Notes

  • Prior to any kind of intervention, conservative measures should be exhausted.
  • Each of the procedures below performed with light to moderate sedation or in some cases, no sedation.  This is per patient choice.
  • The majority of the injections listed below are performed under live X-ray (fluoroscopy) for precision and safety.

Commonly performed interventional techniques

Bursa injection

bursa injectionSurrounding each joint in the body (facets, shoulder, knee, costovertebral and facet joints, etc.) is a bursa, or sac. This is a fluid-filled structure which surrounds and protects the joint. Overuse, misuse, or even disuse (lack of) use of an extremity or joint in its normal range of motion can result in “bursitis”—an inflammation of the bursa. Bursa injections simply involve placing the needle into the sac, and injecting either a steroid solution or local anesthetic solution (or both). In some cases, we use regenerative (stem cell) preparations. Stem cell therapies are an exciting new area of intervention in pain management, as well as other specialties. Use of this modality is limited currently. It is only indicated for certain types of joints with certain degrees of pathology. You would need to consult with our group to determine whether you are a suitable candidate for this modality. In most cases, we are simply injecting local anesthetic and steroid solutions into the bursa as this typically results in resolution without the need for further intervention.

Bursa injections are very safe and are commonly performed in an office setting. They can also be done in a surgical center, with direct continuous X-ray (i.e., fluoroscopy).

How should I prepare for my bursa injection?

There are no mandatory actions that need to be taken prior to a bursa injection. As this is a very straightforward procedure, and there is no need to hold any of your medications. There are really no absolute contraindications to bursa injections, although it would be prudent to avoid if a patient has an active infection. Still, the likelihood of a systemic (total body) infection seeding a bursa sac—because it was injected—is extremely unlikely.

Nonetheless, we need to get a good history and document what medications that you normally take, such as blood-thinners (anticoagulants) and diabetic medications.

If you have the procedure in an office setting, without anesthesia, there is no need to have anyone with you. You can drive yourself home after a bursa injection. If, however, you elect to receive an anesthetic for the injection, please make sure that you have someone with you. Anesthetic medications can slow your reflexes and impair mental processing. You cannot drive or operate any kind of machinery for at least 24 hours following an anesthetic.

What are my instructions the day of the procedure and for eating and / or drinking before and after the procedure?

If the procedure is to be done in an office setting, there is no reason to arrive earlier than your scheduled appointment time. If the procedure is done at a surgical center, we usually ask that patients come in about one hour prior to the procedure. We also ask our patients to refrain from eating for a total of six (6) hours prior to their injection. And that meal needs to be light. Do not have a heavy meal six hours before an anesthetic as you run the risk of aspiration of food. This can cause a very serious pneumonia. After the procedure, they you eat as soon as you are awake and oriented (assuming an anesthetic was administered). You can have clear liquids up to 2 hours before an injection. A clear liquid is anything that you can see through if holding a full glass of this fluid. Coke (Coca-Cola) is not a clear fluid. Water is the preferable liquid. And it is permissible to have any necessary medications that you would take normally, up to two hours prior to your procedure with a small sip of water.
How is the procedure performed?

The procedure is relatively simple. The bursa that is to be injected is marked. The area surrounding this site widely “prepped”. That means that an antibacterial agent is applied to cleanse the skin to avoid infection. In the office, we use simple anatomic guides to find the correct target. If the procedure is done in a surgery center, we may employ the use of fluoroscopy to document precise needle placement.
How long will it take for me to realize benefit from my injection?

Patients typically experience almost immediate relief—virtually within minutes. However, for many patients, there is a delayed response. This is because steroids take several days to work against inflammation.
Will the procedure work for my pain?

Bursa injections are very effective, successful injections. If we have determined that you indeed do have a bursitis condition, injections are a very effective form of treatment.
Is the injection painful?

Bursa injections are well tolerated by most patients and sedation is not needed. Some patients feel that they hurt more than expected and request anesthesia for subsequent injections.
What is injected into the bursa sac?

We typically administer a combination of local anesthetic and steroids. Some patients may qualify for regenerative medicine techniques (i.e., stem cell injections).
How long will my bursa injection work?

Bursa injections are very gratifying procedures for Interventionalists because of the great results. These injections usually provide very rapid relief that can last month’s or longer. In some cases, a single injection can last for years. If there are mechanical issues of gait, posture, misuse or disuse of an extremity or area of the body, bursa injections will need to be repeated. Therefore, we must discuss how to avoid a recurrence when we do your injection. There are ways to avoid—or at least attenuate—reoccurrence.
What are contraindications for bursa injections? That is, what are reasons that I should not have a bursa injection?

There are not any absolute contraindications to a bursa injection. As stated previously, however, it would be prudent to avoid injections (and steroids) when there is an on-going systemic infection. Taking blood-thinners (anti-coagulants) is not a contraindication for a bursa injection.
What are the typical, expected, non-serious side effects from bursa injections?

Several non-serious events can occur after your injection. A small number of patients will experience a worsening of their discomfort for several days. Following that, the pain should rapidly subside. Others achieve very fast pain relief, that is lasting. Some patients will complain of generalized flushing and redness—especially over the upper body, head, neck, and face. This typically subsides within 8-12 hours and I do not recommend anything other than time to cure this side effect.
What are the potential complications from a bursa injection?

Complications are extremely rare. The most likely significant complication from a bursa injection is infection. These occur in only very rare circumstances and are easily treated with oral antibiotics.
How often will I need to have a bursa injection

This is not at all like an epidural steroid injection or other injections. We do not perform these repetitively. Usually, just one bursa injection will do. Occasionally, we will need to repeat the injection. The duration is very good, typically lasting for 6 months or greater.
What should I expect immediately after the procedure?

In the office, we ask the patient to rest for 10 minutes and then they are fee to walk around and engage in normal activities, including driving. If the procedure is performed in a surgery center, we generally keep patients in the recovery area for observation for approximately 30-45 minutes. Once you are awake and oriented (if you received an anesthetic), and have met discharge criteria, you can leave with a companion. You can drive yourself home if you had the procedure done without anesthesia. If anesthetics was administered, we request that you refrain from driving for the next 24 hours.
How long do I have to wait before I can start my normal activities?

For those that get the injection without anesthesia, you can begin with normal activities, including driving, immediately. If the procedure was performed in a surgery center, you cannot drive, operate any kind of machinery, or make any important decisions for the next 24 hours as anesthesia can cause altered mental processing.
When can I start taking my medicines again?

All medications may be restarted immediately following the injection.
How soon can I bathe or shower?

We ask that you wait 24 hours before sitting in water that covers the injection site. Showering is different. For this, we ask that you refrain from showering for 6 hours after the injection.
What are the things that I need to look for after my injections that are potential 'red flags'?

Severe or worsening pain after your injection require an immediate call to our office. Do not leave messages. Call our after-hour paging system or the facility at which the procedure was performed. If there is no answer, go to the nearest emergency room immediately.

Pain that worsens day to day could represent infection and is also considered an emergency. Please follow the same recommendations (above). A fever of 101 degrees or greater for greater than 24 hours may indicate an infection. Also look for motor (muscle strength) and sensory (decreased sensation to touch) over the extremities.

Worrisome post-procedure signs and symptoms (medical emergencies):

  • Severe post-injection pain
  • Worsening post-injection pain
  • Fever of 101 degrees for > 24 hours
  • Change in motor or sensory function

Contact Pain Stop MD today online or by calling 972-556-5738.

Caudal injection

This is an epidural steroid injection which is performed at the base of the sacrum–the large triangular shaped bone below the lumbar spine. The needle is placed through an opening, or “hiatus”, which allows the injected solution to travel upward toward the lumbar spinal segments. This site is well below from the spinal cord or nerve roots, thus rendering this an extremely safe procedure. The caudal epidural space is contiguous with (in communication with) the lumbar epidural space. The purpose of accessing the epidural space at a lower level is again for safety as well as to avoid an area of prior lumbar spine surgery such as an L5-S1 fusion

Like standard epidural steroid injections, caudal injections are used for treatment of inflamed spinal nerve roots and intervertebral discs. They are commonly used in conjunction with other modalities to treat pain including physical therapy, traction, and medications. The purpose is to reduce pain and inflammation and to reduce or eliminate the need for more aggressive, surgical, intervention.

Caudals are well below the spinal cord and spinal roots, thus rendering them very safe. In fact, there has never been a verified case of epidural hematoma (spinal bleeding) following a caudal injection.

Having said this, ESIs (and hence, caudal steroids injections) are still considered “off label” by the FDA, which means that while it falls within the practice of medicine, it is not FDA approved. The FDA requires all glucocorticoid steroid warning labels to state:

The safety and effectiveness of epidural administration of corticosteroids have not been established and corticosteroids are not approved for this use… serious neurologic events, some resulting in death, have been reported with epidural injection of corticosteroids.

How should I prepare for my caudal steroid injection?

It is important to let your treating doctor know what medications you take. There are certain medications, such as blood-thinners (anticoagulants) that are absolute contraindications for a caudal injection. Your doctor also needs to know your medical history. For instance, if you have diabetes, that is important to both you and your treating doctor. Steroids are administered when performing caudal injections. Steroids will cause an elevation in your blood sugar (glucose) level. So, this needs to be paid close attention. And changes in your diabetic medications might be necessary for seven days following a caudal injection. A recent study demonstrated that 80% of the patient’s noted an elevation in their blood sugar following an ESI. Serum glucose levels gradually returned to normal over several days. There were no cases in this study that demonstrated glucose control issues lasting greater than 5 days. As caudals are basically epidural injections at a lower point in the spine, these same facts will apply.

Make sure that you have someone with you on the day of the injection. The injected medications can make you unsteady on your feet. Also, anesthesia medications can slow your reflexes and impair mental processing. You cannot drive or operate any kind of machinery for at least 12 hours following an injection and for 24 hours following an anesthetic.

What are my instructions the day of the procedure and for eating and / or drinking before and after the procedure?

We will give specific instructions before your procedure. We usually ask that patients come in about one hour prior to the procedure. We also ask our patients to refrain from eating for a total of six (6) hours prior to their injection. And that meal needs to be light. Do not have a heavy meal six hours before an anesthetic as you run the risk of aspiration of food. This can cause a very serious pneumonia. After the procedure, they you eat as soon as you are awake and oriented (assuming an anesthetic was administered). You can have clear liquids up to 2 hours before an injection. A clear liquid is anything that you can see through if holding a full glass of this fluid. Coke (Coca-Cola) is not a clear fluid. Water is the preferable liquid. And it is permissible to have any necessary medications that you would take normally, up to two hours prior to your procedure with a small sip of water.
How is the procedure performed?

The procedure is relatively simple. The patient is placed in a surgical gown. The area of skin around the site of interest is widely “prepped”. That means that an antibacterial agent is applied to cleanse the skin to avoid infection. Using the fluoroscopy machine, the sacral “hiatus” is located. This can also be located by simple palpation (feel). This site is then marked with a sterile skin marker (pen). Any one of several different needles can then be used to access the caudal epidural space. I use a 20-gauge needle. Other physicians use a Tuohy needle. The needle is advanced through sacrococcygeal ligament to enter the epidural space. To document correct placement and to avoid the potential for venous injection, a small amount of contrast (dye) material may be injected. If the patient is allergic to this material, this step can be omitted. Another technique to document caudal needle placement is to obtain lateral images of the spine under fluoroscopy. Once the correct site is confirmed, steroid and local anesthetic is injected.
How long will it take for me to realize benefit from my injection?

