Arthritis - Padda Institute Center for Interventional Pain Management

Serious treatment options for serious foot pain

Nearly 60% of patient’s with chronic forefoot pain presenting to a podiatry practice have surgical intervention, yet only 50-60% of them get relief of foot pain long-term and 20% get significantly worse, requiring multiple surgeries. Accurate diagnosis is critical to appropriate treatment, common areas where foot pain is misdiagnosed include:

 

  • Plantar plate disruption

The metatarsophalangeal joint plantar plates are major stabilizers and form part of the plantar capsule. The plantar plates provide strength and support during ambulation. Disruption can lead to toe deformities.  The normal plantar plate is a slightly hyper echoic broad-curved band, which protects the metatarsal head and inserts onto the proximal phalanx. Plantar plate tears typically appear as hypo echoic defects.  The torn plantar plate is often swollen and hyper vascular in the acute phase of degeneration.

 

  • Adventitial Bursitis

Adventitial bursitis is acquired bursitis in the metatarsal fat pad as a result of trauma. Sonographically these areas may either be ill-defined or focal collections. These are generally compressible and hypo echoic, although complex collections may appear heterogeneous.

 

  • Synovitis

Joint effusions are compressible anechoic collections best seen on the dorsal aspect of metatarsophalangeal joints. Synovial proliferation appears on ultrasound as a thickening of the synovial layer. Hyper vascularity and bone erosions may also be present.

 

  • Morton’s Neuroma/ intermetatarsal bursitis

A Morton’s neuroma is caused by mechanical damage to the interdigital nerve, resulting in perineural fibrosis. On ultrasound it commonly appears as an ovoid hypo echoic mass, although the shape and echogenicity may vary. Intermetatarsal bursitis appears as a hypo echoic or anechoic zone in a normally echogenic webspace, generally dorsal to the interdigital nerve, although sometimes enveloping it. This soft tissue collection may become complex and heterogeneous with time. Dynamic assessment of a webspace will show poor compressibility of a neuroma and high compressibility of a bursitis (note: complex bursa may mimic a neuroma).  Treatment options include ultrasound guided cortisone or alcohol injection.

 

Morton’s neuroma or more appropriately entrapment syndrome

Common causes of forefoot pain include joint inflammation (arthritis, capsulitis & synovitis), plantar plate tears, tendinosis (“tendinitis”), bursitis and Morton’s neuroma.

A Morton’s neuroma occurs when scar tissue builds upon a nerve in between the toes known as the interdigital nerve (nerve between the digits, or toes). In Morton’s entrapment, the common plantar digital nerve, also referred to as the intermetatarsal nerve, gets compressed from forefoot plantar pressure in the late midstance and propulsive phases of gait against the distal margin of the transverse intermetatarsal ligament This is most frequently seen in women and is and is attributed to high heeled shoes. The pain is often severe and has an electric shock character to it.  Common symptom descriptions include some or all of the following: “It feels like my sock is wadded up under my foot,” “cramping,” “numbness,” “burning,” “radiating sensations into the adjacent toes,” “the inability to walk barefoot on a hard floor,” and “tingling.”   Others describe a feeling like having a pebble in their shoe or walking on razor blades.  Symptoms include: pain on weight bearing, frequently after only a short time. The nature of the pain varies widely among individuals. Some people experience shooting pain affecting the contiguous halves of two toes. Burning, numbness, and paresthesia may also be experienced.  Usually, patients with Morton’s entrapment demonstrate pain with plantar palpation of the interspace between the metatarsal heads.

As a true nerve entrapment no different in pathology from carpal tunnel syndrome, Morton’s entrapment treatment should be oriented toward decompression. Indeed, the treatment success rate of peripheral nerve decompression in Morton’s entrapment is higher than with surgical resection, has a much lower complication rate, and precludes serious complications associated with nerve excision.

Diagnostic lidocaine blocks are extremely beneficial in assisting in making an accurate diagnosis and can help the practitioner decide on a course of treatment, specifically when two adjacent interspaces are symptomatic.  It has generally been recommended that prior to surgical treatment for Morton’s entrapment, all methods of “conservative” care should be exhausted, including corticosteroid injections, application of offloading pads, sclerosing injections with alcohol or phenol, or radiofrequency ablation.

RADIOFREQUENCY

Radiofrequency nerve treatment is a technique, which has been used for over 10 years for the treatment of longstanding pain. Using local anesthesia, an electrode is placed into the tissue at the painful site and an electric current is delivered, generating heat that destroys the sensory nerve fiber.

