PAIN AND FUNCTIONALITY

We provide the latest mininvasive diagnostic and therapeutic interventions, utilizing a multi-disciplinary approach to treat many types of pain syndromes.

The following range of Pain and Functional Disabilities are sensitive to our selection of treatments.

Regenerative Injection TherapyRegenerative Injection Therapy is a new approach, utilizing minimally invasive interventions to induce and accelerate tissue healing, previously damaged by a disease process or trauma. In some circumstances, tissue regeneration can be accomplished, eliminating the need for more invasive surgical interventions.

 
 
 
Why is Regenerative Therapy Necessary?

Regenerative Injection Therapy Certain tissues in your body are prone to wear and tear. Regenerative Injection TherapyThis may happen from trauma, occupational exposure or overuse. Specific tissues such as ligaments (tissue bands that connect bones with bones) and tendons (tissue bands than connect muscles with bones) are essential in preserving your skeletal stability, joints and range of motion. When affected by chronic degeneration and trauma, the good collagen and cartilage is replaced by a faulty one; creating painful and sometimes incapacitating conditions. Common conditions such as sprains, strains, tennis elbow, joint pain, heel pain, rotator cuff tears and trochanteric bursitis (inflammation of the bursa) are associated with chronic degenerative changes. Commonly prescribed anti-inflammatory medications, although effective sometimes in controlling the pain, do not heal or regenarate tissues. Regenerative therapy is used in cases in which other modalities such a medication, therapy and neuromuscular training have failed.

Which Types of Regenerative Therapies Are Offered?

ProlotherapyProlotherapy. Consists of injecting a solution of a local anesthetic (numbing agent) along with medical grade glucose, into a specific tissue: usually a tendon, ligament or a joint using sonography (unltrasound) guidance. This triggers a more intense healing reaction in the tissues, thus allowing faster healing. Numerous studies have shown ligament strength increase up to 40 %. Platelet Rich Plasma Grafting (PRP)Platelet Rich Plasma Grafting (PRP).An advanced type of therapy, in which the patient’s blood is drawn from a vein and concentrated by a special centrifuge device, ultimately creating a concentrate of platelets in plasma. This concentrate contains up to 500% of bioactive proteins, along with multiple growth factors, which are essential in inducing and accelerating tissue repair and regeneration. Platelet Rich Plasma Grafting (PRP) The PRP is injected into specific tissues by using the most advanced tissue guidance with ultrasound. Most of the benefit is seen in the connective tissues, bone, hyaline cartilages and development of new blood vessels necessary for tissue healing.Platelet Rich Plasma Grafting (PRP)Bone Marrow Aspirate Concentrate (BMAC).This procedure is a more advanced form of regenerative therapy, in which blood is withdrawn from the patient’s bone marrow (Iliac crest) and concentrated in a special device. The concentrate contains a significant amount of stem cells and platelets, which are capable of regenerating tissues to a greater degree than the PRP. The technique is more invasive and costly. It is usually reserved for cases in which there is significant tissue damage, or in patients who have failed other types of regenerative therapy. Sometimes, these grafts are enhanced with fibrin products necessary to create a tissue scaffold, in order to provide a tissue blueprint for regeneration. This new and exciting field is constantly evolving and is at the forefront of regenerative medicine.

Why Not Use Steroid Shots?

Why Not Use Steroid Shots?Although steroids are frequently injected to treat inflammatory conditions with success, they are not usually effective for chronic tissue damage or degenerative tissues. They can potentially cause tissue damage and significant side effects if performed habitually.

 
Which Type of Regenerative Therapy is Best for Me?

Upon reviewing your medical records and undergoing a complete evaluation, your physician will determine which specific therapy is best for you. For simple cases with minimal tissue damage or degeneration, Prolotherapy may be recommended. When the condition is more advanced, then Platelet Rich Plasma Grafting (PRP) or Bone Marrow Aspirate Concentrate (BMAC) may be a more suitable alternative.

How Many Treatments are Usually Necessary?

The amount of treatments is dependent on several factors: type and severity of the damaged tissue, location, nutritional state of the patient, age and genetic factors. Usually with Prolotherapy or PRP, several treatments (usually 3-6), four to six weeks apart, are usually necessary to achieve the desired outcome. With BMAC usually one therapy is performed and if necessary, followed by PRP or Prolotherapy.

Where is the Regenerative Therapy Done?

Regenerative Therapy is mostly performed on ligaments, tendon, joints (major and minor), and sometimes nerves. Usually the treatment of multiple sites are the most efficacious and yield the best outcome. The following are commonly treated conditions:

  • Spine: Sacroiliac joint, Ilio-lumbar ligaments, facet joints. Regenerative Injection Therapy
  • Regenerative Injection TherapyShoulder: Rotator cuff-partial tears, Biceps tendinosis, chronic Glenohumeral ligament sprains, Acromio-clavicular joint dysfunction and pain, Levatorscapula tendinosis.
  • Elbow: Tennis and Golfer's elbow, Ulnar collateral ligament injury, distal biceps tendon partial tear
  • Wrist & Hand: Chronic joint sprain and arthritis.
  • Hip/Pelvis/SI Joints: Pyriformis syndrome, Greater trochanteric bursitis, Sacroiliac joint dysfunction, hamstring strain, bursitis, hip joint arthritis
  • Knee: Patellar tendinitis/tendinopathy, Osgood-Schlatter's disease, quadriceps strain or partial tear, degenerative arthritis, rheumatoid arthritis, Chondromalacia patella, Enthesopathy
  • Ankle & Foot: Chronic ligament strain, chronic Achilles tendinitis, chronic partial tendon tear, plantar fasciitis, arthritic joints.
When Can I Return to Work or Resume My Usual Activities?

Since the procedure is minimally invasive, in 24 hours the patient usually returns to same activity level prior to the procedure. However, every patient is unique and requires specific recommendations. The decision is usually made according to the progress, lack of symptoms and response to therapy. Remember, the regenerative process takes time and usually requires several interventions to achieve the desired goal.

Are There Any Specific Instructions Before or After the Procedure?

