Minimally Invasive Procedures

Epidural Injections (Caudal, Transforaminal, Transluminar)
An injection is the introduction of an anesthetic or steroid medicine into a tendon sheath, ligament, or trigger point(s) for the purpose of reducing pain or to promote the repair of body tissue.

“Epidural” refers to the space outside the dura or covering of the spinal cord and inside the spinal canal. This space runs the length of the spinal cord.

An epidural injection may be ordered by your health care provider as a means to confirm a specific diagnosis and/or decrease pain and inflammation. Inflammation or irritation of a nerve root most commonly originates from a herniated, degenerated, or “leaky” disc at the nerve root level.

In general, epidural injections are recommended to provide pain relief and enable patients to progress with their rehabilitation. Epidural injections may be an effective non surgical option for common conditions such as lumbar disc herniation, degenerative disc disease, and lumbar spinal stenosis.

Where the medicine is injected in the spine depends on the goal of the injection. For pain relief, the injection is done in the epidural space. This is the area that surrounds the nerves within the spinal canal. To locate the source of the pain, the physician may target a specific nerve root.

Epidural injections are done at an outpatient surgery center. Using fluoroscopy (x-ray) guidance so the doctor can better target the direct source of pain, a local anesthetic and a steroid (anti-inflammatory) are injected directly on the surface of the spinal column.

 

What’s a Disc? Each vertebra in your spine is separated from its neighbor by a cushion of cartilage called a disc. Discs, in fact, make up one-third of your spine’s height and serve as hydraulic shock absorbers. The outer ring of the cartilage cushion, called the annulus fibrosa, is dense and layered with crisscrossed fibers, like the covering of a radial tire. The interior cartilage, the nucleus pulposus, is soft and squishy, like thick jelly.
A herniated disc is the most severe disc problem, often caused by a sudden injury. When the disc covering weakens before its center has dried out, the pressure from the center can cause the annulus to crack or rupture and the nucleus pulposa to ooze out. This protrusion can be mild or it can cause severe pain, depending on how much of the disc center escapes and whether it presses against a nerve. Sometimes surgery is the only solution for a herniated disc.

Understanding Anatomy
By learning more about your back anatomy, you can understand how an injection can help relieve or locate your pain. Vertebrae are the bones that stack up to form the spine. Disks are “cushions” that provide padding between the vertebrae. A damaged disk can lead to inflammation and pain. The spinal canal is a tunnel that’s formed within the stacked vertebrae. Nerves run through this canal. The nerves are wrapped by a thin layer of tissue. A nerve root is the part of a nerve that leaves the spinal canal. Inflamed nerve roots can lead to back pain. The sciatic nerve is a nerve that extends down to the leg. When its nerve roots are inflamed, buttock and leg pain often result.

Provocative Discography (Also called “discogram”)
Provocative Discography is a diagnostic test to help identify the source of pain. Physiologic information is gathered by assessing the patient’s pain response during the test. Additionally, anatomical information is obtained by correlating pain response, if obtained, with imaging seen on fluoroscopy during the study

This procedure is reserved for patients who have not responded to medications and conservative treatments, such as physical therapy, and for potential candidates of further treatments, such as IDET or other surgical procedures. Provocative Discography deliberately provokes pain symptoms in order to pinpoint their source in the intervertebral discs. The procedure is designed to create a “roadmap” to show the physician where pain patterns are originating.

This procedure takes place at an outpatient surgery center. A local anesthetic is injected into the skin in the area that is being examined. Using fluoroscopic guidance (x-ray), a needle is inserted through a previously placed needle in the skin and into the disc. A saline solution and radiopaque dye are injected into the disc or discs to be examined. A CAT (CT) scan is usually performed after the dye is injected to obtain images of the dye distribution, which may show tears, scarring, disc bulges, and changes in the nucleus of the disc. The discogram procedure can detect problems within intervertebral discs that may appear normal on the MRI films.