The RF Procedure

A medical provider experienced in interventional procedures performs Radiofrequency ablation. The patient is placed in an appropriate position for the procedure; a diathermy pad is placed on the thigh and the injection site cleansed. Pain relief is achieved by injecting a local anesthetic around the nerve that is responsible for the patient’s pain. Once the nerve and area is anaesthetized (numbed), a fine needle is positioned in proximity to the nerve, with the position of which confirmed by imaging guidance (ultrasound or fluoroscopy).

A thin probe is then passed through the needle, which is connected to a generator that results in radiofrequency energy passing through the probe, resulting in heating of the probe tip. The result of this heat is to destroy the targeted nerve and therefore disrupting the ability of the nerve to transmit pain signals. Finally, long-term local anesthetic and cortisone are injected around the treated nerve in order to minimize discomfort, which may arise following the treatment. Treatment via RFA takes approximately 30 minutes. Further time spent at the clinic for post-procedure recovery may be suggested, depending on the exact nature of a patient’s condition. Ultrasound-guided RFA has successfully alleviated patients’ symptoms of Morton’s neuroma/ entrapment in >85% of cases. Less than 10% of patients progress to surgical intervention, such as endoscopic plantar fasciotomy.

ENDOSCOPIC PLANTAR FASCIOTOMY

EPF is an outpatient procedure. It takes about an hour to perform, and is be done at a hospital or a same-day surgical facility. Using special instrumentation we release the inside band of the plantar fascia responsible for causing your pain. After the procedure, you’ll be taken to a recovery area. As your foot heals, new tissue fills in the gap where the fascia was cut. This lengthens the fascia and reduces strain during foot movement. For best results, see your doctor as directed during the next few weeks or months. Physical therapy or stretching exercises are often prescribed to improve recovery. Wearing shoes with good support is essential for your long-term recovery.

 

 

 

 

Nine reasons why weight loss is so important for chronic pain patients.

Nine reasons why weight loss is so important for chronic pain patients.

1. Pain reduces activity

Pain often leads to reduced activity and exercise, which can cause patient’s to gain weight, due to loss of metabolically active muscle.

2. Pain prevents restful sleep

Pain disrupts sleep, reducing growth hormone production, which causes patients to gain weight.  Pain also causes elevated cortisol levels and epinephrine levels, which reduce sleep and independantly cause obesity.

3. Pain effects hormones

Excessive fat accumulation leads to a buildup of visceral fat which produces xenoestrogens, which inhibit the production of testosterone, which causes further fat weight gain and loss of muscle mass.

4. Obesity predisposes patient’s to diabetes

Excessive fat accumulation decreases insulin sensitivity and produces insulin resistance, a form of pre-diabetes.

5. Pain effects your pocketbook

Pain often leads to significant functional disability, reducing the patient’s standard of living, which encourages the consumption of subsidized foods, often rich in carbohydrates (food stamps buy significantly more calories of carbohydrates than protein).

6. Obesity effects joint load bearing

Excessive weight dramatically increases the amount of load joints must support. For every extra one-pound of fat you have, you increase the force on your lower back by nearly 20-24 pounds. If you are 10 pounds overweight, your back is carrying an extra 240 pounds of force, and if you lose 10 pounds of weight you will reduce load bearing by 240 pounds.

7. High blood sugar reduces the effects of pain medications

Patient’s with elevated blood glucose experience significantly more pain and find that their pain medications are less effective as the glucose level rises and more effective as the glucose levels fall. There is a direct effect on the opiate receptor by excessive glucose, which prevents activation of the receptor.

8. High blood sugar makes proteins sticky (Glycation)

Glucose or sugar is a sticky carbohydrate. Imagine if you poured sticky goo into the engine of your car, it would bind up the machinery. Extra glucose binds onto nearly all of the proteins in your body, making them work less efficiently, and predisposing patient’s to heart attacks and early aging.

9. Carbohydrates are themselves addictive

Although eating sugar may give you an immediate lift or rush, it quickly disappears when insulin drives the blood sugar into the cells, which then leaves you craving for more sugar because your blood sugar level drops precipitously. Elevated blood sugar temporarily seems to partially activate the endogenous opiate receptors and some people do actually become “addicted” to carbohydrates, requiring ever increasing dosages, which leads to fat accumulation.

 

Selective nerve root block (cervical, thoracic or lumbar)


Nerve roots exit your spinal cord and form nerves that travel into your arms or legs. These nerves allow you to move your arms, chest wall, and legs. These nerve roots may become inflamed and painful due to irritation, for example, from a damaged disc or a bony spur.