Typically, we see a “window” of approximately 3-5 days before patients notice a quieting down of their pain issue.
Will the procedure work for my pain?

Most patients do benefit significantly from caudal injections. However, there are some patients that do not derive benefit. If the procedure is performed twice with no success, it is our usual policy to not do a third injection. These injections were, in the past, routinely given as a “series” of three injections. However, I have personally found that if we do not see improvement after two injections, it is not likely that a third will help. However, I have several people that insist on the entire series as this is what gave them sustained relief in the past. So, this is determined on a case-by-case basis. And is of course our decision on this is also determine by what other options we might have to offer the patient.
Is the injection painful?

Caudal injections are not too painful, but many patients fear the idea of having a needle injected into their back. For those–and indeed most patients–we administer a simple light anesthetic so that one feels no pain whatsoever. The anesthetic is sometimes a combination of a sedative-hypnotic such as Versed plus a pain medication such as Fentanyl. In other instances, we use Propofol, a general anesthetic, in low doses.
What is injected into my back during for the caudal injection?

Almost universally, the injections consist of a combination of local anesthetic and steroids.
How long will the injection work?

This is hard question to answer because the results truly are all over the map. And I have had patients for whom I was sure the injection would fail that come back with glowing remarks regarding their pain relief. Conversely, I have seen may patient for whom I was convinced the injection would help, only to later hear that t completely failed. What I typically tell my patients is that these injections almost always decrease the pain. It does not always eliminate all the pain—although, we do see this as well. Then, it’s a matter of duration. It is not unusual to see several months or longer relief from one or two epidural injections. We have seen other patients report only a week or two relief and then others that report 6 months to a year.
What are contraindications for caudal injections. That is, what are reasons that I should not have a caudal?

If you are on a blood-thinner (anticoagulant), and cannot stop these safely before your procedure, then you should not have a caudal injection. Anticoagulants can cause bleeding in the epidural space, which is a relatively confined space. If this occurs, and the bleeding is significant, it can damage spinal nerve roots and the spinal cord. Any active infection is a potential contraindication for a caudal injection. This is determined by various issues that can be discussed with your treating physician. Certain “mild” infections and things like sinusitis are not contraindications for a caudal steroid injection.
What are the typical, expected, non-serious side effects from caudal injections?

Several non-serious events can occur after your caudal. First, I have seen a small percentage complain of generalized flushing, especially over the upper body, head, neck, and face. This typically subsided within 48 hours and I have found that over the counter Benadryl helps significantly. Steroid can cause an elevation in blood sugar (glucose) levels, especially for patient with diabetes or pre-diabetes. A recent study demonstrated that 80% of the patient’s noted an elevation in their blood sugar following their epidural steroid injections (which are almost identical to caudal injections). Serum glucose levels gradually returned to normal over several days. There were no cases in this study that demonstrated glucose control issues lasting greater than 5 days. Additionally, some women complain of heavier and more painful periods. There is evidence that steroids can reduce immune system function, which can make the chance of infection more likely. A very small percentage of patients have experienced what appears to be an allergic reaction to a constituent (component) of the steroid solution. I have found that this is self-limiting and easily treated with oral over the counter Benadryl. Lastly, some patients notice short-lived mood changes, irritability, and insomnia. These occur because of the effect that steroids have on our body. These occur because of the effect that steroids have on our body.
What are the potential complications from a caudal injection?

Although complications are rare, when these do occur, they are serious. The primary concerns are that of infection and bleeding in the spinal space. If this occurs, it is a surgical emergency. Untreated bleeding and infection of the spine can result in permanent and irreversible paralysis of the extremities and / or permanent and irreversible bowel or bladder dysfunction. Thankfully, these are extremely rare. what I tell my patients is that it’s like getting stuck by lightening—twice. First, it must occur, and then the physician must miss it. If those two things occur, the chance of a grave neurologic outcome is virtually assured. The worst-ever complication from ESIs occurred in a 2012-2013 outbreak of fungal meningitis caused by contaminated steroids produced at the New England Compounding Center. Approximately 13,000 patients nationwide were exposed to this contaminated steroid batch (not all of these were ESIs) and this resulted in 64 deaths. Very strict production and oversight were implemented by the Federal Government to minimize the risk of this happening again. Other very, very rare — but serious — complications include arachnoiditis, stroke, brain edema, rectal trauma (and infection), cauda equina syndrome, seizures, vasculitis, blindness, and death.
How often can I have a caudal injection?

This is all based on dose, and the availability of other treatment options. But for the average patient with a chronic pain condition, it is allowable to do a caudal every 3 months. We would still have room for another couple of injections as well to bring that total to around 5-6 each year. But I do not typically use that many unless there are limited options. For instance, there is a select group of individuals that are not surgical candidates and either can’t take enough, or cannot tolerate, pain medications. In those cases, it comes down to quality of life. In other words, what is best for the patient. Sometimes, we are left with only the procedural (caudal injection) option.
What should I expect immediately after the procedure?

Generally, patients are kept in the recovery area and observed for 30-45 minutes. Once you are awake and oriented (if you received an anesthetic), and have met discharge criteria, you can leave with a companion. You cannot drive for 12 hours following an injection and for 24 hours after an anesthetic.
How long do I have to wait before I can start my normal activities?

We ask our patients to go home with a companion. They are not to drive, operate any kind of machinery, or make any important decisions for the next 24 hours as anesthesia can cause altered mental processing. And the injection itself can made a person unstable, with “give-way” weakness. This is due to an increase in blood flow away from your core. We call this orthostatic hypotension, and it is one of the most common reasons patients injure themselves after injection therapies, especially if they were also given an anesthetic. Therefore, be very careful when weight bearing or walking. It might take a lot longer than you expect for your normal balance and muscle strength returns. Use caution and do not walk without assistance for at least 6-8 hours.
When can I start taking my medicines again?

All blood thinning medications may be restarted the following day. Any other medications can be taken as soon as you feel awake and oriented. If contrast dye was used, certain medications need to be held the for 48 hours afterward. These include: Metformin, Sitagliptin, Riomet, Fortamet, Janumet, Glumetza, and Glucophage.
How soon can I bathe or shower?

We ask that you wait 24 hours before sitting in water that covers the injection site. Showering is different. For this, we ask that you refrain from showering until normal sensation and strength have fully returned. So that might be within only 6-8 hours; not less.
What are the things that I need to look for after my injections that are potential 'red flags'?
Severe or worsening pain after your injection require an immediate call to our office. Do not leave messages. Call our after-hour paging system or the facility at which the procedure was performed. If there is no answer, go to the nearest emergency room immediately. This could represent bleeding in the epidural space which if left undiagnosed may result in permanent, irreversible paralysis and/or permanent and irreversible bowel or bladder dysfunction.

Pain that worsens day to day could represent infection of the epidural space and is also considered an emergency. Please do the same things that are cited above for potential epidural bleeding complications. Infection of the epidural space can cause the same severe issues that bleeding can cause. A fever of 101 degrees or greater for greater than 24 hours may indicate an infection. Also look for motor (muscle strength) and sensory (decreased sensation to touch) over the extremities or anus. Any changes in bowel or bladder control (that is, ability to produce or hold stool or urine) could indicate an epidural hematoma (bleeding) or epidural infection.

Note that epidural bleeding is going to occur ether immediately after the injection or shortly thereafter. It is exceedingly rare for these to occur days after your procedure. However, there are rare cases of a bleed a week after an injection. Infection of the epidural space typically presents later, usually 7-14 days following a spinal injection.

Worrisome post-procedure signs and symptoms (medical emergencies):

  • Severe post-injection pain
  • Worsening post-injection pain
  • Fever of 101 degrees for > 24 hours
  • Change in motor or sensory function

Coccyx injection

Coccyx injectionThis small bone rest at the base of the sacrum. There are nerves that run alongside and even on the coccyx, which can become pain generators. This is commonly seen in cases of direct trauma to the coccyx (dislocations, fractures) from falls whereby impact is directed to the base of the spine.  Injection is both diagnostic and therapeutic.  If there is an acute injury, injection of a steroid and local anesthetic solution can calm down and sharply reduce inflammation and resultant pain.  For patients with chronic coccyx (tailbone) pain, injection of a neurolytic solution of neurolytic agent can be utilized to destroy these nerves.  These nerves are not important in terms of functionality.  There are sensory nerves and have no motor function. Destruction of sensory-only nerves does not result in any impairment of function. There is additional information on this subject under the categories listed “Neurolytic / Neurolysis injections”.

How should I prepare for a coccyx injection?

It is important to let your treating doctor know what medications you take. There are certain medications, such as blood-thinners (anticoagulants) that are possible or “relative” contraindications for coccyx injections. In years past, we would not consider doing these injections whilst patients were on blood-thinners. That’s has changed, however. Since the coccyx is well outside of the neuroaxis, it is usually permissible to perform these procedures without stopping the blood-thinner. However, the patient might have more soft tissue swelling from needle trauma and tissue bleeding. While this is self-limiting, it can still produce a large bruise and even a hematoma (a subcutaneous collection of blood). Therefore, it is important that your doctor knows your medical history.

Make sure that you have someone with you on the day of the injection. If you receive an anesthetic, these medications can slow your reflexes and impair mental processing. You cannot drive or operate any kind of machinery for at least 24 hours following an anesthetic.

What are my instructions the day of the procedure and for eating and / or drinking before and after the procedure?

We will give specific instructions before your procedure. We usually ask that patients come in about one hour prior to the procedure. We also ask our patients to refrain from eating for a total of six (6) hours prior to their injection. And that meal needs to be light. Do not have a heavy meal six hours before an anesthetic as you run the risk of aspiration of food. This can cause a very serious pneumonia. After the procedure, they you eat as soon as you are awake and oriented (assuming an anesthetic was administered). You can have clear liquids up to 2 hours before an injection. A clear liquid is anything that you can see through if holding a full glass of this fluid. Coke (Coca-Cola) is not a clear fluid. Water is the preferable liquid. And it is permissible to have any necessary medications that you would take normally, up to two hours prior to your procedure with a small sip of water.
How is the procedure performed?

The procedure is relatively simple. The patient is placed in a surgical gown. The entire coccyx area is widely “prepped”. That means that an antibacterial agent is applied to cleanse the skin to avoid infection. Using the fluoroscopy machine, the coccyx is located, and marked with a sterile skin marker (pen). A 20-gauge or 25-gauge needle is advanced to the posterior aspect of the lateral edge of the coccyx on each side. At this point, a small volume of steroid and local anesthetic is injected. I usually use a fan-lie injection technique to address the entire coccyx, with all its anatomic attachments.
How long will it take for me to realize benefit from my injection?

Patients typically experience a dual response. While the local anesthetic is active (one to several hours), there can be significant relief. After this, the local is metabolized and it then your pain can return to its baseline. It then takes up to 3-5 days before the anti-inflammatory, pain-relieving, effects are realized from the steroid.
Will the procedure work for my pain?

Most patients do benefit significantly from coccyx injections. These pain conditions are notoriously for needling repeat injections. For coccyx pain, it usually requires a series of blocks, numbering upwards of 4-6, separated by 7-10 days between each injection. This interval is not fixed or mandatory. Injections are based on response and duration of effect. For patients that do derive benefit, but not lasting relief, there are other options. These include neurolysis (see below, neurolytic procedures) of the coccygeal nerves. Other techniques include pulse lesioning of the coccygeal nerves or cryotherapy. Surgical resection of the coccyx is not recommended.
Is the injection painful?

