Pain Management

LOWER BACK PAIN

Low back pain is one of the most common musculoskeletal complaint. The anatomy of the lower back consists of the disc, the vertebra body, the spinal canal, the facet joint, the spinal nerves, and the spinal ligaments/muscles. Each of these elements can cause lower back pain, and sometimes pain results from more than one component.

Disc herniation is one of the most common causes of low back pain.  It can be caused by trauma, heavy lifting, and most commonly degenerative disc disease.  Degenerative disease results in weakening of the discs and can lead to spinal stenosis and nerve impingement.  A precisely performed epidural steroid injection can relieve pain from this condition.

Another common cause of lower back pain is from facet arthritis.  The facet joint is a pair of joints in the back portion of spine.  Facet arthritis can result from sports-related injury, auto accident, poor posture, and degenerative disease.  Symptoms include stiffness along the spine, backache after sitting or standing for extended periods, and sharp pain on turning or rotating the back. Facet injection and radiofrequency ablation are effective treatment for this condition.

HIP AND LEG PAIN

Greater trochanteric bursitis is inflammation of the bursa (fluid filled cushion) at the outside of the hip.  When the bursa is inflamed, there is pain at the outside of the hip and often along the outside of the thigh.  Pain is worsened by lying on the affected side or getting up from seated position. Corticosteroid injections can decrease the pain quickly.

Piriformis syndrome is buttock pain caused by spasm of this muscle.  The piriformis muscle can irritate the adjacent sciatic nerve and cause pain, numbness and tingling to the lower leg.  Direct injection of medication to the piriformis muscle can relieve the pain.

Sacroiliac joint pain is one of the most common cause pain in the pelvis and contribute to lower back and leg pain. The sacroiliac joint is the paired joint underneath the gluteal region.  It connects the bottom of the spine to the pelvis and hips.  Sacroiliac joint pain can mimic sciatica. Treatment of this pain can be done through injection of medication into the joint.  Using anesthetics to block the nerves that sense pain in this joint can be effective and can be followed up with radiofrequency ablation.

Meralgia paresthesica has pain, burning, and/or numbness along the outside thigh. It is caused by compression of the lateral femoral cutaneous nerve, often under the inguinal ligament. Predisposing factors include weight gain, pregnancy, local trauma, constricting clothing and diabetes. Nerve block under ultrasound done at this clinic can effectively treat disease.

SHOULDER AND ARM PAIN

Golfers & tennis elbow overuse injuries are the common cause of pain in the elbow.  Tendons and ligaments can be stretched too much in the elbow from sport or work, resulting in golfer’s or tennis elbow.

Rotator cuff injury results in shoulder pain. There is tearing of the tendons and muscles in the shoulder.  Often these injuries require surgical repair.  Minimally invasive treatment involves injection into the joint and blocking the nerves that sense the joint pain.

In Carpal tunnel syndrome the median nerve is compressed in the wrist.  This results in pain, numbness and tingling in the 1^st to 3^rd fingers in the hand.  Injections of corticosteroids by the nerve can relieve this pain.

FOOT PAIN

Ankle sprain is caused by injury of the tendons of the ankle which can manifest as pain and swelling around the ankle and foot.

Peroneal tendonitis is pain along the medial ankle from inflammation of the peroneal tendons.

Plantar fasciitis is pain at the sole of the foot from inflammation of the fascia that forms the arch of the foot.

HEADACHES

Frontal headache is pain from irritation of the upper division of the trigeminal nerve, which is manifest by severe pain by the temples, around the eyes, and in the forehead.  If this pain is uncontrolled by medication, nerve blocks and nerve ablations can be effective treatments.

Occipital neuralgia is pain in the back of the head from irritation of the occipital nerves which can be effectively treated with nerve blocks and ablations.

Cervicogenic headache is headache caused by irritation of the nerves in the neck which send pain signals to the head.

KNEE PAIN

Knee pain can be a debilitating condition.  Most common causes of knee pain are from trauma and arthritis.  Treatment of knee pain includes injection of corticosteroid into the joint.  In addition, we are pioneer of an innovative technique to selectively block and “burn” the nerves that sense knee pain; skin sensation and muscle function are not affected by this technique.

This technique is called genicular nerves radiofrequency ablation. This is an innovative treatment, not yet available at most pain centers. This breakthrough technology transmits radiowaves through small needles to stun painful nerves that mediate knee pain. There is no incision and no need for cortisone injections. This is an additional therapy for patients who have failed or do not want steroid or hyaluronic acid intra-articular knee injections.