A selective nerve root block provides important information to your physician and is not a primary treatment. It serves to prove which nerve is causing your pain by placing temporary numbing medicine over the nerve root of concern. If your main pain improves after the injection then that nerve is most likely causing your pain. If your pain remains unchanged, that nerve probably is not the cause of pain.

 

By confirming or denying your exact source of pain, it provides information allowing for proper treatment, which may include additional nerve blocks and/or surgery at a specific level.  Selective nerve root blocks are similar to epidurals, but instead of putting medication in to cover all of the nerve roots, selective blocks are done so as to cover just one or two nerve roots.

The membrane that covers the spinal cord and nerve roots in your spine is called the dura membrane. The space surrounding the dura is the epidural space. Nerves travel through the epidural space before they form the nerves that travel down your arms, along your ribs and into your legs. These nerve roots may become inflamed, for example, due to irritation from a damaged disc or contact with the bony structure of the spine. A selective epidural injection places anti-inflammatory medicine over the nerve root and into the epidural space to decrease inflammation of the nerve roots therefore reducing your pain. The epidural injection may assist the injury to heal by reducing inflammation. It may provide permanent relief or provide a period of pain relief for several months while the injury/cause of your pain is healing.

The selective nerve root block (SNRB) is a procedure that anesthetizes an individual nerve root, either within the neck (‘cervical’), or in the back (‘thoracic’ or ‘lumbar’), thought to be responsible for the patient’s pain. The nerve root sheath is injected and anesthetized with the intent of relieving this pain.  This procedure is sometimes referred to as a ‘Foraminal Block.’  The SNRB procedure delivers a low volume of concentrated medication directly into the affected nerve root sleeve.

Back Pain is often multifactorial and difficult to diagnose because the symptoms overlap considerably with those of other degenerative disorders of the spine.  The SNRB is useful in both the diagnosis and the treatment of back pain; therefore, it is both a diagnostic as well as a therapeutic procedure. In other words, if we inject a medication within the suspected nerve root sleeve and the pain improves, we are fairly confident that this nerve root is responsible for the pain; conversely, if we inject a medication and the pain is no better, this implies that this nerve root is likely not responsible for the pain.

 

Nerve Root Impingement

Patients with pain from nerve root irritation often have an anatomic cause, which is usually the result of a nearby structure pushing on, or impinging on the nerve, causing irritation of that nerve.

The most common causes of this are either a disc abnormality or an adjacent bone spur, either of which, when in close proximity to the nerve, can irritate it and cause pain in the distribution of that nerve.

 

Radicular Pain

If there is irritation of a nerve in the back or neck, it may cause symptoms of pain, and usually this pain is in the distribution of that particular nerve, referred to as radicular pain.

Dermatomes

 

Patient Selection

SNRB is most effectively used in patients with radicular pain.

These patients should have recent imaging studies (CT or MRI scan), which in many instances help to identify the cause of pain. Not all patients will have an identifiable cause for the pain on imaging, but all should have radicular symptoms.  Electrodiagnostic studies such as EMG are useful in distinguishing peripheral neuropathy, entrapment and radiculopathy.

 

Procedure

The procedure is explained to the patient, questions are answered and informed consent is obtained.

The patient is placed prone (stomach down) for lumbar or thoracic injections, or supine (face up) for cervical injection on the fluoroscopic table, and the area is sterilely cleansed with povidone-iodine (Betadine) and alcohol.

The exact level is located with the fluoroscope, and the skin overlying this area is anesthetized (numbed) with lidocaine. This is either to the right or left of midline on the back.

A needle is sterilely advanced along the nerve root sleeve, which typically elicits a mild degree of radicular pain in the distribution of that nerve. It is important for us to know whether the pain elicited is similar to the patient’s pain (concordant response), or dissimilar (discordant response).

Typically, as small amount of water-soluble contrast (dye) is injected to confirm proper needle tip position.

Once this is confirmed, a mixture of anesthetic (lidocaine or bupivacaine) and anti-inflammatory medication (steroid) is injected.

The needle is slowly withdrawn

This procedure may be performed with either CT or Fluoroscopic guidance.

 

 

What will happen after the procedure?

Immediately after the procedure, you will get up and walk around and try to imitate something that would normally bring about your usual pain. You will then report the percentage of pain relief and record the relief you experience during the next week. We ask that you remain at the Clinic until you feel you are ready to leave.

You may not be able to drive the day of your procedure. Your legs or arms may feel weak or numb for a few hours. You may be referred to a physical therapist immediately afterwards while the numbing medicine is still working. If the doctor prescribes physical therapy, it is very important that you continue with the physical therapy program.

