Pain Management

Spinal and Joint Injections

In many cases of chronic back pain, spinal injections are used both to learn more about what is causing your pain and to treat your pain. Health care providers refer to these two separate uses of spinal injections as diagnostic and therapeutic. The injections can be a diagnostic tool because they give your doctor information that helps him or her make a diagnosis. For example, if an injection provides pain relief in the area that is injected, it is likely that this particular area is the source of the problem. Once the location of one or more sources of pain is discovered, your health care provider can perform other necessary tests to try to determine the actual problem and create the proper treatment plan. The injections are therapeutic in that they can provide temporary treatment and pain relief.

What medications are injected and why?

With most spinal injections, a local anesthetic (numbing medication) called lidocaine, also known as Xylocaine, is injected into a specific area of the spine. Lidocaine is a fast-acting drug, but the effects wear off within about two hours. Therefore, this medication is used more as a diagnostic tool rather than as a long-lasting pain reliever. Another type of anesthetic, called Bupivacaine, also known as Marcaine, can also be used. This anesthetic takes longer to take effect, but it also wears off slower, giving the patient some relief from pain.

A strong anti-inflammatory steroid medication, cortisone, is also commonly injected along with one of the above anesthetics in order to reduce inflammation in the affected areas. Cortisone is long-lasting and can be slow-releasing in order to give the best possible benefits of pain relief. Cortisone may take several days to begin working to reduce inflammation following injection, but the effects can last for months. In some cases, a narcotic medication such as morphine or fentanyl may be mixed with the cortisone and the anesthetic in order to improve pain relief.

Types of Injections and Why They Are Done

Epidural Steroid Injection:

An epidural steroid injection (ESI) is a common type of injection that is given to provide relief from lower back pain and from certain types of neck pain. The epidural space is the space between the spinal sac (called the dura mater) and the inside of the bony spinal canal. It runs the entire length of your spine. Once injected into this area, the medication moves freely up and down the spine to coat the nerve roots and the outside lining of the facet joints of the spine near the area of injection. For example, if the injection is done in the lumbar spine, the medication will usually affect the entire lower portion of the spine.

There are three different ways to perform an epidural injection:

Caudal Block: A caudal block is placed through the sacral gap (a space near the sacrum and below the lumbar spine), into the epidural space. This type of block usually affects the spinal nerves that are at the end of the spinal cord near the sacrum (near the bottom). This collection of nerves is also called the cauda equina. One of the benefits of this type of injection is less chance of a dural puncture, also called a "wet tap." As mentioned above, the dura mater is the spinal sac, the membrane that holds the spinal fluid and protects the cord and nerves from damage.

Translumbar: The most common way of performing an epidural is the translumbar approach. This type of injection is performed by placing a needle between two vertebrae from the back. The needle is inserted between the spinous processes of the two vertebrae. You can usually feel the bumps that make up the spinous process by simply feeling the back of your spine.

Transforaminal: This type of injection is a very selective injection around a specific nerve root. It is most often used for diagnostic purposes, and it is commonly used in the neck. The foramina are the small openings between your vertebrae through which the nerve roots exit the spinal canal and enter the body. By injecting medication only around a specific nerve root, the doctor can determine if this is the nerve root causing the problem.

Indications to use an epidural:

It may be necessary to have several epidural injections in a series over a period for a few weeks. This is because the relief from the epidural injection decreases with time. It is not uncommon to have three lumbar epidural injections, each about ten days apart.

Epidural injections are good for reducing radicular pain caused by nerve irritation from herniated discs and spinal stenosis. A herniated disc occurs when pressure to a disc's outer fibers (annulus) is so great that it rips, and the nucleus ruptures out of its normal space. If it rips near the spinal canal, the bulging disc can push out of its space and into the spinal canal, placing inappropriate pressure on the spinal cord and nerve roots. Spinal stenosis is basically a narrowing of the entire spinal canal, which places pressure on the nerves and spinal cord. The injections are also helpful when the main problem is arthritis of the facet joints in multiple areas. The medication coats the outside of the joints at multiple levels and is absorbed into the joint. This reduces the inflammation inside the joint.

Risks:

With any surgery, there is a risk of complications. When surgery is done near the spine and spinal cord these complications (if they occur) can be very serious. Complications could involve subsequent pain and impairment and the need for additional surgery. You should discuss the complications associated with surgery with your doctor before surgery. The list of complications provided here is not intended to be a complete list of complications and is not a substitute for discussing the risks of surgery with your doctor. Only your doctor can evaluate your condition and inform you of the risks of any medical treatment he or she may recommend.

