by Raj N. Sureja, MD
Interventional Pain Management (IPM) is the medical subspecialty that is devoted to the identification and treatment of acute or chronic pain disorders. As an IPM physician, I interpret the patient’s pain in the context of their clinical history, physical examination, and diagnostic imaging to locate the patient’s pain generator(s). An example of a pain generator is an inflamed vertebra in the spine or an irritated sciatic nerve that affects the lower back, buttock, and/or leg. The goal of treatment is to reduce or eliminate pain, improve function and quality of life, and facilitate the return to work.
We use various minimally-invasive techniques specifically designed to diagnose and treat the underlying causes of painful conditions. Injections (nerve blocks), epidural blocks or other minimally- invasive procedures are used as part of the patient’s care. These interventional treatments are not investigational and are all approved by the FDA. Occasionally, medications are necessary for the initial treatment of pain, but we try to avoid the use of narcotic pain medicine if possible. Physical therapy is often a very important aspect of treatment for the purpose of reducing pain, restoring function, and educating patients in avoiding a recurrence of their problem.
Fluoroscopy is an imaging technique that uses X-ray and a fluorescent screen to see real-time moving internal organs, and in our case, the internal structure of a patient’s musculoskeletal system. The use of fluoroscopy helps guide the physician to precisely inject medications into the area causing the patient’s pain. There are a variety of treatments that we use to treat a wide range of diagnoses. Fluoroscopy affords us a more effective method of treatment for chronic pain, because of the precision it affords. We have a fluoroscopy suite in our office, where we perform all interventional procedures. In this article, we will be highlighting several of the therapies that we use to help our patients feel better.
Epidural Steroid Injections
A very common and minimally-invasive procedure to relieve leg, back, arm, and neck pain caused by inflamed spinal nerves is an Epidural Steroid Injection (ESI). Nerves become inflamed when the passages narrow where the nerves travel from the spine. This narrowing can occur as a result of several causes, such as spondylolisthesis (or slipped vertebrae), joint cysts, disc herniation, or bone spurs. ESIs have been used for decades and are an effective and safe option for people experiencing pain.
An ESI includes two different drugs: a steroid to help alleviate inflammation and an anesthetic agent to numb the nerve. The procedure entails utilizing fluoroscopic (X-ray) guidance to place the needle into position. ESIs are performed on an outpatient basis – most patients request only local anesthetic on the skin, but some do want mild sedation.
The goal of the injection is to provide relief from pain and to help the patient return to normal activities. ESIs are commonly used in combination with a comprehensive rehabilitation program which may include physical therapy, medications, or an exercise regimen. By following the recommendations of a physician, many patients experience relief for weeks, months, and sometimes a year or more. If an ESI is effective, a patient may have 3-4 in a one-year period. ESIs can also be very beneficial during an acute episode of pain of the leg or back. ESIs do not alter the patient’s underlying condition, but they can provide symptom relief that can allow the patient to improve function through physical therapy without suffering as much discomfort.
Radiofrequency Ablation
Radiofrequency Ablation (RFA) is a treatment option to reduce pain. Using X-ray guidance, we place special insulated needles near or on the facet joint nerve. We heat a small area of the nerve tissue using an electrical current. The heat disables the medial branch nerves which decreases the pain signals in that particular area. RFA is often used to treat pain associated with facet joint syndrome. It takes less than two minutes to heat and damage the nerve, but depending on the number of nerves we are treating, the procedure may take up to 1 – 2 hours. This procedure can be used for patients with back, neck, muscle and other pain syndromes.
The degree of relief varies, but more than 70% of patients treated with RFA experience pain relief, which can last from 6 to 12 months, or in some cases, years. It is a safe and effective way to treat some forms of pain, and has few complications. Participating in physical therapy will increase the strength of muscles around the nerve and lessen the level of pain. Sometimes the nerves do grow back, and usually the patient will not experience the same level of pain. If it does return, the procedure can be done again.
Spinal Cord Stimulation (SCS)
When other treatments do not provide relief, Spinal Cord Stimulation may be tried to control nerve-related pain. For patients who cannot or choose not to have surgery, it is an effective alternative for pain relief.
How does it work? A thin cable, or lead, in implanted into the epidural space (around the spinal cord) which imparts a low-level electrical current or pulse to the spinal cord. The lead is attached to a battery which generates energy for the unit, controlled by a hand-held programming unit. The electrical current interferes with the pain signal being sent to the brain. As a result the patient feels less or more tolerable levels of pain.
What are the benefits? SCS trials happen first, typically over a period of 5 – 7 days. If the patient deems the trial successful {significant pain reduction & reduction in pain medication(s)}, then permanent placement will be performed, as minimally-invasive outpatient surgery.
Who will benefit? For what conditions can SCS be used?
• Radiculopathy – Caused by sciatica or pinched nerves for which surgery is not an option.
• Failed Back Surgery Syndrome – Patients who have had Back surgery to correct a mechanical problem who continue to have significant pain.