Although you may feel much better immediately after the injection (due to the numbing medicine), there is a possibility your pain may return within a few hours. It may take a few days for the steroid medication to start working.

You may experience some weakness and/or numbness in your legs a few hours after the procedure. If so, do not engage in any activities that require lifting, balance and coordination.

Drink plenty of clear liquids after the procedure to help remove the dye from the kidneys.

 

 

General Pre/Post Instructions:

You should eat a light meal within a few hours before your procedure. If you are an insulin dependent diabetic, do not change your normal eating pattern prior to the procedure. Please take your routine medications (i.e. high blood pressure and diabetic medications).  Do not take pain medications or anti-inflammatory medications the day of your procedure. You need to be hurting prior to this procedure. Please do not take any medications that may give you pain relief. These medications can be restarted after the procedure if they are needed. If you are on Coumadin, Heparin, Plavix or any other blood thinners (including Aspirin), or the diabetic medication Glucophage you must notify this office so the timing of these medications can be explained. You will either be at our clinic facility for approximately 1-3 hours for your procedure. You may need to bring a driver with you. You may return to your normal activities the day after the procedure, including returning to work.

 

Risks of nerve root injection?

Increased localized back pain, neck pain, arm pain or leg pain can be expected from several days to several weeks and rarely several months. There is a rare risk of permanent injury to nerve tissue with weakness or loss of sensation.  There is also a rare risk of complication from anesthesia used to make you feel more comfortable during the procedure.

As with any procedure, there is a risk of significant complications. The most common side effects from the nerve root block can include (but are not limited to):

  • Allergic reactions to medications
  • Infection (occurs in less than 1 per 15,000 injections)
  • Post-injection flare (nerve root irritation with pain several hours after treatment, which may last days or weeks)
  • Depigmentation (a whitening of the skin)
  • Local fat atrophy (thinning of the skin)
  • Destruction of a motor or sensory nerve in the path of the needle
  • Bleeding, nerve injury, organ injury and death are rare but possible

 

 

Sacroiliac joint injection (SIJI)


Low Back Pain (LBP) is often difficult to diagnose because the symptoms overlap considerably with a variety of disorders of the lumbar spine and hip, often causing overlapping symptomology.  Low back pain of sacroiliac (SI) joint origin is a difficult clinical diagnosis and often one of exclusion. Patients usually have pain over the buttock that may extend to the lateral aspect of the hip and thigh. Pain arising from the SI joint may mimic pain originating from the lumbar disk, lumbar facet, or hip joint. Injection of local anesthetic or contrast material is a useful diagnostic test to determine if the SI joint is the pain source; intraarticular injection of corticosteroids may allow long-term pain relief in affected joints.

A sacroiliac joint injection (SIJI) serves several purposes. First, by placing numbing medicine into the joint, the amount of immediate pain relief you experience will help confirm or deny the joint as a source of your pain. Additionally, the temporary relief of the numbing medicine may better allow a chiropractor or physical therapist to treat that joint. Also, time-release cortisone (steroid) will help to reduce any inflammation that you may have within your joint(s).

The SIJI delivers a low volume of concentrated medication directly into the suspected joint space.

 

 

The SIJI is both diagnostic as well as a therapeutic procedure. In other words, if we inject a medication within the suspected joint space and the pain improves, we are fairly confident that this joint is responsible for the pain; conversely, if we inject a medication and the pain is no better, this implies that this joint is likely not responsible for the pain.  In addition the injection contains a potent steroid, which turns off the inflammatory process, which is causing pain from the joint.

 

What are sacroiliac joints?

The sacroiliac joint is a large joint in the region of your low back and buttocks where your pelvis actually joins with the spine. There is a joint on both the right and left side of your spine. If the joints become painful they may cause pain in your low back, buttocks, abdomen, groin or legs.

Other joints in your body are pivot points that allow movement. Unlike any other joint in your body, the sacroiliac joint is actually fused together by ligaments, and doesn’t move.

Cut away view of sacroiliac joints

 

Like any other joint in the body, can become diseased, and thereby become painful.  Arthritis is probably the most common cause of SI joint pain. Arthritis is a degenerative, inflammatory condition that over time results in loss of joint cartilage, bone overgrowth (‘osteophytes’ or ‘spurs’), erosions of the joint, and ultimately instability of the joint itself may occur in this joint.

 

Injecting the joint is done at an angle and requires imaging

 

The sacroiliac joints and their surrounding tissues are lined with nerves. As this degenerative, inflammatory condition progresses, the nerve endings become irritated and inflamed; this produces the sensation of pain. Any and all of this degenerative process may be painful.