Dural Puncture: A dural puncture ("wet tap") is perhaps the most common complication from an ESI. This complication only occurs in 0.1 to 5 percent of all injections. The result of a dural puncture is usually a spinal headache and nausea. A spinal headache occurs when the puncture in the spinal sac fails to seal itself off. This allows the spinal fluid to continue to leak out and lowers the spinal fluid pressure in the brain. When sitting, the headache and nausea are much worse, because the spinal fluid pressure is lower at the top, near your head, than at the bottom of the spine. The headache usually goes away when you lie down with your feet higher than your head. To treat a spinal headache, a "blood patch" is usually recommended. If the doctor realizes immediately during the procedure he has a wet tap, he may perform a blood patch before he removes the epidural needle. A blood patch is a simple procedure in which about three ounces of blood are drawn from an arm vein and immediately injected into the epidural space with an epidural needle. The blood then clots around the spinal sac and stops the leak by forming a "patch."

Intravascular Injection: There is a small chance that the medication may be injected into one of the small blood vessels that run through the epidural space instead of the epidural space itself. This can cause seizures, cardiac arrest, and even death if too much of the medication goes directly into the blood stream. The chance of this happening is very low. Your doctor can discuss it with you in further detail.

Infection: Epidural injections are done under sterile conditions very similar to surgery. Still, anytime a needle is inserted into the body there is a small chance of infection. Since the needle in an epidural is going near the spine, an infection is much more serious if it occurs. The chance that an infection will occur is extremely small.

Bleeding: An epidural injection can result in a hematoma. A hematoma is simply a collection of blood due to an injury to a blood vessel. An epidural hematoma can be serious if it is big enough to cause enough pressure on the spinal nerves so that they quit working. This can cause problems with the bowels and bladder.

Bladder Dysfunction: Because the epidural injection actually paralyzes the nerves to the bowel and bladder for a short period, you may not have control over your bladder for one to two hours.

Neurologic Complications: There is always a small risk of damage to the spinal nerves. The spinal cord is a bundle of millions of nerves that connects the brain with the rest of the body. If the epidural needle directly injures the spinal nerves, this can cause serious neurologic problems.

Facet Joint Injections

Facet joint injections are used to localize and treat low back pain that is caused by problems of the facet joints. These joints are located on each side of the vertebrae; they join the vertebrae together and allow the spine to move with flexibility. The facet joint injections form a pain block that allows the doctor to confirm that it is a facet joint causing the pain. The medication used also decreases inflammation of the joint that occurs with arthritis and joint degeneration.

To insure that an injection is actually into the facet joint, "fluoroscopy" can be used to confirm that the needle is in the right position before the medication is injected. A fluoroscope uses X-rays to show a TV image, so the doctor can watch as the needle is placed into the joint. The fluoroscope can also magnify the image, increasing accuracy.

There are two types of facet joint injections:

Interarticular: This is injected directly into the joint to block the pain and reduce inflammation.

Nerve Blocks: These help determine whether the joint is indeed a source of pain by blocking the medial branch or the nerves that connect with the joint.

Indications to use a facet joint injection:

A facet joint injection is perhaps the best way to diagnose facet joint syndrome. Joints that may look abnormal on an X-ray may in fact be painless, and joints that look fine may indeed be the source of the pain; only the injection tells the true story. These injections may be used to treat low back pain and determine whether the facet joints are the true culprits. It is also a rather simple procedure with low risk.

Sacroiliac Joint Injections

Sacroiliac (SI) joint pain is easily confused with back pain from the spine. The SI joint is located between the sacrum and the hipbone. In some cases, injecting the SI joint with lidocaine may help your doctor determine whether it is the source of pain or not. If the joint is injected and your pain does not go away, it is probably coming from somewhere else. If the pain goes away immediately, your doctor may also inject cortisone into the joint before removing the needle. The cortisone is added to treat the inflammation from the SI joint arthritis that may be causing your pain. The cortisone injection usually gives temporary relief for several weeks or months.

Indications to use a sacroiliac joint injection:

SI joint injections can be used to prove that the SI joint is the source of pain and subsequently to treat that pain. This injection usually requires the use of fluoroscopic guidance or a CAT scan (computed axial tomography scan) in order to make sure the needle is placed correctly in the joint. CAT scans are X-ray tests that produce X-ray slices taken of the spine, so each section can be examined separately.