When a normal disc is injected, the patient feels a sense of pressure, but not pain. When an abnormal disc is injected, the patient will feel pain. The patient helps the doctor doing the procedure by letting the doctor know if they feel pain, if the pain is like the usual pain, and if the pain is in the area where he/she usually feels pain.

Bones called “vertebrae” make up the spine. Each vertebra has facets (flat surfaces ) that touch where the vertebra fit together. These form a structure called a “facet joint” on each side of the vertebra. Facet joints are located on the back of the spine on each side where one vertebra slightly overlaps the adjacent vertebrae. They glide and allow the complicated movements of the spine.

A facet joint injection is performed to help diagnose and/or treat pain related to disease or injury of the posterior joints of the spine. One or more facet joints in your back or neck can become inflamed (swollen and irritated). This may cause pain. During a facet joint injection, medication is injected into the inflamed joints. This treatment helps reduce inflammation and relieve pain. Pain relief should last for weeks to months. If the pain returns the patient may need a repeat injection.

Injection of these joints, under x-ray imaging guidance, is the only accurate and definite way to diagnose facet joint pain syndrome because certain joints may appear abnormal but not cause pain and, conversely, the problem joints may appear nearly normal.

IDET (IntraDiscal ElectroThermal Therapy)
IDET is the abbreviation for IntraDiscal ElectroThermal Therapy. This is a fairly recent medical procedure approved by the Food and Drug Administration in 1998.

IDET was developed to treat pain originating from a spinal disc. The IDET procedure is typically used to treat patients who have symptoms from small tears of the disc. It is used as an alternative to back surgery.

This procedure is performed at an outpatient surgery center. The patient is generally given intravenous medication to help him or her relax during the procedure. Using fluoroscopy (x-ray guidance), a needle is inserted into the disc. Through the needle, a flexible catheter is placed into the disc. The catheter delivers heat directly to the outer wall and inner disc contents via a heating coil. It is designed to do three things: (1) destroy the pain receptors in the disc, (2) change the structure of the disc material, and (3) cauterize the new pain receptor nerve fibers and blood vessels that have grown into the degenerated discs. This procedure provides significant relief from ongoing pain for 50% to 80% of the patients with chronic, low back pain.

Medial Branch Block (MBB)
A medial branch block is considered a diagnostic test to locate the source of the pain. It is usually performed if it is suspected that the facet joints are contributing to back pain.

Bones called “vertebrae” make up the spine. Each vertebra has facets (flat surfaces ) that touch where the vertebra fit together. These form a structure called a “facet joint” on each side of the vertebra. Facet joints are located on the back of the spine on each side where one vertebra slightly overlaps the adjacent vertebrae. They glide and allow the complicated movements of the spine.

Radiofrequency Neuroablation (Also referred to as “Radiofrequency Thermocoagulation”)
This is a safe, proven means of interrupting pain signals. Radiofrequency current is used to heat up a small volume of nerve tissue, thereby interrupting pain signals from that particular area. This is a treatment used for chronic, low back pain, thoracic spine pain, sacroiliac joint dysfunction, cervical and lumbar radiculopathies, peripheral neuropathies, reflex sympathetic dystrophy, and atypical facial pain.

Radiofrequency needles, accurately placed with the use of fluoroscopic x-ray machines, generate local heat at the tip when electrical current is applied. Radiofrequency can be used to thermocoagulate painful nerves with minimal tissue damage. Radiofrequency treatment of tissue usually blocks pain signals for a prolonged period of time. In some cases, the procedure needs to be repeated because the human body may regenerate pain pathways over time.

Radiofrequency techniques have been available for treating various pain disorders since the early 1970’s. Since the 1980’s physicians specializing in chronic pain diagnosis and treatment have found an increasing number of applications for this established technology. Some more common medical conditions which respond to radiofrequency techniques include chronic low back pain, thoracic spine pain, sacroiliac joint dysfunction, cervical and lumbar radiculopathies, peripheral neuropathies, reflex sympathetic dystrophy, and atypical facial pain.

