain relief than that provided by simple injections or nerve blocks. Many patients who are being considered for this procedure have already undergone simple injection techniques like Epidural Steroid Injection, Facet Joint Injection, Sympathetic Nerve Blocks, or other nerve blocks with pain relief that is less prolonged than desired. By selectively destroying nerves that carry pain impulses, the painful structure can be effectively denervated and the pain reduced or eliminated for anywhere from a few months to up to 12 months.
What types of conditions will respond to Radiofrequency Lesioning?
There are a multitude of chronic pain conditions that respond well to this treatment.
Chronic spinal pain, including spinal arthritis (spondylosis),
→ post-traumatic pain (whiplash),
→ pain after spine surgery
→ other spinal pain conditions are those most commonly treated with RFL.
→ Other conditions like,
→ Complex Regional Pain Syndrome (CRPS or RSD),
peripheral nerve entrapment syndromes.
A patient’s candidacy for RFL is usually determined by the performance of a Diagnostic Nerve Block. This procedure will help to confirm whether a patient’s pain improves just for the duration of the local anesthetic (or not). Patients who have little to no pain relief after a diagnostic nerve block are not candidates for a neurodestructive procedure like RF Lesioning.
lumbar sympathetic block
A lumbar sympathetic block is an injection of medication that helps relieve lower back or leg pain (sciatica). It can be used to treat:
→ Reflex sympathetic dystrophy
→ Complex regional pain syndrome
→ Herpes zoster infection (shingles) involving the legs
→ Vascular insufficiency
→ Peripheral neuropathy
Sympathetic nerves are located on both sides of your spine, in your lower back. A steroid medication and local anesthetic injected into or around your sympathetic nerves can help reduce pain in that area.
Lumbar sympathetic block is performed under local anaesthesia with C-arm guidance.
The suprascapular nerve provides nerve supply to two muscles of the shoulder girdle, and to the shoulder joint. Local anaesthetic blocks of the suprascapular nerve are used to provide pain relief after surgical procedures on the shoulder, and to treat painful shoulder conditions such as frozen shoulder.
The skin over the area through which the needle will pass is prepared with an antiseptic solution. A needle, which is attached to a syringe, is passed through the skin and toward the target. A direct technique places the needle close to the notch in the shoulder blade through which the nerve passes and an indirect technique places the needle onto the floor of the upper part of the shoulder blade.
stellate ganglion block
A stellate ganglion block (sympathetic block) is an injection of local anesthetic into the front of the neck. It is typically ordered by your doctor for pain located in the head, neck, chest or arm that is caused by sympathetically maintained pain (complex regional pain syndrome), causalgia (nerve injury), herpes zoster (shingles) or intractable angina. Stellate ganglion blocks are also used with circulation problems, particularly Raynaud's or complex regional pain symdrome (CRPS), to see if blood flow can be improved.
Stellate ganglion blocks may be of therapeutic or diagnostic value. One of three things will happen:
→ The pain does not go away, but there is other evidence of a sympathetic block, meaning the pain is not responsive to sympathetic blocks. This is of diagnostic value.
→ The pain does not go away and there is no good evidence of a sympathetic block, meaning the block is a technical failure.
→ The pain goes away after the injection and stays away longer than the life of the local anesthetic, meaning the block was of therapeutic value.