Differential Lower Extremity Injections

Various types of injections into certain areas of the lower extremities can help your doctor decide where the pain is most likely coming from. Pain that comes from problems with the back and the spinal nerves can mimic many other conditions. Sometimes it is impossible to tell if the pain you are experiencing is due to a back condition or from a problem in your hip, knee, or foot. To try to determine whether the joint is causing your pain or not, your doctor may suggest injecting medication such as lidocaine into the joint to numb the area. Once the medication is injected, if the pain goes away immediately, it is likely that that joint - not your back - is the source of the pain.

Hardware Injections

At times, your doctor may need to determine whether the metal hardware that has been used during surgery could be contributing to your discomfort. A hardware injection is performed by injecting lidocaine alongside the spinal hardware that was placed in the spine during surgery. If the pain is relieved temporarily by the injection, it may indicate that the hardware is contributing to your pain and whether it needs to be surgically removed.

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Percutaneous Discectomy - DISC Nucleoplasty Pertaneous Discectomy Treatment

DISC Nucleoplasty Percutaneous Discectomy

Historically, open surgery has been used to treat sciatica, by removing part of the intervertebral disc to provide "decompression" and relieve the pressure of the disc on adjacent nerve roots. Patients requiring decompression surgery are typically those suffering sciatica or leg pain caused by a herniated or 'slipped' disc. Disc decompression surgical techniques have advanced and now the surgery is performed through small incisions and even via endoscopes - all done using a microscope or similar technology to view the surgical access into the disc.

For some patients, however, even more minimally-invasive methods have been made available, whereby the entire decompression is performed percutaneously through a needle. Patients who can benefit from percutaneous disc decompression or "percutaneous discectomy" as it is commonly called, are those with pain arising from a contained herniated disc - that is a bulging disc where there is no rupture in the outer wall.

The use of percutaneous procedures to decompress intervertebral discs dates back to the 1960's. Early procedures showed conclusively that percutaneous disc decompression effectively relieves pain for appropriate patients. Early procedures had limitations, and so over the years a variety of more advanced techniques have been developed.

DISC Nucleoplasty

The most advanced form of percutaneous discectomy developed to date is DISC
Nucleoplasty. Introduced in 2000, DISC Nucleoplasty uses a unique plasma technology called Coblation® to remove tissue from the center of the disc. During the procedure, the DISC Nucleoplasty SpineWand is introduced through a needle and placed into the center of the disc where a series of channels are created to remove tissue from the nucleus. Tissue removal from the nucleus acts to decompress the disc and relieve the pressure exerted by the disc on the nearby nerve root (see Figure 1 and Figure 2). As pressure is relieved, pain is reduced, consistent with the clinical results of earlier percutaneous discectomy procedures.

About Coblation Technology

The Coblation plasma technology used in DISC Nucleoplasty has been used for many years in surgical procedures in arthroscopy and ENT. Coblation has been used in two million other procedures and has become the standard treatment in various arthroscopic applications, and is quickly becoming accepted as a less traumatic method of tonsillectomy in children, offering reduced post-operative pain and faster recovery periods.

The reason that DISC Nucleoplasty is such a significant advance in percutaneous discectomy is its use of Coblation. Coblation has been clinically demonstrated to decompress the disc while preserving healthy tissue. This is because Coblation relies on plasma energy (see Figure 3) rather than heat energy to remove tissue.

As a result, DISC Nucleoplasty provides the therapeutic benefits of earlier percutaneous disc decompression techniques, without many of the unfortunate side effects. There is little tissue trauma, and recovery times are faster than ever before.

Clinical Results of DISC Nucleoplasty

A variety of clinical studies have been used to assess the effectiveness of DISC Nucleoplasty. As mentioned earlier, DISC Nucleoplasty has been shown to be a highly effective procedure in treating leg pain such as sciatica. In addition, it has been shown to be effective in treating certain patients with back pain. Initial outcome studies show very high success rates. Average pain reduction is significant - 55%-60%, and patient satisfaction is high - about 90%. High patient satisfaction has largely been due to (i) the relative ease of the procedure, (ii) the lack of trauma or painful rehabilitation period, (iii) the fact that DISC Nucleoplasty does not diminish the effectiveness of any subsequent procedure such as open surgery, and (iv) in the rare instance that the procedure is not deemed a 'success,' the patient is typically no worse off. There is no downside.

Although long-term data is not yet available, the early studies show sustained pain relief out to one-year, with patients remaining steady at their initial post-procedure pain levels. Evidence is mounting that pain relief is sustained through two years post-procedure and beyond.