Coccyx injections are more painful than many other pain management procedures. I usually recommend that the patent receive an anesthetic for the procedure. The anesthetic is sometimes a combination of a sedative-hypnotic such as Versed plus a pain medication such as Fentanyl. In other instances, we use Propofol, a general anesthetic, in low doses.
What is injected when performing a coccyx injection?

Almost universally, the injections consist of a combination of local anesthetic and steroids.
How long will the injection work?

The duration of relief from coccyx injections is variable. But what we have noticed over the last two-plus decades that the typical response is that in which there is a lowering of the pain with each subsequent injection. And again, coccyx pain notoriously requires multiple procedures (repeated procedures) to eliminate the pain.
What are contraindications for coccyx injections? That is, what are reasons that I should not have an injection?

Active infections, especially anything that is near the coccyx would be a contraindication for coccyx injections.
What are the typical, expected, non-serious side effects from coccyx injections?

Several non-serious events can occur after your injection. First, I have seen a small percentage complain of pain at and around the injection site(s). This typically subsids within 48 to 72 hours. Ice packs applied to the area of the injection helps immensely. Steroids can cause an elevation in blood sugar (glucose) levels, especially for patient with diabetes or pre-diabetes. A recent study demonstrated that 80% of the patient’s noted an elevation in their blood sugar following an epidural steroid injection. Results are likely to be very similar with a coccyx injection. Serum glucose levels gradually returned to normal over several days. There were no cases in this study that demonstrated glucose control issues lasting greater than 5 days. There is evidence that steroids can reduce immune system function, which can make the chance of infection more likely. A very small percentage of patients have experienced what appears to be an allergic reaction to a constituent (component) of the steroid solution. I have found that this is self-limiting and easily treated with oral over the counter Benadryl. Lastly, some patients notice short-lived mood changes, irritability, and insomnia. These occur because of the effect that steroids have on our body.
What are the potential complications from a coccyx injection?

Serious complications from coccyx injections are rare. This procedure occurs outside of the neuroaxis and is therefore not close to the spinal cord. Nerve root trauma is unlikely. There is the potential for rectal trauma from the inserted needle. The rectum lies just in front of the coccyx.
How often can I have a coccyx injection?

The number of injections for is based on the duration of pain relief. The typical response is a lessening of pain but not a total eradication of pain. This is the reason why coccygeal (coccyx) injections frequently need to be repeated multiple times. The average is approximately five separate injections.
What should I expect immediately after the procedure?

Generally, patients are kept in the recovery area and observed for 30-45 minutes. Once you are awake and oriented (if you received an anesthetic), and have met discharge criteria, you can leave with a companion. You cannot drive for 12 hours following an injection and for 24 hours after an anesthetic.
How long do I have to wait before I can start my normal activities?

We ask our patients to go home with a companion. They are not to drive, operate any kind of machinery, or make any important decisions for the next 24 hours as anesthesia can cause altered mental processing. Because the local anesthetic can spill over to the adjacent spinal nerve roots, patients may find that they are weak and not stable, with “give-way” weakness. Therefore, be very careful when weight bearing or walking. It might take a lot longer than you expect for your normal balance and muscle strength returns. Use caution and do not walk without assistance for at least 6-8 hours.
When can I start taking my medicines again?

All medications can be taken the day of the procedure—including blood thinners. However, some patients might be asked to hold anticoagulants for very specialized reasons. If this had not been worked out prior to the procedure, we can discuss this issue on the day of your procedure.
How soon can I bathe or shower?

We ask that you wait 24 hours before sitting in water that covers the injection site. Showering is different. For this, we ask that you refrain from showering until normal sensation and strength have fully returned. So that might be within only 6 hours; not less.
What are the things that I need to look for after my injections that are potential 'red flags'?

Severe or worsening pain after your injection require an immediate call to our office. Do not leave messages. Call our after-hour paging system or the facility at which the procedure was performed. If there is no answer, go to the nearest emergency room immediately.

Pain that worsens day to day could represent infection and is also considered an emergency. Please follow the same recommendations (above). A fever of 101 degrees or greater for greater than 24 hours may indicate an infection. Also look for motor (muscle strength) and sensory (decreased sensation to touch) over the extremities.

Worrisome post-procedure signs and symptoms (medical emergencies):

  • Severe post-injection pain
  • Worsening post-injection pain
  • Fever of 101 degrees for > 24 hours
  • Change in motor or sensory function

Contact Pain Stop MD today online or by calling 972-556-5738.

Costovertebral joint injection

In the thoracic spine, where each rib articulates (joins) the thoracic vertebrae, lies each of the 12 costovertebral joints.  There are 12 joints on each side of the thoracic spine. Injury to the thoracic spine, or direct chest wall injuries can cause disruption and inflammation of these joints and their capsules. Injections into these sited will markedly decrease inflammation of the joint, which reduces pain as well as the work and effort of breathing—especially that which is seen in acute injuries.

Discography

discographyThis is purely a diagnostic study performed to help surgeons determine painful spinal segments.  For this procedure, a needle is placed into the disc, or discs, of interest. Following that, contrast solution is injected to look at the architecture of the disc. Any pain response elicited with pressurization of the disc is recorded and matched with current symptoms so as determine to determine whether a disc is painful and in need of surgical intervention–typically, surgical fusion of the vertebrae to alleviate biomechanical load and pressure on the affected disc. Unlike discography performed in many other areas of the country, this procedure is relatively painless as we employ the use of intravenous anesthetics until testing of the disc is needed. At this point, you will be awake and able to answer questions so that accurate information can be obtained for the surgeon. Our patients report minimal discomfort for just a brief period—typically 2 to 3 minutes, during which time we are looking for a response with pressurization of the disc. Once this information is obtained, we administer intravenous pain medications and the patient is taken for additional imaging (CT; computed tomography), to provide additional information on disc architecture.

Dorsal root ganglion (DRG) stimulation

This is a new form of spinal stimulation or neuromodulation in which an electrode is placed next the nerve root as it exits the spine. A low amplitude, high frequency pulse is delivered to the nerve root to block pain signals. Dorsal root ganglion stimulation is a very new and exciting technology that has been offered to only a handful of Pain Management clinicians across the country.  Results of this type of neuromodulation has been nothing less than remarkable. There are certain indications that would render one appropriate for this type of neuromodulation versus standard spinal cord stimulation (see below). These procedures are first done as “trials” or tests, whereby the device can be used by the patient at home for 4-5 days. They can then return to the clinic for assessment. Information is gathered at that time to determine if this will be an effective modality for long-term pain control.

How should I prepare for my DRG trial?

It is important to let your treating doctor know what medications you take. There are certain medications, such as blood-thinners (anticoagulants) that are absolute contraindications for a DRG stimulation. Your doctor also needs to know your medical history. There are certain, but very unusual, conditions which would say your physicians’ hand in terms of performing a DRG trial.

Make sure that you have someone on the day of the procedure. Please note that you will be receiving an anesthetic. The anesthesia personnel will ask questions to make your sure that you have a smooth experience. Because anesthetic medications can slow your reflexes and impair mental processing, you cannot drive or operate any kind of machinery for at least 24 hours following the procedure.

What are my instructions the day of the procedure and for eating and / or drinking before and after the procedure?

We will give specific instructions before your procedure. We usually ask that patients come in about one hour prior to the procedure. We also ask our patients to refrain from eating for a total of six (6) hours prior to their injection. And that meal needs to be light. Do not have a heavy meal six hours before an anesthetic as you run the risk of aspiration of food. This can cause a very serious pneumonia. After the procedure, they you eat as soon as you are awake and oriented (assuming an anesthetic was administered). You can have clear liquids up to 2 hours before an injection. A clear liquid is anything that you can see through if holding a full glass of this fluid. Coke (Coca-Cola) is not a clear fluid. Water is the preferable liquid. And it is permissible to have any necessary medications that you would take normally, up to two hours prior to your procedure with a small sip of water.
How is the procedure performed?

This procedure is technically more difficult that other pain management procedures. And it takes more time. As per standard and customary protocol, the patient is placed in a surgical gown. A wide area of skin is “prepped” and draped in sterile fashion. That means that an antibacterial agent is applied to cleanse the skin to avoid infection. A sterile field is created with a large plastic drape. Using the fluoroscopy machine, the appropriate level of interest for treatment is identified and marked with a sterile skin marker (pen). At this point, anesthetic is administered. A special DRG needle is advanced to the epidural space. Then, an electrode is advanced to the nerve root(s) of interest. Once satisfactorily placed, we allow the patient to wake up slowly from their anesthetic. The unit is then tested to determine is satisfactory coverage is obtained—that is, stimulation over the area that is typically painful.
How long will it take for me to realize benefit from my injection?

Patients typically experience relief starting the next day. There is a gradual onset of relief. Patients usually tell us that it takes 1-2 days before they realize that the pain is decreased.

Of all the procedures in Pain Management, this is one of the more successful interventions. I have seen patients achieve 100% relief. But this is not typical. We are, however, noticing excellent relief overall in most of the trials. Approximately 85% of patients will ask for an implantation of the device following the trial.

Will the procedure work for me?

DRG stimulation is one of the most innovative procedures to be introduced. Pain relief is achieved in at least 85% of patients. However, we do have failures. For those patients, it is simply a matter of finding another way. This technology is not for everyone and that’s why we need to do a trial first.
Is the injection painful?

DRG trials are painful. Anesthesia is needed to perform this procedure because advancing the electrode near the affected nerve root can cause irritation and pain during advancement of the lead. This quickly subsides, thankfully.
What medications be injected into my back when I receive a DRG trial?

Beyond the local anesthetic for the skin and deeper tissue, there are no medications injected into your back—and certainly none in the epidural space.
How long will my DRG trial work?

This is usually a one-and-done kind of intervention. If you have had a successful trial, the next step is to implant the device. After that, we are done. You will not need any kind of additional neuromodulation. You will have a device that controls the unit and a charger to keep the battery in good condition. Remember, if you have the implantation., the battery is implanted too. There is nothing that is attached to anything outside of your battery. It is all “underground”. The unit is charged through the skin with a special pad that is placed over the battery.
What are contraindications for a DRG trial. That is, what are reasons that I should not have a DRG trial?

If you are on a blood-thinner (anticoagulant), and cannot stop these safely before your procedure, then you should not have a DRG trial. Anticoagulants can cause bleeding in the epidural space, which is a relatively confined space. If this occurs, and the bleeding is significant, it can damage spinal nerve roots and the spinal cord. Any active infection is a potential contraindication for a DRG trial. This is determined by various issues that can be discussed with your treating physician. Certain “mild” infections and things like sinusitis are not absolute contraindications for a DRG trial.
What are the typical, expected, non-serious side effects from DRG trial?

Several non-serious events can occur after your trial. There is usually some tenderness at the needle insertion sites. This is almost always very mild. Due to the proximity of the electrode to the spinal nerve root, some patients experience increased pain for 1-2 days over the area of their typically painful sites.
What are the potential complications from trial DRG?

Although complications are rare, when these do occur, they are serious. The primary concerns are that of infection and bleeding. If this occurs, it is a surgical emergency. Untreated bleeding and infection of the spine can result in permanent and irreversible paralysis of the extremities and / or permanent and irreversible bowel or bladder dysfunction. Thankfully, these are extremely rare. what I tell my patients is that it’s like getting stuck by lightening—twice. First, it must occur, and then the physician must miss it. If those two things occur, the chance of a grave neurologic outcome is virtually assured.
How often will I need to have a trial DRG?