With PRP and BMAC, all non-steroidal anti-inflammatory medications (aleve, motrin, ibuprofen, anaprox, etc.) should be stopped for one week prior to and one month after the procedure. According to which specific tissue is treated, certain restrictions will apply. Usually there is localized soreness and discomfort lasting for 24-48 hours. Medications will be prescribed if necessary to alleviate the symptoms. Other instructions will be given which pertains to the specific type of intervention to be performed.

Is the Procedure Covered by My Insurance Plan?

Most insurance plans cover the specific types of procedure. However, the cost of the supplies for PRP and BMAC are frequently excluded. Separate financial arrangements are sometimes necessary.

What Is the Sacroiliac Joint?

Sacroiliac Joint PainSacroiliac Joint Pain The sacroiliac joint (SIJ) is a large joint in the region of the low back are and buttock. It connects the pelvis with the spine (sacrum). It acts as a shock absorber from forces transmitted from the upper body to the legs. As a joint, it has limited motion.

What Is a Sacroiliac Joint Injection?

It is a procedure in which a local anesthetic (numbing medication) and a steroid (long acting anti inflammatory) is injected in the SIJ for the purpose of diagnose or exclude the source of pain and to treat persistent inflammation in the SIJ.

What Are the Indications for Sacroiliac Joint Injections?

Patients with known sacroiliac joint pain, due to conditions such as traumatic, inflammatory and occupational, who have failed conservative therapy. This injection often allows the physical therapist or chiropractor to more effectively restore function and stability. In a significant number of patient with persistent buttock, low back and leg pain, in which an accurate diagnosis have not been obtained, a SIJ injection can determine or exclude the source of pain. With this information, a more specific and accurate treatment can be prescribed.

The Procedure

Usually the procedure is performed under local anesthetic alone. Some patients that are apprehensive may benefit from intravenous sedation. This decision will be made based on individual preference and medical necessity. Oral medications are also available to assist with relaxation before and during the procedure. You will be taken to the procedure suite, place in the fluoroscopy bed lying on your stomach. Blood pressure and cardiac monitors will be applied. Next, your sacroiliac area will be scrub and cleansed in a sterile fashion. With the aid of an X-ray machine, which provides constant imaging (called fluoroscopy), the specific area to be injected will be identified. The physician will then inject a small amount of local anesthetic in the skin and deeper tissues to numb the area. This may be associated with a mild and brief stinging sensation. Once the area is numb, your doctor will insert a small needle into the appropriate sacroiliac joint, under x-ray guidance. A small amount of contrast (X-ray dye) will be injected to confirm proper needle placement. Following this, a solution of local anesthetic and steroid (long acting anti-inflammatory) will be injected in the joint.

After the Procedure

You will go back to the post anesthesia care unit (if you received intravenous sedation), where you will be monitored for 30-60 minutes according to your response. If no sedation was used, according to your specific condition, you may proceed to the post procedure observation area. Immediately after the procedure, you will be evaluated to assess for specific response. A post procedure evaluation form to assess the effectiveness of the injections will be given to the patient prior to discharge. Post procedure instructions will be given in a pre-printed form. A follow up appointment will be made for follow up and to determine if a repeat injection may be necessary. Frequently, according to your specific response, more injections may be indicated. It is not advisable that you drive the day of the procedure.

General Pre and Post Procedure Instructions

If no intravenous sedation is planned, you continue with your usual dietary habits the day of the procedure. If intravenous sedation is planned, avoid eating any king of solid foods prior to the procedure and you may have clear liquids up to 4 hours prior to the procedure. If you are taking Coumadin, Heparin, Plavix or non-steroidal anti-inflamatories (such as aspirin, ketoprofen, naproxen or others), stop taking them at least one week prior to the procedure. If you are diabetic and planning on having IV sedation, our office will give you specific instructions. You will be at the facility or hospital for approximately 1-2 hours for your procedure. It is important that you bring a driver with you, since you will not be allowed to drive the day of the procedure. You may return to your usual pre injection activities in 24 hours. The decision to return to work after the procedure will be made on an individual basis considering medical necessity and your specific condition.

What Are Trigger Points?

Trigger Point InjectionsA trigger points are commonly defined areas of taut muscle bands or palpable knots in the muscle, which are painful. Often, these trigger points can cause localized pain or even referred pain to other areas of your body, which can mimic conditions such as a pinch nerve in your neck or back. They can occur from direct muscle injuries, poor posture, repetitive strain, or secondarily from spine conditions such as a herniated disc. Although most of the time they respond to conservative measures such as massage, muscle relaxants and physical therapy, sometimes trigger point injections are required.

What Are Trigger Point Injections?

Trigger point injections are specific types of local muscle injections use to treat the painful taut bands responsible for pain and spasm. Common medications use in trigger point injections is local anesthetics, saline, glucose and small doses of steroids. Also a technique known as dry needling has shown significant improvement without injecting a medication, just inserting the needle in the muscle. The purpose of the injection is not only to decrease pain, but also to improve function and break the pain cycle.

The Procedure

The injection is performed in the examination room or the procedure suite (if you are having a different procedure). You will be examined and the trigger points will be identified and marked. The skin area will be sterilized with alcohol and numb with a local anesthetic. A small needle is then inserted into the specific site and a specific volume of the medication is injected. The procedure is repeated in the remaining trigger points. Trigger point injections are sometimes repeated, depending on the results and degree of improvement.

After the Procedure

Ice will be applied to the involve area and you will be observed for approximately 15 minutes. Afterwards, you will be discharged and given instructions about the post procedure care.

General Pre and Post Procedure Instructions.

The day of the procedure you should eat and drink routinely. Take your routine medications (blood pressure, diabetes, etc) as prescribed by your doctor. There may be certain medications (blood thinners such as Plavix, Coumadin, others) that, at the discretion of your physician, may have to be discontinue for several days prior to the procedure.At home continue usual medication and therapeutic exercises as prescribe. During the first 24 hours, apply a cold compress to the injected area for 20 minutes, three times a day. Some soreness and localized swelling is expected. Occasional, a small bruise may develop. If severe pain, swelling and bleeding develop, contact our office as soon as possible.