Who is the right patient?

For appropriately selected patients, DISC Nucleoplasty can relieve back and leg pain symptoms including sciatica and radiculopathy and even purely axial pain caused by a 'central focal protrusion' or central bulge of the disc. DISC Nucleoplasty is a widely accepted treatment for patients with small contained herniations for whom open surgical discectomy offers a poor chance of success. It may also be a promising option for patients with large contained herniations for whom open surgery is not considered an appropriate treatment.

There are some conditions that may mean that DISC Nucleoplasty is not right for you. Your diagnosing physician will know if these apply to you or not.

What to Expect From DISC Nucleoplasty

The DISC Nucleoplasty procedure is very straightforward. A patient receives a local anesthetic and possibly mild sedation - no general anesthetic is required. The needle insertion is simple, with little pain. Once the needle is inserted into the disc, the disc decompression itself takes only a few minutes. The entire procedure lasts about 30 minutes, and the patient is able to leave shortly afterwards, with only a small bandage over the needle insertion site.

The post-op recovery after DISC Nucleoplasty is undemanding. Patients typically feel little pain after the procedure. Patients are required to avoid lifting and strenuous exercise for a period of time, and may go back to sedentary work after only a week or two. Patients with more physically demanding occupations may need to wait longer to recommence work. Some physical therapy may be prescribed.

Conclusion

By overcoming the limitations of prior methods of percutaneous discectomy, DISC Nucleoplasty has demonstrated the potential to produce equivalent, or even better, outcomes in a procedure that is simpler, quicker, and less traumatic and has faster recovery-times. Clinical results are very promising, and patients can generally expect rapid and sustained pain reduction after DISC Nucleoplasty.

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Figure 1
Herniated disc compressing nerve root and causing pain.

Figure 2
Following DISC Nucleoplasty procedure - herniation and pain relieved.

Figure 3
DISC Nucleoplasty uses Coblation to precisely remove tissue without trauma.

Kyphoplasty - Minimally Invasive Surgical Solutions and Procedures of Kyphoplasty

KYPHOPLASTY

Vertebral Body Compression Fractures Adversely Impact Overall Health

An estimated 700,000 pathological vertebral body compression fractures occur in the United States each year. Of these, more than one-third become chronically painful. The majority of these fractures (about 85%) are the result of primary osteoporosis; the remainder are due to secondary osteoporosis or osteolytic spinal metastases. These compression fractures lead to progressive deformity and changes in spinal biomechanics and are believed to contribute to increased risk of further fracture. Whether the fracture is painful or not, the spinal deformity caused by two or more fractures dramatically impacts health, daily living and medical costs through loss of lung capacity, reduced mobility, chronic pain, loss of appetite and/or clinical depression. With each osteoporotic vertebral compression fracture, a 9% loss in predicted forced vital capacity and a 15% age-adjusted increase in mortality can be expected.

Traditionally, vertebral body compression fractures were treated medically and rarely with surgical modalities. Unfortunately, the medical management of painful fractures (bed rest, hospitalization, narcotic analgesics and bracing) does nothing to restore spinal alignment and compounds problems associated with osteoporosis. Due to the poor quality of osteoporotic bone and the inherent risks and invasive nature of surgical treatment of vertebral body compression fractures, the procedure has been limited to cases in which there is concurrent spinal instability or neurologic deficit.

Kyphoplasty is an innovative technique that combines vertebroplasty with balloon catheter technology developed for angioplasty. The procedure shows great promise in the treatment of painful, progressive osteoporotic or osteolytic vertebral compression fractures.

Figure 1. Vertebral compression fracture

Kyphoplasty involves extra- or transpedicular cannulation of the vertebral body under fluoroscopic guidance, followed by insertion of an inflatable bone tamp (Figure 2).

Figure 2. Insertion of inflatable bone tamp

Once inflated, the tamp restores the vertebral body toward its original height, while creating a cavity to be filled with bone cement. Cement is injected under relatively low pressure (see Figures 3 through 6 below).

Figure 3. Balloon inflation

Figure 4. Cavity is filled with bone cement

Figure 5. Bone tamp is removed

Figure 6. Bone tamp and inflatable balloon

Vertebroplasty, from which the kyphoplasty technique evolved, was developed in response to limited results of medical and surgical modalities to stabilize and strengthen collapsed vertebral bodies. Interventional neuroradiologists, first in France and then in the United States, began transpedicular percutaneous bone cement injections in 1986. Vertebroplasty offers significant benefits: reduced or eliminated fracture pain, prevention of further collapse, a rapid return to mobility and prevention of bone loss caused by bed rest. However, it does not address spinal deformity. It also requires high-pressure cement injection using low-viscosity cement, which leads to cement leaks in 30-80% of procedures, according to recent studies.