This is not at all like an epidural steroid injection or other injections. This is a one-time test. All the information we need to make the determination as to the appropriateness of neuromodulation will be obtained from this trial.
What should I expect immediately after the procedure?

Generally, patients are kept in the recovery area and observed for 30-45 minutes. Once you are awake and oriented, and have met discharge criteria, you can leave with a companion. You cannot drive for 12 hours following the procedure and for 24 hours after an anesthetic.
How long do I have to wait before I can start my normal activities?

We ask our patients to go home and take it easy for a couple of days. We don’t ask that you do nothing at all but try to avoid too much exertion. On the other hand, we need to see if this technique helps with your normal day to day activities. Therefore, this is a balancing act. We can help you with this. I can say that it is rare that patients find that they are unable to perform all their usual activities. Naturally, swimming is not allowable. Nor is vigorous activity that might displace the leads, as these are simply taped to your back with a strong adhesive.
When can I start taking my medicines again?

All blood thinners (anti-coagulants) must be held for the entire trial. This is critical. Unlike other procedures, one cannot take their blood-thinner the next day. The reason for this is because when you come back for the office visit, we pull out the temporary leads. If you have restarted the blood-thinners, you can bleed into the spinal space and cause severe complications including paralysis. So, this is mandatory. All anticoagulant medications must be help for the trial. You and take then again, the day following the office visit for re-check and lead pull. All other medications can be taken the day of the trial and continued as normal. There is no reason to hold any of these medications. Only blood-thinners present a danger.
How soon can I bathe or shower?

We ask that you refrain from normal bathing or showing for the entirety of your trial. You can take a sponge bath, sitting is a shallow pool of water and cleaning all your body except for the bandaged area. This is annoying but necessary. We don’t want water to loosen the dressings nor do we want it anywhere near the lead insertions site. You cannot shower. There is just no way to do that without getting the dressings wet.
What are the things that I need to look for after my injections that are potential 'red flags'?

Severe or worsening pain after your injection require an immediate call to our office. Do not leave messages. Call our after-hour paging system or the facility at which the procedure was performed. If there is no answer, go to the nearest emergency room immediately. This could represent bleeding in the epidural space which if left undiagnosed may result in permanent, irreversible paralysis and/or permanent and irreversible bowel or bladder dysfunction.

Pain that worsens day to day could represent infection of the epidural space and is also considered an emergency. Please do the same things that are cited above for potential epidural bleeding complications. Infection of the epidural space can cause the same severe issues that bleeding can cause. A fever of 101 degrees or greater for greater than 24 hours may indicate an infection. Also look for motor (muscle strength) and sensory changes (decreased sensation to touch) over the extremities or anus. Any changes in bowel or bladder control (that is, ability to produce or hold stool or urine) could indicate an epidural hematoma (bleeding) or epidural infection.

Note that epidural bleeding is going to occur ether immediately after the injection or shortly thereafter. It is exceedingly rare for these to occur days after your procedure. However, there are rare cases of a bleed a week after an injection. Infection of the epidural space typically presents later, usually 7-14 days following a spinal injection.

Worrisome post-procedure signs and symptoms (medical emergencies):

  • Severe post-injection pain
  • Worsening post-injection pain
  • Fever of 101 degrees for > 24 hours
  • Change in motor or sensory function

Epidural blood patch

epidural blood patchPatients frequently undergo procedures where cerebral spinal fluid is collected and analyzed. This is common for patients undergoing myelography, or spinal cord fluid examination for headache, meningitis, etc. Many patients who have had one of these procedures will develop a severe headache due to loss of cerebral spinal fluid through a hole made in the dura. The dura is the name of the material that surrounds the spinal (intrathecal) space and keeps the cerebrospinal fluid from escaping. Loss of this fluid produces traction on the covering of the brain (meninges), which results in a severe headache. Classically, this headache is relieved only by lying down and any kind of upright or raised position will exacerbate symptoms and bring on severe headache pain. These are also known as postural headaches, or post-dural puncture headaches. The treatment is relatively simple.  Blood is collected from the patient in a strict sterile fashion. This is then injected into the epidural space near the original site of cerebrospinal fluid collection. Blood contains fibrin, which is a protein that tends to clump into a meshwork or “patch” over original puncture needle site, thus stopping the flow of cerebrospinal fluid This procedure has a very high success rate at approximately 90% with the first blood patch, increasing to 95% with the second blood patch. The remaining 5% of patients who do not respond are given instructions for strict bed rest and hydration. With time, the puncture site will close on its own, thus alleviating the headache.

How should I prepare for my epidural blood patch (EBP)?

It is important to let your treating doctor know what medications you take. There are certain medications, such as blood-thinners (anticoagulants) that are absolute contraindications for an EBP. Your doctor also needs to know your medical history. There are certain, but very unusual, conditions which would say your physicians’ hand in terms of performing an EBP.

Make sure that you have someone with you on the day of the injection. If you receive an anesthetic, these medications can slow your reflexes and impair mental processing. You cannot drive or operate any kind of machinery for at least 24 hours following an anesthetic.

What are my instructions the day of the procedure and for eating and / or drinking before and after the procedure?

We will give specific instructions before your procedure. We usually ask that patients come in about one hour prior to the procedure. We also ask our patients to refrain from eating for a total of six (6) hours prior to their injection. And that meal needs to be light. Do not have a heavy meal six hours before an anesthetic as you run the risk of aspiration of food. This can cause a very serious pneumonia. After the procedure, they you eat as soon as you are awake and oriented (assuming an anesthetic was administered). You can have clear liquids up to 2 hours before an injection. A clear liquid is anything that you can see through if holding a full glass of this fluid. Coke (Coca-Cola) is not a clear fluid. Water is the preferable liquid. And it is permissible to have any necessary medications that you would take normally, up to two hours prior to your procedure with a small sip of water.
How is the procedure performed?

The procedure is relatively simple. The patient is placed in a surgical gown. The area of skin near the spinal puncture site is widely “prepped”. That means that an antibacterial agent is applied to cleanse the skin to avoid infection. Using the fluoroscopy machine, the appropriate level of interest for treatment is identified and marked with a sterile skin marker (pen). A special epidural needle, called a Tuohy needle, is advanced to the epidural space. A small amount of contrast (dye) can be injected to document correct needle placement. If the patient is allergic to this material, this step can be omitted. At the same time, an assistant collects blood from either right or left arm, again prepping a wide area so as not to introduce bacteria into the collected blood. Typically, 7-15 cc of your own (autologous) blood is collected. This is then injected slowly through the epidural needle, after it has accessed the epidural space. The blood is injected slowly, so as not to over-pressurize the epidural space, and a rate no greater than 1cc (milliliter) every 3 seconds. Over the next several minutes, the blood clots in place. And the fibrin within the blood starts to form a meshwork patch over the dural defect (hole).
How long will it take for me to realize benefit from my injection?

Patients typically experience almost immediate relief—virtually within minutes. However, we ask patients to lie flat to allow the blood to stay in place and coagulate. So, it is not until the patient is up and out of bed and ambulatory until they feel relief from this intervention.
Will the procedure work for my headache pain?

Again, we usually see immediate effects. But we do want to limit activity for the next 24 hours. This relief occurs in 90% of patients. However, there are some patients that do not derive benefit initially. In this case, we can either allow another 2-3 days to elapse, and try the injection again or, alternatively, we can see if they respond with rest, hydration, and pain medication. This conservative approach occurs frequently as well. For a small percentage of patients, a second EBP is required.
Is the injection painful?

EBPs are not painful, but many patients fear the idea of having a needle injected into their back. For those–and indeed most patients–we administer a simple light anesthetic so that one feels no pain whatsoever. The anesthetic is sometimes a combination of a sedative-hypnotic such as Versed plus a pain medication such as Fentanyl. In other instances, we use Propofol, a general anesthetic, in low doses.
What is injected into my back when I receive an EBP?

Autologous (blood collected from your body) is injected directly into the epidural space.
How long will my EBP work?

These are usually a one-and-done kind of interventions. Once the leak is sealed, it won’t return unless there is a new violation of the dura.
What are contraindications for EBPs. That is, what are reasons that I should not have an EBP?

If you are on a blood-thinner (anticoagulant), and cannot stop these safely before your procedure, then you should not have an EBP. Anticoagulants can cause bleeding in the epidural space, which is a relatively confined space. If this occurs, and the bleeding is significant, it can damage spinal nerve roots and the spinal cord. Any active infection is a potential contraindication for an EBP. This is determined by various issues that can be discussed with your treating physician. Certain “mild” infections and things like sinusitis are not contraindications for an EBP.
What are the typical, expected, non-serious side effects from EBPs?

Several non-serious events can occur after your EBP. A small number of patients will experience a worsening of the headache for several minutes, which then starts to subside. I have seen a small percentage complain of generalized flushing, especially over the upper body, head, neck, and face. This typically subsides within 8-12 hours and I do not recommend anything other than time to cure this side effect.
What are the potential complications from an EBP?

Although complications are rare, when these do occur, they are serious. The primary concerns are that of infection and bleeding. If this occurs, it is a surgical emergency. Untreated bleeding and infection of the spine can result in permanent and irreversible paralysis of the extremities and / or permanent and irreversible bowel or bladder dysfunction. Thankfully, these are extremely rare. what I tell my patients is that it’s like getting stuck by lightening—twice. First, it must occur, and then the physician must miss it. If those two things occur, the chance of a grave neurologic outcome is virtually assured. Another rare potential complication is rectal trauma (and infection), if a caudal approach is utilized for the EBP.
How often will I need to have an EBP?

This is not at all like an epidural steroid injection or other injections. We do not perform these repetitively. Usually, just one EBP is all you will require.
What should I expect immediately after the procedure?

Generally, patients are kept in the recovery area and observed for 30-45 minutes. Once you are awake and oriented (if you received an anesthetic), and have met discharge criteria, you can leave with a companion. You cannot drive for 12 hours following an injection and for 24 hours after an anesthetic.
How long do I have to wait before I can start my normal activities?

We ask our patients to go home and lie relatively flat. A small pillow under your head is acceptable. We ask that you refrain from any strenuous activities for 72 hours, minimum. There is the theoretical change that the patch can become dislodged. However, I have never seen this happen. They are not to drive, operate any kind of machinery, or make any important decisions for the next 24 hours as anesthesia can cause altered mental processing.
When can I start taking my medicines again?

All blood thinning medications may be restarted the following day. Any other medications can be taken as soon as you feel awake and oriented. If contrast dye was used, certain medications need to be held the for 48 hours afterward. These include: Metformin, Sitagliptin, Riomet, Fortamet, Janumet, Glumetza, and Glucophage.
How soon can I bathe or shower?

We ask that you wait 24 hours before sitting in water that covers the injection site. Showering is different. For this, we ask that you refrain from showering for 6 hours after the injection.
What are the things that I need to look for after my injections that are potential 'red flags'?

Severe or worsening pain after your injection require an immediate call to our office. Do not leave messages. Call our after-hour paging system or the facility at which the procedure was performed. If there is no answer, go to the nearest emergency room immediately. This could represent bleeding in the epidural space which if left undiagnosed may result in permanent, irreversible paralysis and/or permanent and irreversible bowel or bladder dysfunction.