This procedure is performed at an outpatient surgery center. The patient is generally given intravenous medication to help them relax during the procedure. The patient is closely watched with an EKG monitor, blood pressure cuff, and blood oxygen monitoring device.

During the procedure the patient lies on his stomach or back, depending on the approach the physician will take. After the local anesthetic and medication for sedation are administered, the doctor will insert a small needle into the area where the patient has experienced pain. Under the guidance of x-ray, the doctor guides the needle to the exact target area. A microelectrode is then inserted through the needle to begin the stimulation process. During this process, the doctor will ask the patient if there is a tingling sensation. The purpose of the simulation process is to help the doctor determine if the electrode is in the optimal area for treatment to produce the most relief.

Once the needle electrode placement is verified, treatment can begin. A small radiofrequency (RF) current travels through the electrode into the surrounding tissue, causing the tissue to heat and eliminate pain pathways.

Radiofrequency treatment of tissue usually blocks pain signals for a prolonged period of time. However, the human body may regenerate pain pathways over time. It is not unusual that the procedure may need to be repeated at some point in the future.

Sacroiliac Joint Injection
Sacroiliac Joint Injections can be both diagnostic and therapeutic. They can help the physician evaluate if the sacroiliac joint is the source of a patient’s pain and provide her with pain relief at the same time by delivering a local anesthetic (numbing medicine) and potent anti-inflammatory (a steroid) into the joint.

There are two sacroiliac joints in the body, one on either side, where the hip bone (part of the pelvis) meets the sacrum (part of the lower spine) in the low back/buttocks area. The sacroiliac joints move by giving or stretching, thereby acting as a shock absorber for the spine.

If these joints become irritated, they can produce pain in the low back, buttocks, groin, abdomen, or legs. This pain can radiate to other areas of the body, including the low back, buttocks, groin, abdomen, or legs. Common pain distributions are shown in the picture.

The sacroiliac joint injection is performed at an out patient surgery center. The patient is positioned on thei stomach and made as comfortable as possible. The skin overlying the joint is cleansed. Then, this area is “numbed” using a local anesthetic in order to minimize the discomfort of the injection. The physician locates the joint using fluoroscopy (x-ray guidance) and places a needle in the joint. Medications, usually an anesthetic (numbing medicine) and a steroid (anti-inflammatory), are injected.

If an initial injection provided a certain amount of pain relief, a second injection may provide additional benefit. If the patient’s pain subsides completely and then returns at a later time, additional injections may be an option.

Selective Nerve Root Blocks
A block is an injection of a local anesthetic into or around a nerve to produce a loss of sensation and/or pain in the part of the body served by that nerve.

Sympathetic Nerve Block
Sympathetic nerves are a network of nerves extending the length of the spine. They control some of the involuntary functions of the body, such as the opening and narrowing of blood vessels.

This block procedure is performed to determine if there is damage to the sympathetic nerve chain and if it is a source of pain. The injection blocks the sympathetic nerves and may reduce pain, swelling, and color and sweating changes in the arms or legs. The injection may also improve mobility.

The procedure involves inserting a needle through the skin and deeper tissues into the sympathetic nerve tissue. Before the injection, the skin and tissues are numbed with a local anesthetic. A local anesthetic is injected into the sympathetic nerve tissue primarily for diagnostic purposes, but it may provide relief from pain far in excess of the duration of the anesthetic.

For diagnosis related to sympathetic nerve involvement, a series of injections is required to treat the problem. The response to the injections varies from patient to patient. Patients who present early during their illness tend to respond better than those who have the treatment after about 6 months after the onset of symptoms. If the first injection provides some relief from pain, repeat injections may be recommended. Usually the duration of relief gets longer after each injection.