Kyphoplasty has several potential advantages over vertebroplasty. It restores vertebral body height with a low risk of cement extravasation. Kyphoplasty is well tolerated and is associated with statistically significant improvements in pain and function.

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Vertebroplasty - Vertebroplasty Treatment using Minimally Invasive Surgical Solutions

Vertebroplasty is a treatment procedure developed by interventional radiologists to stabilize broken bones in the spine caused by osteoporosis. In the procedure, a needle about the size of a cocktail straw is inserted through the skin and into the crushed vertebrae. A surgical bone cement called poly-methylmethacrylate is injected into the bone to stabilize it.

cement in vertebrae after Vertebroplasty

Often, more than one crushed vertebrae can be treated in a single procedure. Surgery is not required because
the doctor is able to guide the needle to the right spot using special X-ray equipment. Vertebroplasty takes from one to two hours to perform depending on how many bones are treated. The procedure may be performed with a local anesthetic that numbs the area to be treated, or the patient may be given general anesthesia.

Vertebroplasty can be performed in an outpatient surgical center, although most patients have the procedure done in a hospital and stay overnight afterwards.

In vertebroplasty, a needle about the width of a cocktail straw is inserted through the skin into the fractured bone. A bone cement is injected. The cement hardens, stabilizes the bone and prevents further collapse. This stops the pain caused by bone rubbing against bone.

Recovery

Some patients experience immediate pain relief after vertebroplasty. Most report that their pain is gone or significantly better within 48 hours. Many people can resume their normal daily activities immediately.

Frequently Asked Questions

Is the procedure safe?

Vertebroplasty is very safe. Although it is a relatively new treatment in the U.S., vertebroplasty has been performed for more than a decade at several centers in France with excellent results. The injection technique also has been successfully used for a number of years in the U.S. to treat other conditions in the spine. For example, it is used to treat cancer and blood vessel abnormalities. The bone cement used to
stabilize the fractured vertebrae has been shown to be safe through many years of use in joint replacement surgeries and other orthopedic procedures.

Who is a candidate for vertebroplasty?

People who have suffered recent compressing fractures that are causing them moderate to severe back pain
are the best candidates for vertebroplasty. In some cases, older fractures may be treated, but the procedure is most successful if it is performed soon after the fracture occurs. The procedure is not used to treat chronic back pain or herniated disks.

How successful is vertebroplasty?

Studies have shown that from 75 percent to 90 percent of people treated with vertebroplasty will have complete or significant reduction of their pain.

What are the risks or complications?

Vertebroplasty is a very safe procedure with few risks or complications. In many studies, no complications were reported. As with any medical procedure, the possibility of complications will depend on the individual patient. For example, patients with tumors in the spine or with other serious medical conditions may be at higher risk for complications from vertebroplasty. You should always ask your doctor to discuss risks and complications with you before you undergo any procedure.

Will vertebroplasty treat or prevent loss of height or "widow’s hump"?

After a vertebra has fractured, there is typically a loss of only 20 percent to 30 percent of the height of the bone. But over several weeks, fractures may reoccur and the vertebra flattens out, until eventually there’s a 70 percent to 90 percent loss of height in the bone. Gradually, the back hunches over and the person loses height, especially if several vertebrae are involved. Vertebroplasty cannot reverse this loss of height or kyphosis (often called "widow’s hump) in individuals who already have these conditions.

Some studies suggest that early treatment of spinal fractures with vertebroplasty can strengthen the spine and improve the posture, which may help prevent further fractures that lead to height loss or kyphosis. Currently, however, there is no evidence to prove that the procedure will prevent these problems. However, new research on the horizon is looking at ways to solve these problems.

On the Horizon

A number of new approaches to vertebroplasty are in development:

Researchers are looking into new cements that will convert to bone and stimulate bone growth.

"Kyphoplasty" is a procedure under investigation that involves inserting a small balloon at the point where the vertebra has collapsed. The balloon is inflated to raise the bone and then cement is injected into the space. Researchers hope the procedure will restore or prevent height loss.

Vertebroplasty may also be used preventively in the future to treat fragile, osteoporotic vertebrae in high-risk patients before they fracture.

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