Procedure may be an alternative to surgery and can work for patient still experiencing pain after surgery. For patients planning knee surgery, performing this procedure pre-op can decrease post-op pain and allow patient to start rehabilitation earlier.

NECK PAIN

Neck pain can result from pinched nerves in the neck or narrowing of the bony canal in your neck. Classic symptoms include pain from the shoulders to the finger tips. It is often accompanied by numbness and tingling sensations. Effective treatment includes cervical epidural steroid injections. Another type of neck pain is from facet degeneration. Classic symptoms involve neck pain traveling to the shoulders and the back of the head. Pain is worsened by turning of the neck. Whiplash injuries to the neck from car accidents can result in this type of pain.

PELVIC PAIN

Pelvis pain afflicts both men and women.  33% of all women will have at least one episode of significant pelvic pain in their lifetime. Pelvic pain can be from infection, endometriosis, or dysfunctional uterine bleeding (DUB). Many causes of pelvic pain have a neurogenic component and nerve blocks can be very effective.  Superior hypogastric plexus nerve blocks and pudendal nerve blocks can relief pelvic pain from endometriosis or DUB. Pain in the inguinal or groin regions can be treated with ilioinguinal nerve blocks.

In men, pelvic pain can be secondary to chronic bladder infection/inflammation.  Pudendal nerve blocks can be very helpful with this type of pain and can work as well as bladder stimulators. Men with pain in the groin regions, especially after inguinal hernia surgery, can benefit from ilioinguinal nerve blocks.  Genitofemoral nerve blocks can relieve pain in the testicles without affecting sexual functions.

Epidural Injections

Epidural steroid injection is used to treat “sciatica” or pinched nerve. A nerve can be pinched or squeezed by a herniated disc, bone growth, enlarged ligaments, or even scar tissue. This results in radicular pain or “sciatica” that radiates from the spine down the nerve. In the lower back, this pain travels down the leg and is called lumbar radiculopathy. In the neck, this pain travels down the arm and is called cervical radiculopathy. In the mid back between the scapula, this pain travels around the chest and is called thoracic radiculopathy.
Epidural steroid injections can also treat degenerative disc disease, spinal stenosis, spondylolysis, radiculitis, and radiculopathy.

Technique

Under x-ray guidance, a small needle will be inserted to the base of the spine and advanced to the epidural space. A small amount of x-ray dye is used to identify the epidural space. Then a long-acting steroid and a local anesthetic are injected which reduce inflammation and irritation of the nerve and interrupt the pain cycle and pain signal transmission. There are several types of epidural steroid injections and your doctor will decide which procedure is most beneficial to you after reviewing your history, performing a physical exam, and reviewing your imaging.

Outcome

Research shows more than 70% of patients experience some immediate improvement of their pain. Epidural steroid injections allow patients to have pain relief, to become active again, and to resume their normal daily activities. If pain relief is partial or not lasting, another injection can be given in 2 weeks which may provide additional relief. Research has shown multiple epidural steroid injections, often in sets of 3, provide better relief than a single injection.

Facet Joint Injections/medial branch block

Arthritis mediated pain in the spine is often due to arthritis in the facet which is a joint the connects one vertebrae to another. A needle can be placed to the nerve that provides sensation to the facet joint. A local anesthetic and/or a long acting steroid can be injected to decrease the pain. This procedure provides rapid relief of spinal pain induced by arthritis. Medial branch blocks can be used as a diagnostic tool to determine the degree of spinal pain from the facet joint. The duration of pain relief varies for each patient. When pain returns, the procedure can be repeated or facet denervation with radiofrequency ablation can be considered.

TECHNIQUE

Patients will lie on their stomachs. Under x ray guidance, several small needles will be inserted to the spine. Medication will be placed to the facet joint and/or the nerves supplying the joint. The procedure will take about 15 – 25 minutes. Patients can drive themselves home.

OUTCOME

If facet disease is the cause of your pain, patients will often experience 50% or more rapid pain relief within the first 6 – 12 hours. The duration of joint pain relief will vary depending on the medication used. Many patients can experience prolonged pain relief. For patients who have pain relief but not long lasting, they may be candidates for radiofrequency ablation of the facet. In a 2007 study, 53% of patients reported pain improvement after facet injections at 8 weeks and 68% reported improvement at 6 months.

Kyphoplasty

Procedure is used to treat patients suffering from thoracic and lumbar spinal pain caused by vertebral compression fractures. Fractures can result from osteoporosis, cancer metastasis, or trauma. These treatment can significantly relieve the severity of pain from spinal fractures without relying on pain medications.