Pain that worsens day to day could represent infection of the epidural space and is also considered an emergency. Please do the same things that are cited above for potential epidural bleeding complications. Infection of the epidural space can cause the same severe issues that bleeding can cause. A fever of 101 degrees or greater for greater than 24 hours may indicate an infection. Also look for motor (muscle strength) or sensory (decreased sensation to touch) changes over the extremities or anus. Any changes in bowel or bladder control (that is, ability to produce or hold stool or urine) could indicate an epidural hematoma (bleeding) or epidural infection.

Note that epidural bleeding is going to occur ether immediately after the injection or shortly thereafter. It is exceedingly rare for these to occur days after your procedure. However, there are rare cases of a bleed a week after an injection. Infection of the epidural space typically presents later, usually 7-14 days following a spinal injection.

Worrisome post-procedure signs and symptoms (medical emergencies):

  • Severe post-injection pain
  • Worsening post-injection pain
  • Fever of 101 degrees for > 24 hours
  • Change in motor or sensory function

Epidural steroid injection (ESIs)

epidural steroid injectionThis is one of the most common procedures performed in pain management.  ESIs can be performed in the cervical, thoracic, lumbar, or caudal region. ESIs are used for treatment of inflamed spinal nerve roots and intervertebral discs. ESIs are used in conjunction with other modalities to treat pain including physical therapy, traction, and medications. The purpose is to reduce pain and inflammation and to reduce or eliminate the need for more aggressive, surgical, intervention.

This form of therapy has been available since the early 1950’s. Underscoring the safety of this procedure further, note that this is the same technical procedure women undergo during routine labor and delivery. A prospective study performed several years ago found that of a total of 4,265 ESIs performed on 1,857 patients, there were no major complications. The most common complication noted was an increase in pain which lasted for several days. This occurred in 2.4% of the ESIs performed.

Having said this, ESIs are still considered “off label” by the FDA, which means that while it falls within the practice of medicine, it is not FDA approved. The FDA requires all glucocorticoid steroid warning labels to state:

The safety and effectiveness of epidural administration of corticosteroids have not been established and corticosteroids are not approved for this use… serious neurologic events, some resulting in death, have been reported with epidural injection of corticosteroids.

How should I prepare for my epidural steroid injection?

It is important to let your treating doctor know what medications you take. There are certain medications, such as blood-thinners (anticoagulants) that are absolute contraindications for an ESI. Your doctor also needs to know your medical history. For instance, if you have diabetes, that is important to both you and your treating doctor. Steroids are administered when performing ESIs. Steroids will cause an elevation in your blood sugar (glucose) level. So, this needs to be paid close attention. And changes in your diabetic medications might be necessary for seven days following an ESI. A recent study demonstrated that 80% of the patient’s noted an elevation in their blood sugar following their ESI. Serum glucose levels gradually returned to normal over several days. There were no cases in this study that demonstrated glucose control issues lasting greater than 5 days.

Make sure that you have someone with you on the day of the injection. The injected medications can make you unsteady on your feet. Also, anesthesia medications can slow your reflexes and impair mental processing. You cannot drive or operate any kind of machinery for at least 12 hours following an injection and for 24 hours following an anesthetic.

What are my instructions the day of the procedure and for eating and / or drinking before and after the procedure?

We will give specific instructions before your procedure. We usually ask that patients come in about one hour prior to the procedure. We also ask our patients to refrain from eating for a total of six (6) hours prior to their injection. And that meal needs to be light. Do not have a heavy meal six hours before an anesthetic as you run the risk of aspiration of food. This can cause a very serious pneumonia. After the procedure, they you eat as soon as you are awake and oriented (assuming an anesthetic was administered). You can have clear liquids up to 2 hours before an injection. A clear liquid is anything that you can see through if holding a full glass of this fluid. Coke (Coca-Cola) is not a clear fluid. Water is the preferable liquid. And it is permissible to have any necessary medications that you would take normally, up to two hours prior to your procedure with a small sip of water.
How is the procedure performed?

The procedure is relatively simple. The patient is placed in a surgical gown. The area of skin around the site of interest is widely “prepped”. That means that an antibacterial agent is applied to cleanse the skin to avoid infection. Using the fluoroscopy machine, the appropriate level of interest for treatment is identified and marked with a sterile skin marker (pen). A special epidural needle, called a Tuohy needle, is advanced to the epidural space. A small amount of contrast (dye) can be injected to document correct needle placement. If the patient is allergic to this material, this step can be omitted. Once correct needle position is confirmed, steroid and local anesthetic is injected.  This space is filled with fat and blood vessels. It surrounds the spinal cord, thus offering cushion and protection.
How long will it take for me to realize benefit from my injection?

Typically, we see a “window” of approximately 3-5 days before patients notice a quieting down of their pain issue.
Will the procedure work for my pain?

Most patients do benefit significantly from ESIs. However, there are some patients that do not derive benefit. If the procedure is performed twice with no success, it is our usual policy to not do a third injection. These injections were, in the past, routinely given as a “series” of three injections. However, I have personally found that if we do not see improvement after two injections, it is not likely that a third will help. However, I have several people that insist on the entire series as this is what gave them sustained relief in the past. So, this is determined on a case-by-case basis. And is of course our decision on this is also determine by what other options we might have to offer the patient.
Is the injection painful?

ESIs are not painful but many patients fear the idea of having a needle injected into their back. For those–and indeed most patients–we administer a simple light anesthetic so that one feels no pain whatsoever. The anesthetic is sometimes a combination of a sedative-hypnotic such as Versed plus a pain medication such as Fentanyl. In other instances, we use Propofol, a general anesthetic, in low doses.
What is injected into my back during an ESI?

Almost universally, the injections consist of a combination of local anesthetic and steroids.
How long will the injection work?

This is hard question to answer because the results truly are all over the map. And I have had patients for whom I was sure the injection would fail that come back with glowing remarks regarding their pain relief. Conversely, I have seen may patient for whom I was convinced the injection would help, only to later hear that t completely failed. What I typically tell my patients is that these injections almost always decrease the pain. It does not always eliminate all the pain—although, we do see this as well. Then, it’s a matter of duration. It is not unusual to see several months or longer relief from one or two epidural injections. We have seen other patients report only a week or two relief and then others that report 6 months to a year.
What are contraindications for ESIs. That is, what are reasons that I should not have an ESI?

If you are on a blood-thinner (anticoagulant), and cannot stop these safely before your procedure, then you should not have an ESI. Anticoagulants can cause bleeding in the epidural space, which is a relatively confined space. If this occurs, and the bleeding is significant, it can damage spinal nerve roots and the spinal cord. Any active infection is a potential contraindication for an ESI. This is determined by various issues that can be discussed with your treating physician. Certain “mild” infections and things like sinusitis are not contraindications for an ESI.
What are the typical, expected, non-serious side effects from ESIs?

Several non-serious events can occur after your ESI. First, I have seen a small percentage complain of generalized flushing, especially over the upper body, head, neck, and face. This typically subsided within 48 hours and I have found that over the counter Benadryl helps significantly. Steroid can cause an elevation in blood sugar (glucose) levels, especially for patient with diabetes or pre-diabetes. A recent study demonstrated that 80% of the patient’s noted an elevation in their blood sugar following their ESI. Serum glucose levels gradually returned to normal over several days. There were no cases in this study that demonstrated glucose control issues lasting greater than 5 days. Additionally, some women complain of heavier and more painful periods. There is evidence that steroids can reduce immune system function, which can make the chance of infection more likely. A very small percentage of patients have experienced what appears to be an allergic reaction to a constituent (component) of the steroid solution. I have found that this is self-limiting and easily treated with oral over the counter Benadryl. Lastly, some patients notice short-lived mood changes, irritability, and insomnia. These occur because of the effect that steroids have on our body. These occur because of the effect that steroids have on our body.
What are the potential complications from an ESI?

Although complications are rare, when these do occur, they are serious. The primary concerns are that of infection and bleeding. If this occurs, it is a surgical emergency. Untreated bleeding and infection of the spine can result in permanent and irreversible paralysis of the extremities and / or permanent and irreversible bowel or bladder dysfunction. Thankfully, these are extremely rare. what I tell my patients is that it’s like getting stuck by lightening—twice. First, it must occur, and then the physician must miss it. If those two things occur, the chance of a grave neurologic outcome is virtually assured. The worst-ever complication from ESIs occurred in a 2012-2013 outbreak of fungal meningitis caused by contaminated steroids produced at the New England Compounding Center. Approximately 13,000 patients nationwide were exposed to this contaminated steroid batch (not all of these were ESIs) and this resulted in 64 deaths. Very strict production and oversight were implemented by the Federal Government to minimize the risk of this happening again. Other, very, very rare—but serious—complications include arachnoiditis, stroke, brain edema, cauda equina syndrome, seizures, vasculitis, blindness, and death.

Another, vastly less concerning, complication of epidural steroid injections is intrathecal injection. This occurs when the needle goes past the epidural space and violates the dura—the sac that surrounds the spine and contains the cerebrospinal fluid (CSF). If this is not recognized when performing the injection local anesthetic and be injected directly into the CSF. This causes profound weakness of the extremities. While this effect will wear off in several hours, it is quite disconcerting to the patient as they cannot move their legs for hours following the procedure. If this occurs when performing a cervical ESI, it can cause difficulty due to temporary paralysis of the diaphragm and intercostal muscles. Again, this will wear off completely.

How often can I have an ESI?

This is all based on dose, and the availability of other treatment options. But for the average patient with a chronic pain condition, it is allowable to do an ESI every 3 months. We would still have room for another couple of injections as well to bring that total to around 5-6 each year. But I do not typically use that many unless there are limited options. For instance, there is a select group of individuals that are not surgical candidates and either can’t take enough, or cannot tolerate, pain medications. In those cases, it comes down to quality of life. In other words, what is best for the patient. Sometimes, we are left with only the procedural (ESI) option.
What should I expect immediately after the procedure?

Generally, patients are kept in the recovery area and observed for 30-45 minutes. Once you are awake and oriented (if you received an anesthetic), and have met discharge criteria, you can leave with a companion. You cannot drive for 12 hours following an injection and for 24 hours after an anesthetic.
How long do I have to wait before I can start my normal activities?

We ask our patients to go home with a companion. They are not to drive, operate any kind of machinery, or make any important decisions for the next 24 hours as anesthesia can cause altered mental processing. And the injection itself can made a person unstable, with “give-way” weakness. This is due to an increase in blood flow away from your core. We call this orthostatic hypotension, and it is one of the most common reasons patients injure themselves after injection therapies, especially if they were also given an anesthetic. Therefore, be very careful when weight bearing or walking. It might take a lot longer than you expect for your normal balance and muscle strength returns. Use caution and do not walk without assistance for at least 6-8 hours.
When can I start taking my medicines again?

All blood thinning medications may be restarted the following day. Any other medications can be taken as soon as you feel awake and oriented. If contrast dye was used, certain medications need to be held the for 48 hours afterward. These include: Metformin, Sitagliptin, Riomet, Fortamet, Janumet, Glumetza, and Glucophage.
How soon can I bathe or shower?

We ask that you wait 24 hours before sitting in water that covers the injection site. Showering is different. For this, we ask that you refrain from showering until normal sensation and strength have fully returned. So that might be within only 6-8 hours; not less.
What are the things that I need to look for after my injections that are potential 'red flags'?

Severe or worsening pain after your injection require an immediate call to our office. Do not leave messages. Call our after-hour paging system or the facility at which the procedure was performed. If there is no answer, go to the nearest emergency room immediately. This could represent bleeding in the epidural space which if left undiagnosed may result in permanent, irreversible paralysis and/or permanent and irreversible bowel or bladder dysfunction.