Intercostal Nerve BlocksWhat Is an Intercostal Nerve?

Intercostal Nerve Blocks It is a nerve that originates from the spinal nerves in the thoracic area, from the 1st to the 12th vertebra. It runs under the ribs and provide the sensation to the skin overlying the chest and upper abdomen, up to the inside of the arm.

What Is an Intercostal Nerve Injection?

It is a procedure in which, a solution of local anesthetic (numbing medication) and an anti-inflammatory (steroid) is injected into a specific intercostal nerve for the purpose of diagnosing a painful disorder or treating a painful condition.

Who Is a Candidate for an Intercostal Nerve Block?

There are multiple conditions that can be associated with intercostal nerve mediated pain. Among the common ones: painful rib fractures, post chest and heart surgery pain, muscle sprain, shingles, chest trauma etc. Sometimes the procedure is performed to diagnose or exclude a pain source. It also assists in rehabilitation and planning for further interventions. The response can be permanent, or the injection may have to be repeated. It all depends on the source of the pain.

The Procedure

The procedure can be performed as an outpatient, in the office, hospital and out patient surgical facility. Usually the procedure is performed under local anesthetic alone. Some patients that are apprehensive may benefit from intravenous sedation. This decision will be made based on individual preference and medical necessity. Oral medications are also available to assist with relaxation before and during the procedure. You will be taken to the procedure suite, place in the fluoroscopy bed lying on your stomach. Blood pressure and cardiac monitors will be applied. Next, the skin overlying the painful nerves or areas will be cleansed with a sterile solution. Then a solution of local anesthetic (numbing medication) and an anti-inflammatory (steroid) is injected into a specific intercostal nerve, under fluoroscopic guidance (X-Ray machine).

After the Procedure

You will go back to the post anesthesia care unit ( if you received intravenous sedation), where you will be monitored for 30-60 minutes according to your response. If no sedation was used, according to your specific condition, you may proceed to the post procedure observation area. Immediately after the procedure, you will be evaluated to assess for specific response. A post procedure evaluation form to assess the effectiveness of the injections will be given to the patient prior to discharge. Post procedure instructions will be given in a pre-printed form. A follow up appointment will be made for follow up and to determine if a repeat injection may be necessary. Frequently, according to your specific response, more injections may be indicated. It is not advisable that you drive the day of the procedure.

General Pre and Post Procedure Instructions

If no intravenous sedation is planned, you continue with your usual dietary habits the day of the procedure. If intravenous sedation is planned, avoid eating any king of solid foods prior to the procedure and you may have clear liquids up to 4 hours prior to the procedure. If you are taking Coumadin, Heparin, Plavix or non-steroidal anti-inflamatories (such as aspirin, ketoprofen, naproxen or others), stop taking them at least one week prior to the procedure. If you are diabetic and planning on having IV sedation, our office will give you specific instructions. The decision to return to work after the procedure will be made on an individual basis considering medical necessity and your specific condition. After this procedure, although remote there is a possibility of developing shortness of breath within 24 hours. If this happens contact the nearest emergency room for care.

Basics of Spinal Cord Stimulation

The information presented in this section was obtained from Advanced Neuromodulation Systems and Medtronics.

What Is Spinal Cord Stimulation?

Spinal Cord StimulationSpinal Cord StimulationIf you or someone you care about has been living with chronic pain, spinal cord stimulation (SCS) may provide new hope. Spinal cord stimulation is a medical therapy for people who suffer from certain types of chronic neuropathic pain. SCS is not a cure for pain. The objective with this therapy is to reduce a patient’s pain to a manageable level, so the patient can return to a more normal lifestyle. Spinal cord stimulation is actually part of a broader category of therapies called neurostimulation, which includes peripheral nerve stimulation. Neurostimulation therapies are used for pain relief or symptom relief from certain types of chronic pain and neurological disorders. Spinal cord stimulation and peripheral nerve stimulation use an implanted device—a spinal cord stimulator (sometimes called a pacemaker for pain)—to deliver low levels of electrical energy directly to nerve fibers. This direct approach to treating pain at its source can be very effective. The type of neurostimulation that might be appropriate for your condition depends upon many factors, including the cause of your pain or neurologic disorder as well as its type and location.

Neurostimulation

Neurostimulation sends mild electrical impulses to the spinal cord to relieve pain. Neurostimulation is the stimulation of the spinal cord by tiny electrical impulses. An implanted lead (a flexible insulated wire), which is powered by an implanted battery or receiver, is placed near your spinal cord. This lead and an implanted neurostimulator send electrical impulses that block the pain messages to your brain. Some patients describe the feeling of neurostimulation as "tingling." You can also think of neurostimulation as the rubbing of your "funny bone" after you've bumped it. Rubbing masks the feeling of pain just as the tingling produced by the neurostimulation system masks the feeling of pain.

Patient Profile

People with certain kinds of chronic pain may be candidates for neurostimulation therapy. Click here to learn about types of pain treated. The following critera are used to determine whether or not neurostimulation is appropriate for chronic pain sufferers:

  • More conservative therapies have failed to adequately help the pain.
  • An observable pathology exists that is associated with the pain.
  • Further traditional surgical intervention is not indicated.
  • No serious untreated drug habituation for your pain condition exists.
  • Psychological evaluation and clearance for implantation have been received.
  • No medical issues exist that would present problems with doing the surgery.
Neurostimulation Trial