The primary role for imaging studies prior to the procedure is that while arthritis is probably the most common cause for sacroiliac joint pain, other rare conditions need to also be considered, and imaging helps to evaluate for this.

 

What is sacroiliac joint pain?

Pain arising from the sacroiliac joints is often difficult to accurately diagnose

SI join pain may be unilateral or bilateral, and may include the following:

  • Groin pain
  • Sitting intolerance (can stay seated for only short periods of time)
  • Referred numbness, burning or tingling in the buttock or lower extremity
  • No associated radiculopathy
Typical pain pattern for sacroiliac joint

 

 

Who benefits from SIJI?

Patients who have chronic low back pain without radicular symptoms are candidates for SIJI.

Routine imaging prior to this procedure includes plain film X-RAYs, but may include CT and/or MRI scanning.  Neurodiagnostic testing such as EMG maybe necessary as well.

 

How is the SIJI done?

The procedure is explained to the patient, questions are answered and informed consent is obtained.

The patient is placed prone (stomach down) on the fluoroscopic table or CT scanner and the lower back is sterilely cleansed with povidone-iodine (Betadine) and alcohol.

The exact level is then located, and the skin overlying this area is anesthetized (numbed) with lidocaine.

A needle is sterilely advanced into the lower ½ of the SI joint.

Typically, as small amount of water-soluble contrast (dye) is injected to confirm proper needle tip position.

Once this is confirmed, a mixture of anesthetic (lidocaine or bupivacaine) and anti-inflammatory medication (steroid) is injected.

The needle is slowly withdrawn

This procedure may be performed with either CT or fluoroscopic guidance, but is most often done with fluoroscopic guidance. The SIJI should NOT be done without guidance imaging, as it is merely a trigger point unless needle tip in the joint can be confirmed.

Joint injection with arthrogram

 

What will happen after the procedure?

Immediately after the procedure, you will get up and walk around and try to imitate something that would normally bring about your usual pain. We ask that you to remain at the Clinic until you feel are ready to leave.  You will then report the percentage of pain relief and record the relief you experience during the next week.

You may not be able to drive the day of your procedure. Your legs may feel weak or numb for a few hours. You may be referred to a physical therapist immediately afterwards while the numbing medicine is still working. If the doctor prescribes physical therapy, it is very important that you continue with the physical therapy program.

Although you may feel much better immediately after the injection (due to the numbing medicine), there is a possibility your pain may return within a few hours. It may take a few days for the steroid medication to start working.

You may experience some weakness and/or numbness in your legs a few hours after the procedure. If so, do not engage in any activities that require lifting, balance and coordination.

Drink plenty of clear liquids after the procedure to help remove the dye from the kidneys.

 

General Pre/Post Instructions:

You should eat a light meal within a few hours before your procedure. If you are an insulin dependent diabetic, do not change your normal eating pattern prior to the procedure. Please take your routine medications (i.e. high blood pressure and diabetic medications).  Do not take pain medications or anti-inflammatory medications the day of your procedure. You need to be hurting prior to this procedure. Please do not take any medications that may give you pain relief. These medications can be restarted after the procedure if they are needed. If you are on Coumadin, Heparin, Plavix or any other blood thinners (including Aspirin), or the diabetic medication Glucophage you must notify this office so the timing of these medications can be explained. You will either be at our clinic facility for approximately 1-3 hours for your procedure. You may need to bring a driver with you. You may return to your normal activities the day after the procedure, including returning to work.

 

Risks of joint injection?

Increased localized back pain and/or leg pain can be expected from several days to several weeks and rarely several months. Destabilization of the sacroiliac joint is a risk and post injection training to strengthen the paraspinous and iliopsoas muscles can reduce this possibility.  There is a rare risk of permanent injury to nerve tissue with weakness or loss of sensation.  There is also a rare risk of complication from anesthesia used to make you feel more comfortable during the procedure.

As with any procedure, there is a risk of significant complications. The most common side effects from the SIJI include (but are not limited to):

  • Allergic reactions to medications
  • Infection (occurs in less than 1 per 15,000 injections)
  • Post-injection flare (joint swelling and pain several hours after treatment, which may last days or weeks)
  • Depigmentation (a whitening of the skin)
  • Local fat atrophy (thinning of the skin)
  • Destruction of a motor or sensory nerve in the path of the needle
  • Bleeding, nerve injury, organ injury and death are rare but possible

 

 

 

 

Facet Joint Injection (zygapophyseal joint injection)

What are facet joints and why are facet joint injections helpful?

