These common procedures are performed by our physicians.
Epidural Steroid Injections (Interlaminar, Caudal and Transforaminal)
Epidural steroid injections are used to deliver medication close to the site of injury or pathology within the spine. Steroids act to reduce inflammation, decrease pain and possibly improve function. A local anesthetic is often injected with the steroid, providing short-term pain relief and diagnostic information. This injection is commonly utilized for nerve root irritation, radiculopathy (sciatica) or even neck or low back pain. Epidural steroid injections are also useful in treating degenerative disc disease, spine arthritis, postsurgical pain and postherpetic neuralgia. There are three common approaches undertaken with this technique:
- Interlaminar epidural injection: This technique typically delivers medication to the posterior epidural space, which is guided by a fluoroscope (a type of real-time X-ray). This procedure is especially useful in the treatment of diffuse spinal disorders like spinal stenosis.
- Caudal epidural injection: This approach utilizes an access point at the tailbone. This technique is commonly chosen for pain in the lower spine or coccyx. It is particularly useful in patients with previous spinal surgery where the interlaminar approach is less reliable. This injection is also performed under fluoroscopic guidance.
- Transforaminal epidural injection: This technique is a very precise, fluoroscopically guided approach to delivering a small volume of medication to the site of the problem in the spine, typically located at the anterior epidural space. This method is also very effective in treating nerve root pain (extremity pain).
Facet Joint (Zygapophysial) Injections (Intra-articular, Medical Branch Block)
The facet joints are located in the posterior aspect of the spine and are responsible for about 10 to 15 percent of the support of the body given by the spine. Because of this important role, the facet joints are common sources of pain. They are often affected by degenerative arthritis or acute injuries like whiplash. In the neck, pain referred from this joint might manifest as headaches, shoulder pain or upper back pain. These joints can cause low back, buttock or thigh and leg pain when originating in the lumbar spine.
During intra-articular injections, the joints are penetrated with a needle, followed by injection of contrast to confirm placement. Then, a combination of local anesthetic and steroid are injected.
Medial branch blocks involve the injection of a small amount of local anesthetic at the two small nerves that supply each facet joint. This highly specific procedure is diagnostic, often predicting success with radiofrequency ablation (detailed below).
In situations where pain originating from the facet joint can be fully isolated through medial branch blocks, these specific nerves can be selectively destroyed by delivering thermal energy. This technology can also be utilized in sympathetic-mediated pain. This procedure involves the precise placement of radiofrequency needles along the appropriate nerves. Once placed, there are number of motor and sensory stimulation tests performed to confirm that the targeted nerves are the sources of the pain. This confirmation is followed by the delivery of thermal energy, which destroys the nerves and ends the transmission of pain.
Sacroiliac Joint Injections
The sacroiliac joints are located at the junction of the spine and the pelvis. These paired joints are susceptible to stress, injury and arthritis, and are often the cause of chronic low back pain. They often respond to steroid injections under fluoroscopic guidance. Radiofrequency ablation is possible with the sacroiliac joints, and diagnostic injections with local anesthetic can predict its effectiveness.
Provocative discography is a technique utilized to diagnose internal disc disruption and resulting pain. This procedure is divided into provocative and morphological components. The provocative portion is an attempt to reproduce the patient’s “typical” pain — by inducing the pain, the cause can be verified. Abnormal discs are identified and injected; adjacent control (normal) discs are also injected. Concordant pain is elicited when an abnormal disc is injected replicating the patient’s typical pain. Often disc morphology (the shape of the disc, which can result in affected nerves) can also be noted with injection of contrast material which makes it easier to see the mechanics of the disc and nerves. The morphology is also confirmed via a CT scan immediately following the procedure. The combination of the information gleaned from these two components of the study can be useful in identifying the causative agent in disc-related low back pain.
Spinal Cord Stimulation
This procedure involves the placement of two electrodes into the epidural space at appropriate levels to provide electrical stimulation of the spinal cord, which interferes with the transmission of pain. This technique is effective for the treatment of persistent extremity pain (in the arm or leg), nerve-related pain, certain types of low back pain, specific cases of abdominal pain and other resistant cases of pain with multiple causes. The stimulation can be adjusted by the patient, which allows customized treatment. Prior to permanent implantation of these electrodes, a trial is undertaken. This is a three- to seven-day period during which the electrodes are placed without an incision, and attached to an external power source. This period is a “test drive,” during which the effectiveness of the device is determined. If appropriate, permanent implantation in which the electrodes are surgically placed is performed as an outpatient procedure.
Sympathetic Nerve Interventions
The sympathetic nervous system, which is involved with the control of various nonvoluntary activities (pupil dilation, digestion, heart rate), has been implicated in the development of various pain syndromes. Interventions targeting this system involve the injection of local anesthetic at the sympathetic ganglia in the cervical or lumbar spine. Furthermore, radiofrequency ablation, chemical neurolysis and spinal cord stimulation are other procedures targeting this system.
Peripheral Joint Injections
The most common indications for peripheral joint injections include arthritis and joint effusion. These procedures are often performed based on anatomical landmarks in select joints (such as the hip or glenohumeral in the shoulder) using fluoroscopic guidance. Commonly, local anesthetic and steroids are injected. Joint fluid replacement is also utilized in appropriate situations to treat pain related to joint pathology.
Epidural Lysis of Adhesions
In rare situations following neck or low back surgery, scar tissue (adhesions) might develop around a nerve root that causes compression and severe pain. Using a steerable catheter placed via an introducer needle, these adhesions are destroyed or broken up. This treatment is reserved for those patients who have previously failed conservative treatments such as medications and epidural injections.
Percutaneous Lumbar Disc Decompression (DeKompressor®, Acutherm)
Disc decompression can be effective for the treatment of small, contained disc herniations primarily causing lower extremity pain. This procedure involves using a needle to remove excess material from the center of the disc to reduce pressure on the nerve roots and to potentially resolve the disc protrusion. By removing material, the disc returns to a more circular shape and prevents pain by protecting the nerve.
Intradiscal Annuloplasty (IDET, Transdiscal Biaculoplasty)
These procedures are utilized for the treatment of disc-related low back pain. Once discography has been used to determine which disc is causing pain, these procedures involve the delivery of thermal energy to the posterior aspect of the disc resulting in collagen formation, thereby “sealing” the ruptured disc as well as reducing aberrant nerve growth into the disc. IDET involves a single needle to provide energy, while transdiscal biaculoplasty uses two introducer needles to seal a larger area.
Trigger Point Injections
In some instances, a specific muscle can become taut and cause pain, either as a primary process or as a result of an underlying trigger. These trigger points can be treated with injections of local anesthetic and steroids as part of a treatment plan which typically also includes physical therapy and stretching.