• Epidural Fibrosis – The compression of nerves (where they exit the spine) by the development of scar tissue.
• Arachnoiditis – Nerve tissue inflammation near the spine
• Complex Regional Pain Syndrome (CRPS) – The Sympathetic Nervous System causes an exaggerated pain response to an injury with accompanying loss of function to the affected limb.
• Painful Diabetic Peripheral Neuropathy
Vertebroplasty/Kyphoplasty
When you lose a significant amount of bone, it can result in vertebral fracture or collapse. Bone loss is caused by: osteoporosis, cancer, chemotherapy, menopause, radiation therapy, and hyperthyroidism. Spinal fractures can be extremely painful and the pain can last for several days or more. For pain lasting more than a week, a visit with an OSC Orthopaedist can determine what is causing the discomfort. In most cases, conservative treatment is tried first, including rest and medication for pain. If conservative treatment is not successful, other options will be considered.
Vertebroplasty and kyphoplasty are similar, minimally-invasive options used to stabilize compression fractures in the spine. Vertebroplasty involves the injection of bone cement to provide an “internal cast” for compression fracture. The fractures are supported when the cement hardens and they can heal. Kyphoplasty involves the insertion a balloon into the fractured areas. The balloon gently inflates to restore the fractured bone to the appropriate height and shape. Bone cement is then injected into the space to permanently restore the patient’s stature. Both procedures relieve pain and restore function, reduce or eliminate pain and allow a return to normal activities.
Recent developments, including coverage by insurance companies and improved surgical kits are now making it able to do the procedures in our office, instead of in hospital. Surgically, special blocks for anesthetizing the area and significantly smaller needles have eliminated (for most people) the need for anesthesia, paving the way for the procedure to be done in an office setting. OSC has two sterile fluoroscopy procedure rooms where our physicians perform these procedures. We started doing in-office vertebroplasties in 2008, and in July 2012, we began in-office kyphoplasties. Dr. Mark McFarland and Dr. Raj Sureja are the OSC physicians who perform these procedures in the office.
The benefits to having this procedure done at OSC are as follows:
1. No anesthesia is required, resulting in no recovery time. Elderly patients or people who have negative reactions to anesthesia do not need to fear this procedure
2. The procedure takes less than 30 minutes; 90 minutes is approximately the total time the patient is in our office. Compare this to spending 4-6 hours, or more, in the hospital.
3. The cost of an in-office procedure is thousands less PER PROCEDURE. The patient pays significantly less, as does the insurer.
4. Medicare and other insurers are covering these in-office procedures. The patient may have some financial responsibility, but it will be less than if the patient went to the hospital for the same procedure.
Selective Nerve Root Blocks
Irritated nerves can cause significant pain and discomfort. Nerve roots are attached to the spinal cord, and one exits each side of the spine at each vertebrae. These nerves are the communicators in our bodies, carrying signals throughout the body to and from the brain, muscles, and skin. A nerve root can become irritated or compressed from a damaged disc or from contact with a bone spur. Symptoms may include pain, tingling, numbness, or weakness. We have tools to help determine the cause of the pain and also to help alleviate the discomfort.
The area of the body where you are experiencing symptoms points to where the nerves are inflamed. Nerve irritation in the neck (cervical spine) can cause symptoms in the neck, arm or shoulder. Nerve irritation in the upper and mid back (thoracic spine) can produce upper back pain or pain along the ribs and chest wall. Irritation in the lower back (lumbar spine) can produce symptoms in the lower back, hip, buttock, or legs.
One of the tools in our toolbox is the Selective Nerve Root Block (SNRB). These are very similar to Epidural Steroid Injections (ESIs). Like ESIs, the medication used includes a steroid to decrease inflammation and an anesthetic to numb the area. For SNRBs, we administer the injection under the vision of an X-ray machine so we can be sure the injection enters the site exactly where we want it to enter.
ESIs and SNRBs are a little bit different. The purpose of an ESI is to inject medication to treat all the nerve roots in a certain area, while a Selective Nerve Root Block is to numb just one or two spinal nerves. We use SNRBs for two reasons: diagnostic or therapeutic. For the diagnostic block, enough medication is utilized to numb one root to determine if that root is causing the patient’s pain and discomfort. If the pain subsides after the injection, the pain generator is presumed to have been identified. We use a larger volume of the medications to treat the irritated nerve for a therapeutic block.
If you are interested to learn more, please make an appointment to see a Pain Management Specialist at OSC.
Dr. Raj Sureja is a Fellowship-Trained, Interventional Pain Management Specialist whose practice is focused on treatment of spine-related disorders, through minimally-invasive interventional procedures. Recently voted a “Top Doc for 2012” in a survey of Hampton Roads Physicians, Dr. Sureja practices at Orthopaedic & Spine Center in Newport News, VA. To learn more about Dr. Sureja call 757-596-1900.