In order to have a neurostimulation system implanted, you must first have a successful neurostimulation trial. The trial screening procedure—or test of a short test stimulation period in the operating room and an evaluation period of several days at home. During the evaluation period, your doctor determines your response to neurostimulation and your level of pain relief. It also gives you an opportunity to experience the system and enables the doctor to assess your battery requirements. During the trial screening, your doctor will place a lead in your back to deliver electrical stimulation to the spinal cord. The lead placement is one of the keys to successful results with a neurostimulation system. Your involvement is very important to proper placement, so be sure to follow your doctor’s instructions carefully. Typically, you will receive a local anesthetic and mild sedatives to keep you comfortable during the procedure. After that, your doctor will place the lead in your back. There are two types of neurostimulation trials: percutaneous and "cut-down." For the percutaneous trial, a needle is placed in your back. Through it, the test stimulation lead is inserted into the desired area of the spine. The end of the lead that remains on the outside of your body is secured to your back with surgical tape. After the trial period concludes (usually after several days), the lead will be removed. The percutaneous test stimulation is similar to an epidural nerve block, except that the lead will be inserted and left in your back during the trial. For the cut-down trial stimulation, your doctor makes a surgical incision, implants the permanent lead, and closes the incision. If you qualify for implantation in the latter case, the permanent lead will stay in place but will be attached to the implanted neurostimulator. After the lead is placed, your doctor will connect the lead wires to an external screener that allows your nurse or doctor to adjust your stimulation.

Implant Procedure

If your neurostimulation trial is successful, you may be a candidate for implantation of a neurostimulation system. The surgical procedure to implant the neurostimulation system may require a brief hospital stay. Before the surgery, you and your doctor will decide where to position the neurostimulator for your comfort. During the surgical procedure, an incision is made over the spine so that your doctor can place the lead and connect it to the extension. The extension is tunneled under the skin and connected to the neurostimulator. Your doctor will then form a pocket under your skin (usually in the abdominal area) that is large enough to hold the neurostimulator. Once the extension is connected to the neurostimulator, the incisions are closed and the surgery is complete. Fully impanted neurostimulation system (left) and a neurostimulation sstem with an external power source (right).

A Treatment with Real Advantages

Spinal cord stimulation has three significant advantages. First, it can be very effective in reducing chronic pain from certain conditions. Second, you can have an SCS trial before you have a permanent system implanted. An SCS trial allows you to see if the therapy will work for you. And lastly, the implanted device can be turned off permanently or removed if you don’t achieve the desired level of relief.

How Does Spinal Cord Stimulation Work?

To understand how spinal cord stimulation (SCS) works, it is helpful to understand the components of a spinal cord stimulation system. SCS systems typically consist of three components designed to work together:

  • Leads
  • A generator/receiver
  • A programmer/transmitter

Getting a SCS system involves a relatively short surgical procedure during which a lead or leads are placed in the space above of the spinal column (epidural space) and a generator/receiver is inserted under the skin. The leads are connected to the genereator/receiver. When the generator/receiver’s power is turned on, electrical energy is sent through the leads to electrodes that stimulate the nerve fibers associated with painful areas. This stimulation effectively changes the pain messages and replaces them with a more pleasant sensation called paresthesia. If a patient likes the stimulation sensation, and it helps to relieve his or her pain, then spinal cord stimulation is a good option. For some patients, however, the sensation is not pleasant and/or it does not relieve pain. That is why a trial procedure is normally performed to determine how a patient will respond to stimulation. Each type of SCS system has advantages and disadvantages. Should you consider getting a spinal cord stimulator, you and your physician will decide which system is best for your situation. This decision will be based on factors such as your pain pattern, your lifestyle, and how much electrical energy is required to provide adequate pain relief.

Leads

Leads are very thin wires or cables. One end of the lead is connected to the implanted generator/receiver, and the other end is placed near the nerve fibers that are to be stimulated. The end near the nerve fibers has metal electrodes that can deliver mild electrical impulses. Manufacturers offer a variety of leads to meet the needs of patients and physicians. Leads can vary by

  • Type (such as whether they are percutaneous or surgical)
  • Number of electrodes (such as 4, 8, or 16 )
  • Electrode shape, configuration, and spacing
  • Length
Types of Leads

Percutaneous leads can be implanted through a needle and may not need a surgical incision. The advantages of percutaneous leads are that they are faster and easier to place. The disadvantages are that they are more prone to move (migrate) than surgical leads and that their cylindrical electrode shape makes them less energy efficient. Surgical leads, also called paddle leads, are larger and require a surgical incision. The advantages of surgical leads are that they are less prone to move (migrate) than percutaneous leads and that their flat shape makes them more energy efficient. The disadvantage is that they do require a surgical procedure to place (implant). Percutaneous leads are almost always used for trial stimulation, whereas either percutaneous or surgical leads can be used for permanent implantation.

Number of Electrodes

Each lead has at least four electrodes, but a lead can contain as many as 16 electrodes. The number of electrodes used depends upon the condition being treated as well as the physician’s preference. For example, more complex pain patterns, such as those involving more than one area and more than one extremity (arms and/or legs), involve more nerve structures. Additional electrodes are often required to stimulate all of these structures. Implanting fewer electrodes than you need can result in less pain relief. In fact, many physicians believe that it is best to implant extra electrodes, just in case the pain pattern changes or the lead moves (migrates). If a change or migration occurs and extra electrodes are available, your physician can often reestablish pain relief by “electronically repositioning” the electrodes. Electronic repositioning is accomplished by reprogramming the power supply,which requires a visit to your physician. However, if the lead migrates and extra electrodes are not available, then you may have to undergo another surgical procedure to reposition the lead. Thus, placing extra electrodes is like buying insurance, because it provides you and your physician with some protection against possible problems.

