Common procedures performed by our physician include:
Epidural Steroid Injections (Interlaminar, Caudal & Transforaminal)
Epidural steroid injections are used to deliver medication close to the site of injury or pathology within the spine. Steroids act to reduce inflammation, decrease pain and possibly improve function. A local anesthetic is often injected with the steroid, providing short-term pain relief and diagnostic information. This injection is commonly utilized for nerve root irritation, radiculopathy (sciatica) or even neck or low back pain. Other indications include degenerative disc disease, spine arthritis, post-surgical pain, and post-herpetic neuralgia. There are three common approaches undertaken with this technique:
Interlaminar Epidural Injection: This technique typically delivers medication to the posterior epidural space via fluoroscopic guidance. This procedure is useful, particularly in the treatment of diffuse spinal disorders such as spinal stenosis.
Caudal Epidural Injection: This approach utilizes an access point at the tailbone. This technique is commonly chosen for pain in the lower spine or coccyx. It is particularly useful in patients with previous spinal surgery where the interlaminar approach is less reliable. This injection is also performed under fluoroscopic guidance.
Transforaminal Epidural Injection: This technique is a very precise, fluoroscopically guided approach to delivering a small volume of medication to the site of the pathology in the spine, typically located at the anterior epidural space. Additionally, this method is superior in treating nerve root pain (extremity pain).
Facet Joint (Zygapophysial) Injections (Intra-articular, Medical Branch Block)
The facet joints are common sources of pain; they are often affected by degenerative arthritis or acute injuries such as whiplash. In the neck, pain referred from this joint might manifest as headaches, shoulder pain, and upper back pain. These joints can cause low back, buttock, or thigh and leg pain when originating in the lumbar spine. These joints are located in the posterior aspect of the spine and are responsible for ~10-15% of the support attributed to the spine. During intra-articular injections, the joints are penetrated with a needle followed by injection of contrast to confirm placement. Then a combination of local anesthetic and steroid are injected. Medial branch blocks involved the injection of a small amount of local anesthetic at the two small nerves that supply each facet joint. This highly specific procedure is diagnostic, often predicting success with radiofrequency ablation.
In situations where pain originating from the facet joint is isolated via medial branch blocks, these specific nerves can be selectively destroyed by delivering thermal energy. This technology can also be utilized in sympathetic-mediated pain. This procedure involves the precise placement of radiofrequency needles along the appropriate nerves confirming location with motor and sensory stimulation followed by the delivery of thermal energy.
Sacroiliac Joint Injections
The sacro-iliac joints represents the junction of the spine and the pelvis. These paired joints are implicated in the etiology of chronic low back pain and are susceptible to stress, injury and arthritis. They often respond to steroid injections under fluroscopic guidance. Alternatively, diagnostic injections with local anesthetic might positively predict for radiofrequency ablation.
Provocative discography is a technique utlized to diagnose internal disc disruption and resultant discogenic pain. This procedure is divided into provocative and morphological components. The provocative portion is an attempt to reproduce the patient's "typical" pain. Abnormal discs are identified and injected; adjacent control (normal) discs are also injected. Concordant pain is elicited when an abnormal disc is injected replicating the patient's typical pain. Often disc morphology can also be noted with injection of contrast material. The morphology is also confirmed via a CT scan immediately following the procedure. The combination of the information gleaned from these two components of the study can be useful in identifying the causative agent in disc-related low back pain.
Spinal Cord Stimulation
This procedure involves the placement of two electrodes into the epidural space at appropriate levels to provide electrical stimulation of the spinal cord in an effort to interfere with the transmission of pain. This technique is effective for the treatment of persistent extremity pain (arm, leg), nerve-related pain, certain types of low back pain, specific cases of abdominal pain and other resistant cases of pain of multi-factorial etiology. The stimulation can be adjusted by the patient allowing individualized customization of treatment. Prior to permanent implantation of these electrodes, a trial is undertaken. This is a 3-7 day period during which the electrodes are placed without an incision, and attached to an external power source. This period is a "test-drive" during which the effectiveness of this device is determined. Permanent implantation where appropriate is an outpatient procedure during which the electrodes are surgically placed.
Sympathetic Nerve Interventions
The sympathetic nervous system which involved with the control of various non-voluntary activities (pupil dilation, digestion, heart rate) has been implicated in the development of various pain syndromes. Interventions targeting this system involve the injection of local anesthetic at the sympathetic ganglia in the cervical or lumbar spine. Furthermore, radiofrequency ablation, chemical neurolysis, and spinal cord stimulation are other procedures targeting this system.
Peripheral Joint Injections
The most common indications for peripheral joint injections include arthritis and joint effusion. These procedures are often performed based on anatomical landmarks, in select joints (Hip, Glenohumeral) fluroscopic guidance is undertaken. Commonly, local anesthetic and steroids are injected. Joint fluid replacement is also utlized in appropriate situations to treat pain related to joint pathology.
Epidural Lysis of Adhesions
In rare situations following neck or low back surgery scar, tissue (adhesions) might develop around a nerve root causing compression and severe pain. Using a steerable catheter placed via an introducer needle these adhesions are destroyed or "borken up." This therapeudic modality is reserved for those patients who have previously failed conservative treatments such as medications and epidural injections.
Percutaneous Lumbar Disc Decompression (DeKompressor, Acutherm)
Disc decompression can be effective for the treatment of small, contained disc herniations primarily causing lower extremity pain. This procedure involves the removal of nuclear material percutaneously from the disc to reduce pressure on the nerve roots and to potentially resolve the disc protrusion. The procedure involves the introduction of a small extraction device into the disc through a needle.
Intradiscal Anuloplasty (IDET, Transdiscal Biaculoplasty)
These procedures are utilized for the treatment of disc-related low back pain. Typically following identification of causative discs by discography, these procedures involve the delivery of thermal energy to the posterior aspect of the disc resulting in collagen formation thereby "sealing" the disc as well as reducing aberrant nerve growth into the disc. IDET involves the introduction of a catheter into the disc via an introducer needle. Transdiscal Biaculoplasty is performed via a bipolar method producing a field between two introducer needles.
Trigger Point Injections
In some instances a specific muscle might be implicated in the development of pain due to the development of taut bands either as a primary process or as a result of an underlying trigger. These trigger points can be treated with injections of local anesthetic often times with steroid as one portion of a treatment plan including physical therapy and stretching as well as other modalities.