The spine is designed to bend and turn. Along with the intervertebral discs, facet joints (also referred to as Z joints or zygapophyseal joints) enable the spine to bend and twist. Each vertebra has two sets of facet joints. One set of facet joints is located at the top and a corresponding set is at the bottom.

Facets joint are small joints a little larger than the size of your thumbnails located in pairs on the back of your spine. They provide stability and guide motion in your back. If the joints become painful they may cause pain in your neck, shoulder, low back, abdomen, buttocks, groin or legs.   The pattern and location of pain helps to determine the likely facet joints involved.

 

Working like a hinge, the articulating surfaces of each facet joint are coated with smooth cartilage allowing friction free movement. Although the facet joint bones fit snugly together, there is a lubrication system. The lubricating ‘oil’ is called synovial fluid and resembles uncooked egg whites. This fluid also nourishes the cartilage tissues.

A block that is performed to confirm that a facet joint is the source of pain and decrease pain and inflammation in a facet joint or joints.

 

I. Introduction

 

  • The Facet Joint injection (FJI) procedure targets the facet joint thought to be responsible for a patient’s back pain. The joint is injected and anesthetized with the intent of relieving this pain.
  • The facet injection procedure delivers a low volume of concentrated medication directly into the affected joint.
  • Back Pain is often multifactorial and difficult to diagnose because the symptoms overlap considerably with those of other degenerative disorders of the spine.
  • The FJI is useful in both the diagnosis and the treatment of back pain; therefore, it is both a diagnostic as well as a therapeutic procedure. In other words, if we inject a medication within the suspected joint space and the pain improves, we are fairly confident that this joint is responsible for the pain; conversely, if we inject a medication and the pain is no better, this implies that this joint is likely not responsible for the pain.

 

II. The Facet Joints

 

  • The Facet Joints are the joints of the spine (cervical, thoracic, and lumbar). They contain joint fluid and are lined by cartilage. There are two facet joints at each level of the spine, one on the right and one on the left.
  • The function of the facet joints of the spine is to allow movement (flexion, extension, bending side-to-side) and rotation.
  • Like any other joint in the body, facet joints can become diseased, and thereby become painful.
  • By far the most common disease affecting the facet joints is arthritis. This is a degenerative, inflammatory condition that over time results in loss of joint cartilage, bone overgrowth (‘osteophytes’ or ‘spurs’), erosions of the joint, and ultimately instability of the joint itself.  Facet joints are also damaged by trauma, and frequently are the source of pain after whiplash type injuries.  Facet injury can also occur with disc height loss, in front of the disc.
  • The facet joints and their surrounding tissues are lined with nerves. As this degenerative, inflammatory condition progresses, the nerve endings become irritated and inflamed; this produces the sensation of pain. Any and all of this degenerative process may be painful.
  • The primary role for imaging studies prior to the procedure is to evaluate for other possible causes of back pain.

 

 

III. Facetogenic Pain (‘Facet Syndrome’)

 

Just as imaging studies demonstrate typical patterns of facet joint degeneration, patients with facetogenic pain often have a typical history and physical examination suggestive of this disease. This is sometimes referred to as “Facet Syndrome”.

The exact definition and what constitutes the ‘Facet Syndrome’ is somewhat controversial, but includes the following:

 

Cervical

  • Unilateral or bilateral neck pain
  • Decreased range of motion
  • Tenderness over the affected facet joint(s)
  • Headaches
  • ‘Referred’ pain, or pain which is referred to other areas, such as the shoulder, or upper arm

Lumbar

  • Unilateral or bilateral low back pain, often worsened by rest in any position
  • Deep pain which may radiate to the hip, thigh and upper leg
  • Pain worsened by twisting or rotation, and exacerbated by moving from sitting to standing
  • Improvement of pain by standing, walking, or repeated activity
  • Morning stiffness
  • Pain directly over involved facet joint

 

 

IV. Patient Selection

 

  • Oftentimes more than one facet joint is inflamed or degenerated. In addition, there are other factors, which may be contributing to a patient’s back pain, including disc disease, referred pain, as well as psychological factors. This can make the exact site and level responsible for the facet pain more challenging to localize and diagnose.
  • Unfortunately, while imaging studies (X-RAYs, MRI and CT scans) are helpful in screening the spine for potential causes of back pain, they are often unreliable in determining whether or not a given facet joint may be the source of pain.
  • They help in identifying and characterizing the extent of facet degeneration, but like any other joint in the body, the extent of degeneration doesn’t necessarily correlate with the amount of pain. In other words, some patients may show severely degenerated facet joints on imaging studies, but be relatively asymptomatic.
  • Conversely, some patients experiencing severe pain from the facet joints (facetogenic pain) may show relatively mild degenerative findings on imaging studies. For this reason, the patient’s history and physical exam are very important in helping to clarify the source and level responsible for pain.