Pain that worsens day to day could represent infection of the epidural space and is also considered an emergency. Please do the same things that are cited above for potential epidural bleeding complications. Infection of the epidural space can cause the same severe issues that bleeding can cause. A fever of 101 degrees or greater for greater than 24 hours may indicate an infection. Also look for motor (muscle strength) or sensory changes (decreased sensation to touch) over the extremities or anus. Any changes in bowel or bladder control (that is, ability to produce or hold stool or urine) could indicate an epidural hematoma (bleeding) or epidural infection.

Note that epidural bleeding is going to occur ether immediately after the injection or shortly thereafter. It is exceedingly rare for these to occur days after your procedure. However, there are rare cases of a bleed a week after an injection. Infection of the epidural space typically presents later, usually 7-14 days following a spinal injection.

Worrisome post-procedure signs and symptoms (medical emergencies):

  • Severe post-injection pain
  • Worsening post-injection pain
  • Fever of 101 degrees for > 24 hours
  • Change in motor or sensory function

Facet injection

facet injectionThese are injections of the joints between each vertebra.  There are cervical, thoracic and lumbar facet joints.  Each joint has its own small bursa, which is a special protective layer around the joint, filled with a lubricating fluid called synovial fluid.  Commonly, these joints and their bursa become inflamed, particularly as one ages and with arthritic changes start to occur. As with other injections, a needle is inserted under direct, live X-ray (fluoroscopy).  At each affected site, a solution of local anesthetic and steroids is injected. This typically results in marked reduction in inflammation and pain.

How should I prepare for my facet injection?

It is important to let your treating doctor know what medications you take. There are certain medications, such as blood-thinners (anticoagulants) that are possible or “relative” contraindications for facet injections. In years past, we would not consider doing these injections whilst patients were on blood-thinners. That’s has changed, however. Since facet joint are not in contact with the spine itself, and not in the “neuraxis”, it is usually permissible to perform these procedures without stopping the blood-thinner. However, the patient might have more soft tissue swelling from deep tissue bleeding. While this is self-limiting, it can still produce a large bruise and even a hematoma (a subcutaneous collection of blood). Therefore, it is important that your doctor knows your medical history.

Make sure that you have someone with you on the day of the injection. If you receive an anesthetic, these medications can slow your reflexes and impair mental processing. You cannot drive or operate any kind of machinery for at least 24 hours following an anesthetic.

What are my instructions the day of the procedure and for eating and / or drinking before and after the procedure?

We will give specific instructions before your procedure. We usually ask that patients come in about one hour prior to the procedure. We also ask our patients to refrain from eating for a total of six (6) hours prior to their injection. And that meal needs to be light. Do not have a heavy meal six hours before an anesthetic as you run the risk of aspiration of food. This can cause a very serious pneumonia. After the procedure, they you eat as soon as you are awake and oriented (assuming an anesthetic was administered). You can have clear liquids up to 2 hours before an injection. A clear liquid is anything that you can see through if holding a full glass of this fluid. Coke (Coca-Cola) is not a clear fluid. Water is the preferable liquid. And it is permissible to have any necessary medications that you would take normally, up to two hours prior to your procedure with a small sip of water.
How is the procedure performed?

The procedure is relatively simple. The patient is placed in a surgical gown. The area of skin near the spinal puncture site is widely “prepped”. That means that an antibacterial agent is applied to cleanse the skin to avoid infection. Using the fluoroscopy machine, the appropriate level(s) of interest for treatment is identified and marked with a sterile skin marker (pen). A spinal needle is advanced to the desired facet joint. At this point, a small volume of steroid and local anesthetic is injected directly into the joint(s).
How long will it take for me to realize benefit from my injection?

Patients typically experience a dual response. While the local anesthetic is active (one to several hours), there can be significant relief. After this, the local is metabolized and it then your pain can return to its baseline. It then takes up to 3-5 days before the anti-inflammatory, pain-relieving, effects are realized from the steroid.
Will the procedure work for my pain?

Most patients do benefit significantly from facet joint injections. However, there are some patients that do not derive benefit. If you derive benefit that is lasting, we leave things alone unless or until the pain returns. If there is immediate relief that does not last beyond the local effect, one can consider radiofrequency lesioning (RF lesioning).
Is the injection painful?

Facet are not painful, but many patients fear the idea of having a needle injected into their back. For those–and indeed most patients–we administer a simple light anesthetic so that one feels no pain whatsoever. The anesthetic is sometimes a combination of a sedative-hypnotic such as Versed plus a pain medication such as Fentanyl. In other instances, we use Propofol, a general anesthetic, in low doses.
What is injected when performing a facet injection?

Almost universally, the injections consist of a combination of local anesthetic and steroids. Some patients benefit from regenerative techniques where stem cells are utilized.
How long will the injection work?

This is hard question to answer because the results truly are all over the map. And I have had patients for whom I was sure the injection would fail that come back with glowing remarks regarding their pain relief. Conversely, I have seen may patient for whom I was convinced the injection would help, only to later hear that t completely failed. What I typically tell my patients is that these injections almost always decrease the pain. It does not always eliminate all the pain—although, we do see this as well. Then, it’s a matter of duration. It is not unusual to see several months or longer relief from one or two facet injections. We have seen other patients report only a week or two relief and then others that report 6 months to a year.
What are contraindications for facet injections? That is, what are reasons that I should not have an injection?

In years past, we would hold anticoagulants (blood-thinners) before facet injections. This is not necessary. However, you may experience increased soft tissue swelling secondary to deep tissue bleeding. While this is self-limiting, it can still produce a large bruise and even a hematoma (a subcutaneous collection of blood). Therefore, it is important that your doctor knows your medical history.
What are the typical, expected, non-serious side effects from facet injections?

Several non-serious events can occur after your injection. First, I have seen a small percentage complain of pain at and around the injection site(s). This typically subsids within 48 to 72 hours. Ice packs applied to the area of the injection helps immensely. Steroids can cause an elevation in blood sugar (glucose) levels, especially for patient with diabetes or pre-diabetes. A recent study demonstrated that 80% of the patient’s noted an elevation in their blood sugar following an epidural steroid injection. Results are likely to be very similar with a facet injection. Serum glucose levels gradually returned to normal over several days. There were no cases in this study that demonstrated glucose control issues lasting greater than 5 days. There is evidence that steroids can reduce immune system function, which can make the chance of infection more likely. A very small percentage of patients have experienced what appears to be an allergic reaction to a constituent (component) of the steroid solution. I have found that this is self-limiting and easily treated with oral over the counter Benadryl. Lastly, some patients notice short-lived mood changes, irritability, and insomnia. These occur because of the effect that steroids have on our body.
What are the potential complications from a facet injection?

Serious complications from facet injections are basically unheard of. This procedure occurs outside of the neuroaxis and is therefore not close to the spinal cord. Nerve root trauma may occur, however. But this is very rare. The worst-ever complication from injection therapies occurred in a 2012-2013 outbreak of fungal meningitis caused by contaminated steroids produced at the New England Compounding Center. Approximately 13,000 patients nationwide were exposed to this contaminated steroid batch (only a few of these were facet injections) and this resulted in 64 deaths. Very strict production and oversight were implemented by the Federal Government to minimize the risk of this happening again.
How often can I have a facet injection?

The number of injections for is based on the duration of pain relief. The typical response is several weeks. Sometimes, we only see a day or two of relief. But this is not discouraging. Facets are rather unique in that we can do a more permanent block once we have determined that the facets are important pain generators. So, if you realize only several hours of relief from a facet injection (that is, a local anesthetic response only), then you would be a very good candidate for radiofrequency (RF) lesioning of the nerve that supplies the facet joint. This nerve is a tiny hair-like fiber that is a sensory-only nerve. Therefore, we can destroy this nerve without affecting any kind of motor function or activity. This is unique to facet injections for all the spinal procedures that are available. For patients that do not even get a local anesthetic effect, there is no justification for RF lesioning. It would fail because failure to achieve relief with the local anesthetic proves that the facets are not the main issue; they are not the primary pain generator.
What should I expect immediately after the procedure?

Generally, patients are kept in the recovery area and observed for 30-45 minutes. Once you are awake and oriented (if you received an anesthetic), and have met discharge criteria, you can leave with a companion. You cannot drive for 12 hours following an injection and for 24 hours after an anesthetic.
How long do I have to wait before I can start my normal activities?

We ask our patients to go home with a companion. They are not to drive, operate any kind of machinery, or make any important decisions for the next 24 hours as anesthesia can cause altered mental processing. Because the local anesthetic can spill over to the adjacent spinal nerve roots, patients may find that they are weak and not stable, with “give-way” weakness. Therefore, be very careful when weight bearing or walking. It might take a lot longer than you expect for your normal balance and muscle strength returns. Use caution and do not walk without assistance for at least 6-8 hours.
When can I start taking my medicines again?

All medications can be taken the day of the procedure—including blood thinners. However, some patients might be asked to hold anticoagulants for very specialized reasons. If this had not been worked out prior to the procedure, we can discuss this issue on the day of your procedure.
How soon can I bathe or shower?

We ask that you wait 24 hours before sitting in water that covers the injection site. Showering is different. For this, we ask that you refrain from showering until normal sensation and strength have fully returned. So that might be within only 6 hours; not less.
What are the things that I need to look for after my injections that are potential 'red flags'?

Severe or worsening pain after your injection require an immediate call to our office. Do not leave messages. Call our after-hour paging system or the facility at which the procedure was performed. If there is no answer, go to the nearest emergency room immediately.

Pain that worsens day to day could represent infection and is also considered an emergency. Please follow the same recommendations (above). A fever of 101 degrees or greater for greater than 24 hours may indicate an infection. Also look for motor (decreased strength) and sensory (decreased sensation to touch) over the extremities.

Worrisome post-procedure signs and symptoms (medical emergencies):

  • Severe post-injection pain
  • Worsening post-injection pain
  • Fever of 101 degrees for > 24 hours
  • Change in motor or sensory function

Contact Pain Stop MD today online or by calling 972-556-5738.

Hardware injection

hardware injectionPatients with surgical hardware–such as those whom have had a scoliosis repair patients or patients with spinal fusions–may develop pain at the hardware sites. This is the point at which the medal interfaces with your natural bone.  We are often asked by our surgical colleagues to inject these sites to determine whether the hardware / bony interface is painful. If there is immediate pain relief, the surgeon may elect to remove the hardware, thus reducing pain.  Most hardware injections are performed with local anesthetic only.  There is no additional benefit to adding steroids at these sites.

How should I prepare for my hardware injection?

It is important to let your treating doctor know what medications you take. There are certain medications, such as blood-thinners (anticoagulants) that are possible or “relative” contraindications for hardware injections. In years past, we would not consider doing these injections whilst patients were on blood-thinners. That’s has changed, however. Since these sites are not in contact with the spine itself, and not in the “neuroaxis”, it is usually permissible to perform these procedures without stopping the blood-thinner. However, the patient might have more soft tissue swelling from deep tissue bleeding. While this is self-limiting, it can still produce a large bruise and even a hematoma (a subcutaneous collection of blood). Therefore, it is important that your doctor knows your medical history.

Make sure that you have someone with you on the day of the injection. If you receive an anesthetic, these medications can slow your reflexes and impair mental processing. You cannot drive or operate any kind of machinery for at least 24 hours following an anesthetic.

What are my instructions the day of the procedure and for eating and / or drinking before and after the procedure?