Power Source—IPG, RECHARGEABLE IPG and RF Systems

Three types of SCS systems are available for spinal cord stimulation: conventional implantable pulse generators, rechargeable implantable pulse generators, and radio frequency systems. Each of these systems uses a different power source to send the electrical energy to the electrodes: Conventional implantable pulse generator (IPG). An IPG is powered by a battery. The IPG itself consists of the battery and electronics that are housed in a single metal container, which is completely implanted under the skin. The IPG is connected to a lead or leads that are placed over the spinal cord. It is important to note that from time to time the IPG must be surgically replaced when its battery runs out. Rechargeable implantable pulse generator (RECHARGEABLE IPG). Like a conventional IPG, a RECHARGEABLE IPG is battery powered and consists of a battery and electronics within a metal container that is implanted under the skin. The difference is that the RECHARGEABLE IPG’s battery is rechargeable. How often the battery must be recharged depends on how much the RECHARGEABLE IPG will eventually reach a point when its battery fails to hold a practical charge. This means that the charge will not last long enough for routine activities, such as working a normal job shift or attending a sporting event. When this happens, it is necessary to replace the RECHARGEABLE IPG in a surgical procedure. Radio frequency system (RF). With an RF spinal cord stimulator, the power source has two parts: a receiver, which is implanted under the skin, and a transmitter, which is worn outside the body pke a cell phone or pager. The receiver contains a metal antenna and electronics—but no battery—and is connected to the leads. The transmitter, which contains an antenna, electronics, and a replaceable or rechargeable battery, delivers radio waves through the skin to the implanted receiver. The receiver then sends the electrical impulses to the lead(s).

Programmer/Transmitter

A programmer and transmitter are devices used to program an SCS system and to adjust the intensity of the stimulation. Programs are the various electrical settings (amplitude, frequency, pulse width, and polarity) that are transmitted to each electrode on the lead. The ANS external programmer/transmitter allows your physician to create as many programs as he or she feels is necessary (up to 24) for your pain patterns. It also allows you to choose the best program for your pain as it changes throughout the day or as you move or change positions. A programmer/transmitter allows you to change programs and turn the stimulation up or down—just like you can change the channels or volume on your TV with a remote control. In fact, some people call the ANS spinal cord stimulation system “a remote control for pain.”

What Are Intervertebral Discs?

DiscographyDiscography The discs are gel like pads that separate the vertebral bodies of your spine. If provides stability, range of motion and most importantly, they act as shock absorbers. Certain conditions can create changes in the internal structure of the disc creating a painful condition. The source of the pain can be the disc itself, ligaments surrounding the spinal canal or nerves (being irritated by a herniated disc or a tear on the disc). Pain can be referred to your arms, legs, and neck and back, hips, abdomen and chest wall. Other structures such as muscles, joints and ligaments in your spine, along with internal organs, can produce similar symptoms.

What Is Discography and What Are the Indications?

Sometimes, in spite of diagnostic tests such as MRI, CT Scan and Myelogram, the source of the pain remains unknown. Discography is a minimally invasive test, designed to confirm whether the intervertebral disc is the source of the pain. Studies have demonstrated that the presence or absence of a herniated or degenerative disc, do not correlate with pain in a significant number of patients. In these specific situations, discography is useful not only in identifying the source of pain, but it will help the surgeon or interventional pain medicine specialist plan the correct treatment.

The Procedure

The procedure can be performed as an outpatient, in the office, hospital or out patient surgical facility. Usually the procedure is performed under local anesthetic with intravenous sedation, in order to facilitate relaxation and assist in comfort. Also an intravenous antibiotic will be administered prior to the procedure. You will be taken to the procedure suite, place in the fluoroscopy bed lying on your stomach. Blood pressure and cardiac monitors will be applied. Next, the skin overlying the respective discs will be cleansed with special solutions, sterilizing the local. Then a solution of local anesthetic (numbing medication) is infiltrated in the skin and deeper tissues overlying the discs. Under fluoroscopic guidance (X-ray machine), a special needle is inserted into the respective disc. You may feel temporary discomfort during this time. Once the needle(s) are in the proper position, a small amount of contrast will be injected into the disc. Your doctor will ask you to describe what you feel as the dye is being injected. During this time, you will communicate as accurately as possible, your experience. If discomfort is reproduced at the usual location, your physician will then ask you to describe the intensity, in a scale from 1-10. The procedure usually takes around 20-30 minutes, according to the number of discs being evaluated. The procedure usually takes 30 minutes.

After the Procedure

You will go back to the post anesthesia care unit (if you received intravenous sedation), where you will be monitored for 30-60 minutes according to your response. Post procedure instructions will be given in a pre-printed form. A follow up appointment will be made for post procedure evaluation in approximately one week. Medications will be given post procedure to assist in managing any discomfort. The post procedure discomfort is usually minor and can be manage with ice packs and medications.

General Pre and Post Procedure Instructions

If no intravenous sedation is planned, you continue with your usual dietary habits the day of the procedure. If intravenous sedation is planned, avoid eating any king of solid foods prior to the procedure and you may have clear liquids up to 4 hours prior to the procedure. If you are taking Coumadin, Heparin, Plavix or non-steroidal anti-inflamatories (such as aspirin, ketoprofen, naproxen or others), stop taking them at least one week prior to the procedure. If you are diabetic and planning on having IV sedation, our office will give you specific instructions. The decision to return to work after the procedure will be made on an individual basis considering medical necessity and your specific condition.

What Is an IDET (Intra-Discal Electrothermal Therapy)

A relatively new treatment for back pain resulting from problems within the cushioning discs is intradiscal electrothermal annuloplasty, also called intradiscal electrothermal therapy (IDET). This outpatient procedure, applies high heat directly to the inside of the disc. Different mechanism of action, have been postulated to explain how the IDET works. It can destroy the small nerve endings in the posterior wall of the disc (annulus) responsible for pain transmission. The high heat can produce several changes in the protein matrix in the nucleus (gel inside the disc) decreasing the ongoing inflammatory process. Last, it can potentially help sealed the tears in the annulus (fibrous outer wall) of the disc. Intra-Discal Electrothermal Therapy-IDET

Who Is a Candidate for an IDET?

Patients suffering from mainly low back pain, due to a painful disc, which failed conservative therapy including but not limited to: physical therapy, chiropractic care, medication management and injections. The diagnosis and identification of a specific disc as the source of pain, is achieved by a diagnostic test called discography. If the patients symptoms are mainly low back pain, buttock and occasionally referred leg pain. Patients must have a significant amount of disc space present (at least 50 % or original level) and no evidence of neurological deficits.