 

 

V. Procedure: Lumbar, Thoracic or Cervical Facet Joint Injection

 

What will happen to me during the procedure?

The procedure is explained to the patient, questions are answered and informed consent is obtained.

 

You will be placed on the x-ray table on your stomach in such a way that your doctor can best visualize these joints in your back using x-ray guidance. The skin on your back will be scrubbed using a sterile scrub (soap). Next, the physician will numb a small area of skin with numbing medicine. This medicine stings for several seconds.

 

After the numbing medicine has been given time to be effective, your doctor will direct a very small needle using x-ray guidance into the joint. A small amount of contrast (dye) is then injected to insure proper needle position inside the joint space. Then, a small mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) will be injected.

 

One or several joints may be injected depending on the location of your usual pain.

 

 

What will happen after the procedure?

Immediately after the procedure, you will get up and walk and try to imitate something that would normally bring about your usual pain. You will then report the percentage of pain relief and record the relief you experience during the next week.

 

You should not drive the day of the procedure. Your legs may feel weak or numb for a few hours.

 

General Pre/Post Instructions

  • You should eat a light meal within a few hours before your procedure. If you are an insulin dependent diabetic, do not change your normal eating pattern prior to the procedure. Please take your routine medications (i.e. high blood pressure and diabetic medications).
  • Do not take pain medications or anti-inflammatory medications the day the day of your procedure. You need to be hurting prior to this procedure. Please do not take any medications that may give you pain relief or lessen your usual pain. These medications can be restarted after the procedure if they are needed.
  • If you are on Coumadin, Heparin, Plavix or any other blood thinners (including Aspirin), or the diabetic medication Glucophage you must notify this office so the timing of these medications can be explained. You will be at the clinic for approximately 1-3 hours for your procedure.
  • You will need to bring a driver with you. You may return to your normal activities the day after the procedure, including returning to work.

 

 

What if I don’t get any relief from the facet joint injections?

If you don’t get relief from the facet joint injections, it is unlikely that this is a source of your pain.  You should then consider with your physician the other possible sources of your pain.  This may include other diagnostic blocks or imaging studies.

 

What happens if I get relief from the injection, but my pain comes back after a few hours or days?

This is the most common scenario with facetogenic pain.  Typically the local anesthetic wears off over the next six hours and the pain may return.   After a series of successful diagnostic facet blocks, the next step is usually to proceed with a Radiofrequency Neurolysis (RF).

 

Potential Risks of  Joint Injections

 

As with any procedure, there is a risk of significant complications. The most common side effects from the joint injection include (but are not limited to):

 

  • Allergic reactions to medication or dye used
  • Infection (occurs in less than 1 per 15,000 injections)
  • Post-injection flare (joint swelling and pain several hours after the corticosteroid injection)
  • Depigmentation (a whitening of the skin)
  • Local fat atrophy (thinning of the skin)
  • Rupture of a tendon or capsule located in the path of the injection
  • Bleeding, nerve injury, organ injury and death are rare but possible

 

 

 

Hip Joint Injection

The hip joint is a large joint where the leg joins the pelvis, functioning as a ball and socket joint. The top of the thigh bone (the femur) is a round ball, which fits into the socket formed by a cavity in the pelvic bone. The ball is held in the socket by a grouping of ligaments that form a capsule around the joint. This capsule of ligaments contains a lubricating synovial fluid and cartilage, which allows the two bones to move against each other with minimal friction.

 

Bones of the lower extremity

 

 

If this joint experiences arthritis, injury or mechanical stress, one may experience hip, buttock, leg or low back pain. A hip joint injection may be considered for patients with these symptoms, which can help relieve the pain as well as help diagnose the direct cause of pain by injecting medicine directly into the joint. These injections can help diagnose the source of pain, as well as alleviate the discomfort:

Hip Joint Injections

I. Introduction

The Hip Joint injection procedure targets the hip joint thought to be responsible for a patient’s pain. The joint is injected and anesthetized with the intent of relieving this pain. The hip injection procedure delivers a low volume of concentrated medication directly into the affected hip joint. Hip pain usually arises from a degenerated or osteoarthritic hip. However, occasionally it can be “referred” pain, meaning that the patient feels the pain in the hip, but it is actually coming from the lumbar spine, and less commonly from the knee on the same side.