TECHNIQUE

One or two needles are placed through small incision in the skin. Then a small balloon is inserted into the fracture to create a space. Medical grade, acrylic cement is injected into the space to strength the bone. The cement solidifies quickly to provide stability, pain relief, and prevent further loss of vertebral height. During the procedure, patient is given light sedation. After completion, the incision is covered by bandage without any stitches. This is outpatient procedure which lasts 1 – 1.5 hours.

OUTCOME

Kyphoplasty is common procedure done to treat painful spinal fractures. In a landmark 2007 study, the procedure can reduce pain, increase vertebral body height, and decrease wedge angulation. Patients with untreated, spine compression fractures may develop kyphosis or “hunchback” curvature of the spine over time due to vertebral height loss. In a 2006 study, kyphoplasty can decrease height reduction and may prevent future kyphosis.

Radiofrequency Ablation

It is an innovative procedure to treat facet joint mediated arthritis pain in the spine. Procedure is done for patients who receive relief from facet joint injection or media branch block. Under precise x ray guidance, small specialized needles are placed to the facet nerve pain pathways and radio wave generated heat is applied to deactivate these nerves. This procedure is done after patients have responded to a nerve block of the painful area. This allows precise identification of the correct nerve causing pain.

TECHNIQUE

Under precise x ray guidance, small specialized needles are placed to painful nerve. Once the needle is in position, a thin electrode is placed inside the needle. The nerve is “tested” further to confirm exact position by stimulating the nerves and muscles in its territory. Then local anesthestic is injected to numb the nerve, so that patient will not experience significant discomfort when the needle is heated. Radiowave generated heat is applied to deactivate these nerves. Other nerves in the region are not affected. Pain relief from this procedure can last between 6-24 months. Success of this procedure is dependent on precise placement of the needles and the skill of the interventionalist.
Radiofrequency ablation can also be used for treating pain from :

• Knee pain
• Shoulder pain
• Hip pain
• Facial pain
• Occipital neuralgia
• Headache
• Groin pain
• Pelvic pain
• Sacroiliitis
• Neck pain

Spinal Cord Stimulation

This revolutionary therapy blocks pain signals from traveling up the spinal cord to the brain. The device is place in the epidural space near the spinal cord and delivers low electrical impulses to block pain. A small battery is implanted under the skin to supply the energy. The spinal cord stimulator has a remote control for individual adjustment. This treatment can work, even when spine surgery has been unsuccessful.

First, a trial or test run of the therapy is done. One or two soft, thin wire electrical leads is placed through a needle into the spinal epidural space. The stimulator is taped to your back and worn for 5-7 days. If the trial successfully relieves your pain, then a permanent device is placed below the skin.

Conditions that can be treated with spinal cord stimulator include:

• nerve compression refractory to other treatments
• failed back surgery – more than 50% of patients who fail surgery report > 50% pain relief with spinal cord stimulator
• spinal stenosis
• radiculopathy
• complex regional pain syndrome (CRPS or RSD)
• peripheral neuropathy

Nerve Block

Nerve blocks are used to give immediate pain relief through injection of local anesthetics and/or steroids. Advantages of nerve blocks include control of acute pain, desensitization of sensory pain cycle, and diagnosis of occult source of pain.

Some of the areas that nerve blocks can be performed:

• Trigeminal nerve blocks: treatment of facial pain
• Occipital nerve blocks: treatment of posterior headaches
• Periorbitai nerve blocks: treatment of frontal headaches or headaches around or behind the eyes
• Ilioinguinal/iliohypogastric nerve block: treatment of groin and pubic region pain
• Sympathetic nerve block: treatment of complex regional pain syndrome (CRPS) in the lower extremities
• Stellate ganglion nerve block: treatment of complex regional pain syndrome (CRPS) in the upper extremities
• Knee nerve block: treatment of knee pain from arthritis or trauma. Can be effective with pain that is unrelieved by joint injection, surgery, or knee replacement
• Shoulder nerve block: treatment of shoulder pain from arthritis or trauma. Can be effective with pain that is unrelieved by joint injection, surgery, or shoulder replacement
• Ganglion impar nerve block: treatment of coccydynia or tailbone pain. Procedure can help relief pain from lower sacral fractures or perineal pain.
• Pudendal /Superior hypogastric nerve block: treatment of pain from uterus or bladder. May be effective in treatment for pain from endometriosis, pelvic floor, and external genitalia
• Carpel tunnel injection: treatment of pain and sensory changes due to irritation of the median nerve in the wrist.
• Genitofemoral nerve block: treatment of testicular pain