The Procedure

Usually the procedure is performed under intravenous sedation with local anesthetic supplementation. Oral medications are also available to assist with relaxation before and during the procedure. You will be taken to the procedure suite, place in the fluoroscopy bed lying on your stomach. Blood pressure and cardiac monitors will be applied. Next, your lower back area will be scrub and cleansed in a sterile fashion. With the aid of an X-ray guidance, which provides constant imaging (called fluoroscopy), the inter- vertebral discs are identified. The physician will then inject a small amount of local anesthetic in the skin and deeper tissues to numb the area. This may be associated with mild and brief stinging sensations. Once the area is numb, your doctor will insert a special needle into the appropriate disc nucleus, under x-ray guidance. A small amount of contrast (X-ray dye) will be injected to confirm proper needle placement. Then, the Electro-Thermal Catheter is inserted and positioned inside the disc in the back wall of the annulus. Proper position is confirmed by X-ray and of the posterior disc wall is performed for approximately 17 minutes, to a maximum of 90 degrees Centigrade. The procedure usually takes about 30 minutes and is associated with minimum post -operative discomfort.

After the Procedure

You will go back to the post anesthesia care unit (if you received intravenous sedation), where you will be monitored for 30-60 minutes according to your response. Post procedure instructions will be given in a pre-printed form. A follow up appointment will be made for post procedure evaluation in approximately one week. Medications prescribed for the post -operative period may include: an antibiotic, a muscle relaxant and an analgesic/anti-inflammatory. The post procedure discomfort is usually minor and can be manage with ice packs and medications.

General Pre and Post Procedure Instructions

If intravenous sedation is planned, avoid eating any king of solid foods prior to the procedure and you may have clear liquids up to 4 hours prior to the procedure. If you are taking Coumadin, Heparin, Plavix or non-steroidal anti-inflamatories (such as aspirin, ketoprofen, naproxen or others), stop taking them at least one week prior to the procedure. If you are diabetic and planning on having IV sedation, our office will give you specific instructions. The decision to return to work after the procedure will be made on an individual basis considering medical necessity and your specific condition.

What Is a Nucleoplasty?

It is a minimally invasive procedure developed to treat patients with contained or small disc herniation, causing persistent leg or arm pain. Nucleoplasty means removal of the nucleus, which is the gel like substance in the center of the disc. The procedure is performed under X-ray guidance, inserting a special needle through the skin and into the nucleus. With a special device (spine wand) a portion of the nucleus is evaporated by a process called ablation and coblation. The end result is a decrease in the size of the herniated disc, relieving the pressure on the nerve or ligaments of the spine. Once the spine wand is removed, the small opening in the disc seals by itself.

Nucleoplasty
Who Is a Candidate for Nucleoplasty?

Nucleoplasty is reserved for patients with mainly persistent leg pain due to a small and contained disc herniations, not responding to conservative therapy such as: medications, chiropractic care, physical therapy and injections. A contained disc herniation or disc bulge occurs when the wall of the disc (annulus) weakens but does not break open; it still holds the nucleus pulposus. In other words, the gel in the center of the disc is "contained" within the wall of the disc. These patients do not have significant neurological deficits (leg weakness or inability to control their bowel or bladder functions). It is considered a minimally invasive procedure and performed as an outpatient. Multiple discs can be treated during the same procedure.

The Procedure

Usually the procedure is performed under intravenous sedation with local anesthetic supplementation. Oral medications are also available to assist with relaxation before and during the procedure. You will be taken to the procedure suite, place in the fluoroscopy bed lying on your stomach. Blood pressure and cardiac monitors will be applied. Next, your upper or lower back area will be scrub and cleansed in a sterile fashion. With the aid of an X-ray guidance, which provides constant imaging (called fluoroscopy), the inter- vertebral discs are identified. The physician will then inject a small amount of local anesthetic in the skin and deeper tissues to numb the area. This may be associated with mild and brief stinging sensations. Once the area is numb, your doctor will insert a special needle into the appropriate disc nucleus, under x-ray guidance. A small amount of contrast (X-ray dye) will be injected to confirm proper needle placement. Then, part of the nucleus is removed by a process called coblation-ablation, which heats and evaporates a controlled amount of nucleus. The procedure usually takes about 20 minutes and is associated with minimum post -operative discomfort.

After the Procedure

You will go back to the post anesthesia care unit ( if you received intravenous sedation), where you will be monitored for 30-60 minutes according to your response.Post procedure instructions will be given in a pre-printed form. A follow up appointment will be made for post procedure evaluation in approximately one week. Medications will be given for the post -operative period which will include an antibiotic, a muscle relaxant and an analgesic/anti-inflammatory. The post procedure discomfort is usually minor and can be manage with ice packs and medications.

General Pre and Post Procedure Instructions

If no intravenous sedation is planned, you continue with your usual dietary habits the day of the procedure. If intravenous sedation is planned, avoid eating any king of solid foods prior to the procedure and you may have clear liquids up to 4 hours prior to the procedure. If you are taking Coumadin, Heparin, Plavix or non-steroidal anti-inflamatories (such as aspirin, ketoprofen, naproxen or others), stop taking them at least one week prior to the procedure. If you are diabetic and planning on having IV sedation, our office will give you specific instructions. The decision to return to work after the procedure will be made on an individual basis considering medical necessity and your specific condition.

What is Percutaneus Disc Decompression?

It is a minimally invasive procedure developed to treat patients with contained or small disc herniation, causing persistent leg or arm pain. Disc decompression means removal of a specific amount of the nucleus, which is the gel like substance in the center of the disc, in order to decrease the pressure and reduce the herniation. The procedure is performed under X-ray guidance, inserting a special needle through the skin and into the nucleus. With a special device (spine wand) a portion of the nucleus is evaporated by a process called ablation and coblation. The end result is a decrease in the size of the herniated disc, relieving the pressure on the nerve or ligaments of the spine. Once the spine wand is removed, the small opening in the disc seals by itself. Percutaneus Disc Decompression-Dekompressor

Who Is a Candidate for Disc Decompression?