We will give specific instructions before your procedure. We usually ask that patients come in about one hour prior to the procedure. We also ask our patients to refrain from eating for a total of six (6) hours prior to their injection. And that meal needs to be light. Do not have a heavy meal six hours before an anesthetic as you run the risk of aspiration of food. This can cause a very serious pneumonia. After the procedure, they you eat as soon as you are awake and oriented (assuming an anesthetic was administered). You can have clear liquids up to 2 hours before an injection. A clear liquid is anything that you can see through if holding a full glass of this fluid. Coke (Coca-Cola) is not a clear fluid. Water is the preferable liquid. And it is permissible to have any necessary medications that you would take normally, up to two hours prior to your procedure with a small sip of water.
How is the procedure performed?

The procedure is simple. The patient is placed in a surgical gown. The area of skin near the spinal puncture site is widely “prepped”. That means that an antibacterial agent is applied to cleanse the skin to avoid infection. Using the fluoroscopy machine, the appropriate level(s) of interest for treatment is identified and marked with a sterile skin marker (pen). A spinal needle is advanced to the desired bony-metal interface. Then, in a fan-like fashion, local anesthetic is injected around the interface, making sure to cover the entire area. At this point, a small volume of local anesthetic is injected. Some clinicians elect to add a small amount of steroid, but I usually don’t. This is a diagnostic procedure. With or without steroids, if you have significant hardware pain, injections are not going to provide a cure.
How long will it take for me to realize benefit from my injection?

Patients will either feel better immediately or not. And then, It’s a matter of degree of relief. Remember, this is a diagnostic procedure. We need for you to keep track of your response, preferably using a 0-10 pain scale. Document, or tell the nursing staff or our office staff what your staring pain score is We will ask you anyway, but it is useful for you to also follow this. Then mark down your pain after the procedure and for the next few hours. Also, document when the pain returns to baseline.

If you have no pain relief whatsoever after the injection, this suggests – but does not prove – that you do not have a significant hardware pain issue.

Will the procedure work for my pain?

Most patients do benefit from hardware injections, but the relief is short-lived; usually just the duration of the local anesthetic. But that is not something to be disappointed about. Remember, this is a diagnostic procedure. We are trying to see if the hardware is causing pain.
Is the injection painful?

Hardware injections can be painful. Most patients opt for an anesthetic to avoid injecting into chronically inflamed bony sites. For these patients, we administer a simple light anesthetic so that one feels no pain whatsoever. The anesthetic is sometimes a combination of a sedative-hypnotic such as Versed plus a pain medication such as Fentanyl. In other instances, we use Propofol, a general anesthetic, in low doses.
What is injected when performing a hardware injection?

Plain local anesthetic is the usual choice. Ost clinicians do not use steroid as this is a diagnostic procedure.
How long will the injection work?

We usually do not see relief beyond the known duration of the local anesthetic used. For Lidocaine, this would be around 45-60 minutes. For Bupivacaine, it would be 2-3 hours and for Ropivacaine, we can see up to 6 hours relief.
What are contraindications for hardware injections? That is, what are reasons that I should not have an injection?

In years past, we would hold anticoagulants (blood-thinners) before facet injections. This is not necessary. However, you may experience increased soft tissue swelling secondary to deep tissue bleeding. While this is self-limiting, it can still produce a large bruise and even a hematoma (a subcutaneous collection of blood). Therefore, it is important that your doctor knows your medical history.
What are the typical, expected, non-serious side effects from hardware injections?

Several non-serious events can occur after your injection. First, I have seen a small percentage complain of pain at and around the injection site(s). This typically subsids within 48 to 72 hours. Ice packs applied to the area of the injection helps immensely. If steroids are used (and again, this is not the usual case), they can cause an elevation in blood sugar (glucose) levels, especially for patient with diabetes or pre-diabetes.
What are the potential complications from a hardware injection?

Serious complications from these injections are basically unheard of. This procedure occurs outside of the neuroaxis and is therefore not close to the spinal cord. Nerve root trauma may occur, however. But this is very rare.
How often can I have a hardware injection?

You only need one. This is a diagnostic injection. So, we learn everything we need to know with just one injection. The relief will not last as this is for diagnostic purposes.
What should I expect immediately after the procedure?

Generally, patients are kept in the recovery area and observed for 30-45 minutes. Once you are awake and oriented (if you received an anesthetic), and have met discharge criteria, you can leave with a companion. You cannot drive for 12 hours following an injection and for 24 hours after an anesthetic.
How long do I have to wait before I can start my normal activities?

We ask our patients to go home with a companion. They are not to drive, operate any kind of machinery, or make any important decisions for the next 24 hours as anesthesia can cause altered mental processing. Because the local anesthetic can spill over to the adjacent spinal nerve roots, patients may find that they are weak and not stable, with “give-way” weakness. Therefore, be very careful when weight bearing or walking. It might take a lot longer than you expect for your normal balance and muscle strength returns. Use caution and do not walk without assistance for at least 6-8 hours.
When can I start taking my medicines again?

All medications can be taken the day of the procedure — including blood thinners.
How soon can I bathe or shower?

We ask that you wait 24 hours before sitting in water that covers the injection site. Showering is different. For this, we ask that you refrain from showering until normal sensation and strength have fully returned. So that might be within only 6 hours; not less.
What are the things that I need to look for after my injections that are potential 'red flags'?

Severe or worsening pain after your injection require an immediate call to our office. Do not leave messages. Call our after-hour paging system or the facility at which the procedure was performed. If there is no answer, go to the nearest emergency room immediately.

Pain that worsens day to day could represent infection and is also considered an emergency. Please follow the same recommendations (above). A fever of 101 degrees or greater for greater than 24 hours may indicate an infection. Also look for motor (decreased strength) and sensory (decreased sensation to touch) over the extremities.

Worrisome post-procedure signs and symptoms (medical emergencies):

  • Severe post-injection pain
  • Worsening post-injection pain
  • Fever of 101 degrees for > 24 hours
  • Change in motor or sensory function

Intercostal injection

Below each rib is a nerve call the intercostal nerve.  With chest wall injuries, thoracic wall surgeries, and even pregnancy, this nerve can be aggravated or stretched, causing a very typical semi-circumferential band of pain in the area or areas affected.  An intercostal block is a diagnostic and/or therapeutic injection of the nerve root to isolate the source of pain.  In cases of chronic intercostal pain (intercostal neuralgia) the nerve can be destroyed with a neurolytic solution containing phenol. There is additional information on this subject under the category “Neurolytic / Neurolysis injections”.

Joint injection (shoulder, hip, knee)

joint injectionJoint injections are performed on large, intermediate, and small joints throughout the body. This is a common procedure performed in patients who have inflammation and arthritis of various bursa and joints in the body. Local anesthetic and steroid are injected into the joint to reduce inflammation.  This is a highly effective treatment widely used by physicians in multiple specialties.

Overuse, misuse, or even disuse (lack of) use of an extremity or joint in its normal range of motion can result in pain—but acute and chronic.

Another treatment method is regenerative (stem cell) preparations. Stem cell therapies are an exciting new area of intervention in pain management, as well as other specialties. Use of this modality is limited currently. It is only indicated for certain types of joints with certain degrees of pathology. You would need to consult with our group to determine whether you are a suitable candidate for this modality. In most cases, we are simply injecting local anesthetic and steroid solutions into the bursa as this typically results in resolution without the need for further intervention.

Lastly, we can inject a lubricating solution into the joint. This medication does, not contain any steroid. An example of this kind of medication is Synvisc. These injections are done in a series of three, separated by one week.

Joint injections are very safe and are commonly performed in an office setting., They can also be done in a surgical center, with direct continuous X-ray (i.e., fluoroscopy).

How should I prepare for my joint injection?

There are no mandatory actions that need to be taken prior to a joint injection. As this is a very straightforward procedure, and there is no need to hold any of your medications. There are really no absolute contraindications to these injections, beyond active joint infection. Naturally, it would be prudent to avoid if a patient has an active systemic infection. Still, the likelihood of a systemic (total body) infection seeding a joint—because it was injected—is extremely unlikely.

Nonetheless, we need to get a good history and document what medications that you normally take, such as blood-thinners (anticoagulants) and diabetic medications.

If you have the procedure in an office setting, without anesthesia, there is no need to have anyone with you. You can drive yourself home afterwards. If, however, you elect to receive an anesthetic for the injection, please make sure that you have someone with you. Anesthetic medications can slow your reflexes and impair mental processing. You cannot drive or operate any kind of machinery for at least 24 hours following an anesthetic.

What are my instructions the day of the procedure and for eating and / or drinking before and after the procedure?

If the procedure is to be done at the office, there are no special instructions for eating or drinking and there is no reason to arrive earlier than your scheduled appointment time. If the procedure is done at a surgical center, we usually ask that patients come in about one hour prior to the procedure. We also ask our patients to refrain from eating for a total of six (6) hours prior to their injection. And that meal needs to be light. Do not have a heavy meal six hours before an anesthetic as you run the risk of aspiration of food. This can cause a very serious pneumonia. After the procedure, they you eat as soon as you are awake and oriented (assuming an anesthetic was administered). You can have clear liquids up to 2 hours before an injection. A clear liquid is anything that you can see through if holding a full glass of this fluid. Coke (Coca-Cola) is not a clear fluid. Water is the preferable liquid. And it is permissible to have any necessary medications that you would take normally, up to two hours prior to your procedure with a small sip of water.
How is the procedure performed?

This is a very simple procedure. The joint that is to be injected is marked. The area surrounding this site widely “prepped”. That means that an antibacterial agent is applied to cleanse the skin to avoid infection. In the office, we use simple anatomic guides to find the correct target. If the procedure is done in a surgery center, we may employ the use of fluoroscopy to document precise needle placement.
How long will it take for me to realize benefit from my injection?

Patients typically experience almost immediate relief—virtually within minutes. However, for many patients, there is a delayed response. This is because steroids take several days to work against inflammation.
Will the procedure work for my pain?

Joint injections are very effective, successful procedures. If we have determined that you indeed do have a significant joint pain condition, injections are a very effective form of treatment.
Is the injection painful?

Joint injections are well tolerated by the most patients and sedation is not needed. Some patients feel that they hurt more than expected and request anesthesia for subsequent injections.
What is injected into the joint?

We typically administer a combination of local anesthetic and steroids. Some patients may qualify for regenerative medicine techniques (i.e., stem cell injections), or joint lubricant solutions (Synvisc).
How long will my bursa injection work?

Joint injections are very gratifying procedures for Interventionalists because of the great results. These injections usually provide very rapid relief that can last month’s or longer. In some cases, a single injection can last for years. If there are mechanical issues with the joint, resulting in misuse or disuse of an extremity or area of the body, it is likely that these injections will need to be repeated. If the condition is arthritis, the results vary, and we can decide as to what best to do based on the response to the first injection. Also, there are ways to avoid — or at least attenuate — reoccurrence.
What are contraindications for joint injections? That is, what are reasons that I should not have an injection?
There aren’t any absolute contraindications to joint injections other than active joint infection. Anticoagulants have not been shown to cause complications. It is very rare to bleed into a joint and if this does happen, the treatment is simple aspiration (needle removal of the fluid. Therefore, we do not ask our patients to withhold blood – thinners prior to these procedures.
What are the typical, expected, non-serious side effects from joint injections?

Several non-serious events can occur after your injection. A small number of patients will experience a worsening of their discomfort for several days. Following that, the pain should rapidly subside. Others achieve very fast pain relief, that is lasting. Some patients will complain of generalized flushing and redness—especially over the upper body, head, neck, and face. This typically subsides within 8-12 hours and I do not recommend anything other than time to cure this side effect.
What are the potential complications from a joint injection?