 

The hip joint injection is useful in both the diagnosis and the treatment of hip pain; therefore, it is both a diagnostic as well as a therapeutic procedure. In other words, if we inject a medication within the suspected hip joint space and the pain improves, we are fairly confident that the hip joint is responsible for the pain; conversely, if we inject a medication and the pain is no better, this implies that the pain is likely referred, most often from the lower back or the knee.

 

Frequently a dye is injected in order to evaluate the appearance of the joint and verify positioning of the injected medications.

 

II. The Hip Joints

 

The Hip Joints contain joint fluid and are lined by cartilage.

Like any other joint in the body, hip joints can become diseased, and thereby become painful.

By far the most common disease affecting the hip joints is arthritis. This is a degenerative, inflammatory condition that over time results in loss of joint cartilage, bone overgrowth (‘osteophytes’ or ‘spurs’), erosions of the joint, and ultimately instability of the joint itself.

The hip joints and their surrounding tissues are lined with nerves. As this degenerative, inflammatory condition progresses, the nerve endings become irritated and inflamed; this produces the sensation of pain. Any and all of this degenerative process may be painful.

The primary role for imaging studies prior to the procedure is to evaluate for other arthritis, or other less likely causes of back pain.

III. Patient Selection

 

Unfortunately, while imaging studies (X-rays, MRI and CT scans) are helpful in screening the hips for a potential cause of pain, but are often unreliable in determining whether or not a given hip joint may be the source of pain.

They help in identifying and characterizing the extent of hip degeneration, but like any other joint in the body, the extent of degeneration doesn’t necessarily correlate with the amount of pain. In other words, some patients may show severely degenerated hip joints on imaging studies, but be relatively asymptomatic. Conversely, some patients experiencing severe pain from the hip joints may show relatively mild degenerative findings on imaging studies. For this reason, the patient’s history and physical exam are very important in helping to clarify the source responsible for pain.

 

IV. Procedure: Hip Join Injection

 

The procedure is explained to the patient, questions are answered and informed consent is obtained. The patient is placed on the fluoroscopic table, and the symptomatic hip is sterilely cleansed with povidone-iodine (Betadine) and alcohol.

The exact level is located with the fluoroscope, and the skin overlying this area is anesthetized (numbed) with lidocaine.  A needle is sterilely advanced into the hip joint.  A small amount of water-soluble contrast (dye) is injected to confirm proper needle tip position.  Once this is confirmed, a mixture of anesthetic (lidocaine or bupivacaine) and anti-inflammatory medication (steroid) is injected. The needle is slowly withdrawn.  This procedure is performed with Fluoroscopic (X-RAY) guidance.

 

The injection itself only takes a few minutes, but the overall procedure will usually take between thirty and sixty minutes. After the hip joint injection procedure, the patient typically remains resting on the table for twenty to thirty minutes, and then is asked to move the area of usual discomfort to try to provoke the usual pain. Patients may or may not obtain pain relief in the first few hours after the injection, depending upon whether or not the joint that was injected is the main source of the patient’s pain. On occasion, the patient may feel numb or experience a slightly weak or odd feeling in the leg for a few hours after the injection.

 

Shortly after the procedure, the interventional pain physician will examine the patient to determine if there has been improvement.

 

 

Some individuals may have pain that mimics pain from the hip joint but is actually coming from bursitis adjacent to the hip.

Trochanteric bursitis

 

The trochanteric bursa is located over the prominent bone on the side of the hip. Women and middle-aged to older people are more often affected by this type of bursitis. It may occur spontaneously without specific injury. Also, walking abnormally due to arthritis in the hip, knee, ankle, foot, or back can cause it. Symptoms include pain gradually occurring over the side of the hip (and sometimes traveling down the thigh); pain when sleeping on the side affected by bursitis, rising from a deep chair, sitting in a car, or climbing stairs; and occasionally, pain when walking.

 

Ischial bursitis

 

The ischial bursa is located below the bone in your buttock called the ischium. Inflammation may occur as a result of injury or prolonged sitting on hard surfaces. Symptoms include pain when sitting or lying down on the buttocks and pain that travels to the back of the thigh. Ischial bursitis is also called “weaver’s bottom” or “tailor’s seat.”

 

 

Potential Risks of Hip Joint Injections

As with any procedure, there is a risk of significant complications. The most common side effects from the hip joint or bursa injection include (but are not limited to):

  • Allergic reactions to medication or dye used
  • Infection (occurs in less than 1 per 15,000 injections)
  • Post-injection flare (joint swelling and pain several hours after the corticosteroid injection)
  • Depigmentation (a whitening of the skin)
  • Local fat atrophy (thinning of the skin)
  • Rupture of a tendon located in the path of the injection
  • Bleeding, nerve injury, organ injury and death are rare but possible