Percutaneus disc decompression is reserved for patients with mainly persistent leg pain due to a small and contained disc herniations, not responding to conservative therapy such as: medications, chiropractic care, physical therapy and injections. These patients do not have significant neurological deficits (leg weakness or inability to control their bowel or bladder functions). It is considered a minimally invasive procedure and performed as an outpatient. Multiple discs can be treated during the same procedure. Recently , patients with low back pain and contained disc herniations, have been treated successfully with disc decompression.

The Procedure

Usually the procedure is performed under intravenous sedation with local anesthetic supplementation. Oral medications are also available to assist with relaxation before and during the procedure. You will be taken to the procedure suite, place in the fluoroscopy bed lying on your stomach. Blood pressure and cardiac monitors will be applied. Next, your upper or lower back area will be scrub and cleansed in a sterile fashion. With the aid of an X-ray guidance, which provides constant imaging (called fluoroscopy), the inter- vertebral discs are identified. The physician will then inject a small amount of local anesthetic in the skin and deeper tissues to numb the area. This may be associated with mild and brief stinging sensations. Once the area is numb, your doctor will insert a special device into the appropriate disc nucleus, under x-ray guidance. A small amount of contrast (X-ray dye) will be injected to confirm proper needle placement. Then, part of the nucleus is removed by using the Dekompressor device, which actually removes one to two cc of nucleus material. The procedure usually takes about 20 minutes and is associated with minimum post -operative discomfort.

After the Procedure

You will go back to the post anesthesia care unit ( if you received intravenous sedation), where you will be monitored for 30-60 minutes according to your response. Post procedure instructions will be given in a pre-printed form. A follow up appointment will be made for post procedure evaluation in approximately one week. Medications will be given for the post -operative period which will include an antibiotic, a muscle relaxant and an analgesic/anti-inflammatory. The post procedure discomfort is usually minor and can be manage with ice packs and and medications. Specific instructions are given to the patient for the post operative period.

What Is Percutaneus Vertebroplasty ?

It is a minimally invasive procedure use to treat patients who suffer from painful vertebral compression fractures, not responding to conservative therapy.

About Compression Fractures

Percutaneous VertebroplastyPercutaneous VertebroplastyVertebrae are the bones of the back, which join together to make up the spinal column. In a compression fracture of the vertebrae, the bone tissue ofthe vertebral body collapses. More than one vertebra may be affected. This condition is commonly caused by osteoporosis and less often by tumor, or trauma to the back. When the fracture occurs as a result of osteoporosis, the vertebrae in the thoracic (chest) and lower spine are usually affected, and symptoms may become worse with walking. With multiple fractures, kyphosis, a forward hump-like curvature of the spine, may result. Pressure on the spinal cord may occur producing symptoms of numbness,tingling, or weakness. Symptoms depend up on the area of the back that is affected. In some cases, the fracture heals without treatment and the pain goes away. In others, the bone does not stabilize and continues to move, causing persistent pain that in turn limits physical activities and reduces independence.

Treating Vertebral Compression Fractures

Historically, patients with compression fractures have been treated with conservative treatment including strong pain medications, prolonged bed-rest, or external bracing. These treatments can result in long recovery times and disruption of daily life. Vertebroplasty is an option to failed conservative treatment for vertebral compression fractures. This minimally invasive procedure is performed by specialists including interventional radiologists, neuroradiologists, surgeons and pain management physicians using x-ray guidance to accurately place specially formulated acrylic bone cement. Read “How the procedure works” for more details.

Description of Procedure
  1. Vertebral Compression Fracture, causing pain and deformity.
  2. A biopsy neelde is guided into the fractured vertebra through a small incison in the skin.
  3. Acrylic bone cement is shown flowing into the vertebra, filling the spaces within the bone.
  4. Restored vertebra with bone cement, stabilizing the vertebral structure and relieving pain.
The Procedure

Usually the procedure is performed under intravenous sedation with local anesthetic supplementation. Oral medications are also available to assist with relaxation before and during the procedure. You will be taken to the procedure suite, place in the fluoroscopy bed lying on your stomach. Blood pressure and cardiac monitors will be applied. Next, your upper or lower back area will be scrub and cleansed in a sterile fashion. With the aid of an X-ray guidance, which provides constant imaging (called fluoroscopy), the vertebral fractures are identified. The physician will then inject a small amount of local anesthetic in the skin and deeper tissues to numb the area. This may be associated with mild and brief stinging sensations. Once the area is numb, your doctor will make a small nick in the skin, then insert a special needle into the appropriate fracture vertebrae, under x-ray guidance. A biocompatible bone cement is injected through the needle into the vertebral body. The needle is then removed, and the cement allowed to hardened (usually within 10 minutes). The small skin nick is covered with a bandage. The whole procedure takes between 30 minutes to 2 hours (depending on how many vertebrae are treated).

After the Procedure

You will go back to the post anesthesia care unit, where you will be monitored for 30-60 minutes after the procedure. Typically, most patients resume normal activities within 24-48 hours. Some patients experience immediate pain relief after the procedure, others may take up to 48 hours. Post procedure instructions will be given in a pre-printed form. A follow up appointment will be made for post procedure evaluation in approximately one week. Medications will be given for the post -operative period which may include a muscle relaxant and an analgesic/anti-inflammatory.The post procedure discomfort is usually minor and can be manage with ice packs and medications.

General Pre and Post Procedure Instructions

If no intravenous sedation is planned, you continue with your usual dietary habits the day of the procedure. If intravenous sedation is planned, avoid eating any king of solid foods prior to the procedure (for at least 6 hours) and you may have clear liquids up to 4 hours prior to the procedure. If you are taking Coumadin, Heparin, Plavix or non-steroidal anti-inflamatories (such as aspirin, ketoprofen, naproxen or others), stop taking them at least one week prior to the procedure. If you are diabetic an

What Is a Rhizotomy?

It is a procedure in which a radioquency device is used to coagulate the median branch nerve of the facets (Cervical, Lumbar, Thoracic). The lesion is created, by heating the nerve to 80 degrees Centigrade for approximately 80-90 seconds.

Who Is a Candidate for a Rhizotomy?