Complications are extremely rare. The most likely significant complication from this procedure is infection. These occur in only very rare circumstances and are treated with antibiotics.
How often will I need to have a bursa injection

This is not at all like an epidural steroid injection or other injections. We do not perform these repetitively. Usually, just one bursa injection will do. Occasionally, we will need to repeat the injection. The duration is very good, typically lasting for 4-6 months or greater.
What should I expect immediately after the procedure?

In the office, we ask the patient to rest for 10 minutes and then they are fee to walk around and engage in normal activities, including driving. If the procedure is performed in a surgery center, we generally keep patients in the recovery area for observation for approximately 30-45 minutes. Once you are awake and oriented (if you received an anesthetic), and have met discharge criteria, you can leave with a companion. You can drive yourself home if you had the procedure done without anesthesia. If anesthetics was administered, we request that you refrain from driving for the next 24 hours.
How long do I have to wait before I can start my normal activities?

For those that get the injection without anesthesia, you can begin with normal activities, including driving, immediately. If the procedure was performed in a surgery center, you are not to drive, operate any kind of machinery, or make any important decisions for the next 24 hours as anesthesia can cause altered mental processing.
When can I start taking my medicines again?

All medications may be restarted immediately following the injection.
How soon can I bathe or shower?

We ask that you wait 24 hours before sitting in water that covers the injection site. Showering is different. For this, we ask that you refrain from showering for 6 hours after the injection.
What are the things that I need to look for after my injections that are potential 'red flags'?

Severe or worsening pain after your injection require an immediate call to our office. Do not leave messages. Call our after-hour paging system or the facility at which the procedure was performed. If there is no answer, go to the nearest emergency room immediately.

Pain that worsens day to day could represent infection and is also considered an emergency. Please follow the same recommendations (above). A fever of 101 degrees or greater for greater than 24 hours may indicate an infection. Also look for motor (muscle strength) and sensory (decreased sensation to touch) over the extremities.

Worrisome post-procedure signs and symptoms (medical emergencies):

  • Severe post-injection pain
  • Worsening post-injection pain
  • Fever of 101 degrees for > 24 hours
  • Change in motor or sensory function

Contact Pain Stop MD today online or by calling 972-556-5738.

Lumbar sympathetic injection

This injection is used for patients with vascular insufficiency or those with an unusual chronic pain state called Complex Regional Pain Syndrome (CRPS) or Reflex Sympathetic Dystrophy (RSD). Additional information on these conditions can be located under the header “Disease States”.  The lumbar sympathetic chain carries small fibers that normally conduct signals involved in the sensation of touch, position of a body part, or vascular tone. But when diseased, these nerves can transmit pain signals.  Injecting or ablating (destroying) this chain can significantly improve pain from vascular insufficiency or from that caused by CRPS / RSD. of the lower extremities.  The injection typically occurs at the lumbar one, or lumbar two segment (L1 or L2).

Medial branch injection

medial branch injectionEach facet joint in the body is supplied by several small sensory nerves: These hair-like fibers are called the medial branches.  These are purely sensory nerves, with no motor function whatsoever.  By blocking these nerve fibers, one can determine which spinal segment(s) is painful.  Medial branch blocks can be used in place of a facet injection as either technique will block pain signals from the joint. The medial branch block is purely a diagnostic block.  No steroid is used for this block as it is purely intended to diagnose which levels of the spinal column are painful.  A successful medial branch block is typically followed by radiofrequency (RF) lesioning (see below).

Pars injection

This is an injection of a fracture of the vertebral column, namely the pedicle of the vertebral body, which is part of the bony arch over the spinal space. Pars fractures are almost entirely limited to L4 and L5. This injection is both diagnostic and therapeutic.  As with other injections, the injectate is typically a solution containing local anesthetic and steroid.

Peripheral nerve block

Any nerve in the body can potentially become painful due to trauma, inflammation, entrapment, radiation (for the treatment of certain cancers), chemotherapy, or direct toxicity from drugs.  Injection of these nerves is primarily diagnostic to determine the exact cause of pain and to isolate the pain generator to one or more peripheral nerves. The injection also determines the next Appropriate treatment.  If a diagnostic block with local anesthetic is successful, this opens a door for other treatments including neurolytic injections (whereby the nerve is destroyed), surgical resection, or neuromodulation techniques to block the pain signal emanating from the nerve.

Prolotherapy

This is a technique in which a substance is injected at a painful site to intentionally cause an exaggerated inflammatory response. By doing this, the natural healing response elicited helps strengthen the area by causing scarring and / or thickening of surrounding ligaments to help strengthen the site. Therefore, this is typically used over certain joints such as the vertebral column or the sacroiliac joint. Several different prolo agents can be used to accomplish this.

Rhizotomy (radiofrequency – RF) lesioning

This is another destructive, ablative technique, much like neurolytic injections. The difference is that a heat source is applied to the nerves of interest with RF lesioning whereby neurolytic injections employ the use of injected substances. The typical sites for RF lesioning are the cervical, thoracic, or lumbar medial branches (for facet pain) or the sacroiliac joints. The standard accepted technique is to first block the medial branch innervating (suppling nerve input) to the joint. If significant pain relief is achieved, the nerve can be lesioned.

Sacroiliac joint injection

This is a large joint formed by the at the junction of the ilium and sacrum.  It is a common source of pain, particularly with patients who have previously undergone lumbar spine fusion.  The SI joint obtains a greater biomechanical load by a fusion of the lower lumbar vertebrae and the stress imposed this joint can cause chronic inflammation.  There is also direct pathology of the sacroiliac joint.  Regardless of previous surgical intervention, which will respond this block as well.  Much like other procedures, this is a simple injection involving localized anesthetic and steroid directly into the joint under fluoroscopy.  Live x-ray fluoroscopy

Selective nerve root block

selective nerve root blockResponsive typically requested by the surgeon to determine the referring surgeon to determine which spinal segments are affected.  For instance, the patient has multilevel spinal disease, the goal of the surgical intervention is to continue only what is necessary and not fix every single disease level.  Some sites are not painful.  So, with selective nerve root block, one can isolate which exact spinal segments are affected such that surgical intervention will be more limited and more effective.  We also use block for chronic inflammation.  Nonsurgical inflammation or postsurgical information about the spinal root.  These are done over the cervical, thoracic and lumbar spine.  As with other injections, a combination of local anesthetic and steroid is injected under direct continuous and live x-ray fluoroscopy.

Spinal cord stimulation

This is a highly effective technique involving neuromodulation.  An electrode or pair of electrodes is placed in the epidural space.  Stimulation drives a high frequency low amplitude signal through the epidural space and onto the spinal column spinal cord.  The electrodes are not near or on the spinal cord, and in the safe epidural space.  The technique is ideal for cervical and lumbar pain conditions.  Thoracic spinal cord stimulation is not routinely employed and has variable results.  Spinal cord stimulation is used for chronic pain conditions, neuropathy, postsurgical pain that is refractory to conservative measures, diabetes mellitus, neuropathy, and multiple other pain conditions.  It is a very effective modality.

Sympathetic ganglion (or Stellate ganglion) injection

This injection issues for patients with vascular insufficiency or complex regional pain syndrome (see separate section under “Disease States”.  The lumbar sympathetic chain carries small fibers.  They can transmit pain, signal, but also control the diameter or caliber of blood vessels.  Injecting this chain or even ablating or destroying this chain can significantly improve pain from vascular insufficiency or from that caused by complex regional pain syndrome (CRPS) or reflex sympathetic dystrophy (RSD) of the lower extremities.  The injection typically occurs at the lumbar one, or lumbar two segment.

Trigger point injection

These injections directly into painful muscle spasms or knots.  Patient’s frequently have an area antibody, typically adjacent to the cervical or lumbar spine, which is painful and in constant spasm.  Trigger point injections into these muscle bundles else break the spasm, reduce inflammation, and allow the muscle to return to his normal resting state.  This procedure can be done with local anesthetic only, local anesthetic with a smaller on this amount of steroid, or even dry needling in which case, no material is directed into the nerve root rather than nerve is the muscle was made to relax and stop spasming by insertion of a needle directly into it

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Less commonly performed interventional techniques

Celiac plexus injection

This is a collection of nerves and perform a bundle, or plexus, in the mid to upper abdomen.  Celiac plexus blockade is usually reserved for patients with pancreatic or upper abdominal cancer.  Successful interruption of the pain signal is then followed by neurolysis –destruction of the nerve plexus.

Cluneal nerve block

nerve blockMany patients who have had spinal fusion surgeries have pain at the bone graft site.  This is a place where the surgeons take bone, the patient’s own bone to help stabilize and fuse the spine spinal segments.  The iliac crest is the most common site for bone harvesting.  This area is supplied by the cluneal.  We frequently see patients who complain of pain over the bone harvest site more than the spinal surgical site itself.  In those instances, an injection of local anesthetic without steroid.  His diagnostic.  If successful, this is followed by neurolysis (see below).

Ganglion Impar

Injection at this site is used to treat patients with pelvic and rectal pain.  This, the ganglion Impar.  As part of the sympathetic nervous system and is a collection of nerves located ventral or just below the sacrococcygeal junction.  Successful pain relief with this injection is typically followed by neurolysis (see below).

Hypogastric plexus injection

This injection is used to relieve pelvic pain or pain coming from the uterus or ovaries prostate testicles: Bladder and lower intestines.  He can also be used to reduce pain from endometriosis, irritable bowel syndrome and radiation injuries of the pelvis from cancer treatment.

Neurolytic / Neurolysis injection

This is an injection designed to kill nerve tissue.  It is reserved for sensory nerves or cancer.  Terminal cancer pain.  Patient’s only.  Typical neurolytic blocks include neuro lysis of the coccygeal nerves, intercostal nerves, medial branch neuro lysis, celiac plexus or lysis, cluneal, neural lysis, ganglion Impar neural lysis, and superior hypogastric plexus neurolysis.  In this procedure, a solution of phenol, typically in glycerin, is injected onto the nerve or plexus.  Of interest.  After 5-7 days or more, the nerve sheath.  She is breakdown, thus rendering of nerves nonfunctional.  There is also direct damage to nerves and cells.  This is intended to disrupt or eliminate conduction function of the nerves themselves, thus alleviating pain from that site.  This particularly useful for neuromas, which are discrete nerve tangles, manifested by pinpoint exquisite sensitivity over site.  Using commonly seen in patients following surgery with neuroma at the surgical scar.  Neuroma are also commonly found in the hands and feet, or any other part of the body. Successful blockade of the painful in pulse with local anesthetic needs to perceive injection with any kind of neurolytic material as latter is obstructive process.  One need not shore, and nerve is not painful, so I do not a successful diagnostic block, first is mandatory before proceeding on to neurolytic injections.

Piriformis injection

Injection of this muscle is indicated for the treatment of buttock posterior thigh, and low back pain.  Piriformis syndrome (see Disease States) is frequently seen in office workers where prolonged and uninterrupted sitting is required. It is also seen in cases of entrapment of the muscle or sciatic nerve. In more rare instances pain is generated due to an anatomic abnormality in which the sciatic nerve courses through the muscle itself. Injection of this muscle is diagnostic.  If pain is relieved for enough time, the injection can be safely repeated. In instances whereby the pain returns rapidly, one may consider Botox injections or surgical section of the piriformis muscle.