Patients that have facet pain previously diagnosed by facet injection, resulting in excellent, but short lasting relief. The purpose of the median branch rhizotomy is to create long lasting relief, so that improve function and rehabilitation can be accomplished.

The Procedure

The procedure can be performed as an outpatient, in the office, hospital or out patient surgical facility. Usually the procedure is performed under local anesthetic with intravenous sedation, in order to facilitate relaxation and assist in comfort. This decision will be made based on individual preference and medical necessity. Oral medications are also available to assist with relaxation before and during the procedure. You will be taken to the procedure suite, place in the fluoroscopy bed lying on your stomach. Blood pressure and cardiac monitors will be applied. Next, the skin overlying the facets area is cleansed with a sterile solution. Then a solution of local anesthetic (numbing medication) is infiltrated in the skin and deeper tissues overlying the respective facet joints median nerve. Under fluoroscopic guidance (X-ray machine), a special needle is inserted in the facet nerve and coagulated with the radiofrequency device. The procedure usually takes 30 minutes.

After the Procedure

You will go back to the post anesthesia care unit (if you received intravenous sedation), where you will be monitored for 30-60 minutes according to your response. If no sedation was used, according to your specific condition, you may proceed to the post procedure observation area. Immediately after the procedure, you will be evaluated to assess for specific response. Post procedure instructions will be given in a pre-printed form. It can take as long as three weeks before the full benefit from the Rhizotomy can be noticed. It is not advisable that you drive the day of the procedure.

General Pre and Post Procedure Instructions

If no intravenous sedation is planned, you continue with your usual dietary habits the day of the procedure. If intravenous sedation is planned, avoid eating any king of solid foods prior to the procedure and you may have clear liquids up to 4 hours prior to the procedure. If you are taking Coumadin, Heparin, Plavix or non-steroidal anti-inflamatories (such as aspirin, ketoprofen, naproxen or others), stop taking them at least one week prior to the procedure. If you are diabetic and planning on having IV sedation, our office will give you specific instructions. The decision to return to work after the procedure will be made on an individual basis considering medical necessity and your specific condition.

X-ray

This test uses radiation to take a picture of structures inside the body, especially bones. Back x-rays may show signs of arthritis, degenerative disk disease, osteoporosis, or a tumor.

MRI Scan

This test uses strong magnetic waves to take pictures of structures inside the body. An MRI can show disc herniations, disc degeneration, spinal cord or spinal nerve root compression, tumors, or infections in the spine. Patients who have had previous back surgery will need a contrast, Gadolinium, injected. This substance helps differentiate scar tissue resulting from previous surgery. Gadolinium enhances the images of structures and alters local magnetic field in tissues being examined. Normal and abnormal tissue responds differently to the alteration from the contrast allowing the radiologist to visualize tissue abnormalities and disease processes. There is slight risk of an allergic reaction to contrast material, however, most reactions are mild and can be controlled with medications.For some patients, MRI is not an option. An MRI cannot be done for patients who have:

  • Pacemakers - an MRI can cause malfunction
  • Shrapnel
  • Bone plates or pins
  • Aneurysm clips - an MRI may cause the clip to tear the artery it is trying to protect
  • Metal fragments in eye - can cause eye damage or blindness
  • Implanted spinal cord stimulators
  • Inner ear implants
  • Dental implants - some are magnetic
  • Metal heart valves
  • Tattooed eyeliner - iron pigments can cause irritation
  • Women who have intrauterine devices (IUD)
  • Pregnant women
Nerve Conduction Study- Neural Scan

In this test, an electrical current is passed through a nerve to determine the health or disease of that nerve. This test is used in combination with an EMG.

Electromyography (EMG)

This test measures the electrical activity of muscle by placing needle electrodes into the muscle.

Myelography

In this test, a special dye is injected into the spinal canal. X-rays are then taken to see how the dye lines the space in the spinal canal and see if there are disc herniations or pinched nerves in the spine. A CT scan is usually performed after a myelogram in order to help visualize structures in the spine.

Before the CT/Myelogram

You will be instructed about not eating or drinking before the test. You will need to remove all jewelry, hairpins, hearing aids, and dental work. You will lie on a moving table that slides into a scanner. The scanner moves around to change angles of x-rays. Advise the Radiology Department if:

  • You are pregnant
  • Allergic to iodine dye
  • Have kidney problems - the contrast can damage the kidneys
  • Have diabetes
  • Have had a barium enema within 4 days of the CT Myelogram
After CT/Myelogram

You will be instructed to keep your head elevated and not to bend over or lie flat. This helps keep the contrast material out of your head.

CT Scan

This type of x-ray uses a computer to generate images of structures inside the body. CT scans of the spine may show disc herniations, tumors, arthritis, vertebral fractures, or the stability of spinal fusions.

Bone Scan

A bone scan evaluates bones for infection, disease, fractures, tumors or other bone abnormalities. Bone scans examine the entire skeletal system. The scan can help diagnose the cause of unexplained bone pain, such as low back pain, detect damage to bones caused by infection or other disease, evaluate damage to bones, detect cancer that has metastasized to bones, and monitor conditions that can affect bones such as trauma or infection.A small amount of radioactive tracer is injected into the bloodstream and the bones will absorb it. It may take up to three hours for the tracer to be absorbed and the scan to begin. During the waiting period, patients may be asked to drink 5-8 cups of water to help eliminate any radioactive tracer that is not absorbed into the bones. You can eat and drink as normal before the scan.A Bone scan can take up to an hour. You will lie on your back while a scan camera moves slowly above and around your body. The camera will scan for the radioactive tracer and produce pictures of bones. The camera does not produce radiation. A normal bone scan will show the tracer evenly distributed throughout the bones. An abnormal bone scan shows the tracer accumulated in an area of the bone, indicating a "hot spot".Hot spots may be caused by a fracture that is healing, bone cancer, bone infection, arthritis, or a disease of a bone. Some bones lack the tracer indicating a "cold spot". Cold spots may be caused by a certain type of cancer or lack of blood supply to a bone. The body rids itself of the injected radioactive tracer thru urine or stool and is usually eliminated over a period of 24 hours

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