Axial Pain - Padda Institute Center for Interventional Pain Management

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.

 

Opioids: use and misuse in chronic pain management

Opioids have been historically used for pain for thousands of years, but opioid therapy for chronic non-cancer pain remains controversial, despite the fact that opioids are one of the most commonly prescribed medications in the United States.  The prevalence of chronic pain in the adult population averages a median point prevalence rate of 15%, but some studies suggest rates of nearly 40%.  Prevalence rates are higher in the elderly, those suffering significant physically traumatic injuries, or malignancy.  Pain is often associated with severe functional limitations and difficulty in performing daily life activities.  Pain disables more people than heart disease and cancer combined, carrying a significant societal cost.

Papaver somniferum (opium poppy), is the species of plant from which opium and poppy seeds are extracted. Opium is the source of many opiates, including morphine, thebaine, codeine, papaverine, and noscapine.

 

 

Although pain is difficult to measure directly in individual patient, as it is considered a “subjective” symptom, its effects are abundantly clear in the suffering individual and their immediate caregivers, reducing individual and caregiver socioeconomic status. Reduced earnings are evident in not only the individual with pain, but their immediate associated caregivers by at least one quartile, which is reversed upon adequate relief of pain and return to function of the individual.

 

Judicious use of opioids in selected patients with chronic non-cancer pain who have not responded to other treatments and analgesic medications is considered acceptable, but remains controversial due to concerns regarding the long-term effectiveness, safety, risk of tolerance, dependence, and abuse.  Keep in mind that the efficacy of opioids for chronic non-cancer pain has been demonstrated in only short-term trials, including those for neuropathic pain, but the evidence is limited for long term chronic non-cancer pain.

 

Regulatory concerns by prescribers are neither inconsequential nor unfounded, due to the unprecedented diversion rates by unscrupulous “patients,” with up to 30% of patients diverting some or all of their medication for direct economic gain or for recreational abuse.  Simultaneously, empowered patients rightfully demand relief from suffering while regulatory bodies rightfully attempt to limit improper prescribing as a significant public health and policy concern.  Sophisticated illegitimate patients also leverage physician prescribing by threatening regulatory reporting for under prescribing or by fabricating physician quality of care concerns.

Legitimate prescribers often feel caught between the needs of patient’s presenting with subjective complaints, and their fear of improper prescribing to unscrupulous sophisticated “patients.”

Further muddying the waters, some individuals truly legitimate in their need for opioid analgesia, undergo neuroplastic changes in the peripheral and central nervous system (CNS) leading to a sensitization of pronociceptive pathways, resulting in a opioid-induced hyperalgesia (OIH).  The condition is characterized by a paradoxical response, whereby a patient receiving opioids for the treatment of pain could actually become more sensitive to stimuli, resulting in a reduction in the opioid’s treatment effect in the absence of disease progression, often mimicking the neurobehavioral effects of addiction.  Escalating doses in chronic opioid therapy might cause OIH by inducing a vicious cycle of increasing dosage and anxiety for both the physician and patient.  Referral to a qualified interventional pain clinic for multimodal therapy to minimize opioid utilization is strongly encouraged for patient’s with suspected OIH, reducing both physician anxiety and improving patient care.

Safely navigating a course of care in these treacherous waters poses a difficult challenge to the prescriber, sworn to relieve suffering of the individual but cognizant of the unintended consequences to society and to self for inadvertent improper prescribing.

Although many of these challenging patients can be managed in a primary setting, the necessity for close monitoring for therapeutic use, overuse, abuse, and diversion of controlled substances is an absolute necessity and requires specific unwavering treatment protocols, which will result in occasional patient dissatisfaction, sometimes quite vocal. These protocols must include a methodology to monitor consumption against prescription dispensation, with an accurate cost effective biological validation, such as a qualitative in-office urine drug screen cross validated by a more sensitive quantitative laboratory analysis.  These protocols must also minimize the use of opioids overall, using adjuvant therapies which should include interventional, behavioral, non-opioid pharmaceutical, or physical therapy options.

Most importantly, a clearly defined prescriber exit strategy should exist when utilizing opioids to treat chronic pain because of the potential complications in managing these patients such as opioid dependence, addiction, and abuse.

 

Vertebroplasty for compression fractures.

Bed rest and strong pain medicine are no longer the only treatments for back pain caused by compression fractures of the spine. Now there is a breakthrough minimally invasive medical procedure called percutaneous vertebroplasty that uses bone cement to fill in the spaces of a broken or crushed vertebra.

 

Vertebroplasty is a pain treatment for vertebral compression fractures that fail to respond to conventional medical therapy, such as minimal or no pain relief with analgesics or narcotic doses that are intolerable.  Vertebroplasty stabilizes the collapsed vertebra with the injection of medical-grade bone cement into the spine. This reduces pain, and can prevent further collapse of the vertebra, thereby preventing the height loss and spine curvature commonly seen as a result of osteoporosis. Vertebroplasty dramatically improves back pain within hours of the procedure, provides long-term pain relief and has a low complication rate, as demonstrated in multiple studies.

Percutaneous vertebroplasty strengthens the treated vertebra and gives pain relief in most patients. The term “percutaneous” means injecting a fluid through a needle. “Plasty” means to mold or form. Thus, vertebroplasty helps mold the vertebrae by injecting a fluid into the bone. In this case, the doctor injects a bone cement mixture of polymethylmethacrylate (the same cement used in joint replacement surgery), barium or tantalum powder (makes the cement visible on X-ray), an antibiotic, and a solvent into the vertebral body.  The cement hardens within 15 minutes and stabilizes the fracture, like an internal cast.

 

Vertebrae are bones that form a flexible column to protect the spinal cord. A compression fracture occurs when a vertebra breaks or is crushed. When this happens, a person can feel extreme pain that may last a lifetime. Often the pain keeps the person from performing normal activities. Certain cancers, benign tumors, or osteoporosis of the spine can cause compression fractures.

 

Osteoporosis, the most common form of compression fractures, is the loss of bone mass.   Osteoporosis is the most common cause of vertebral compression fractures in the United States. The National Osteoporosis Foundation (NOF) estimates that over 50 million Americans over the age of 50 currently have osteoporosis or low bone mass with serious risk of osteoporosis.  A large portion of this population will suffer debilitating pain caused by vertebral compression fractures. It is most often found in women after menopause, and can also be caused by certain medications or diseases. Osteoporosis is the most common form of compression fractures.  Nearly all vertebral fractures in otherwise healthy people are due to osteoporosis, and can occur from a minor impact, such as a bump or a fall, in those who suffer from this bone-weakening disease. People who have a spinal fracture often don’t realize that they may have osteoporosis, because the disease is asymptomatic until a fracture occurs.  Many patients with compression fractures caused by Osteoporosis can be helped with this procedure.

 

 

[box type=”info”] Factors that increase the likelihood of developing osteoporosis include:

  • Being female
  • Being thin or having a small frame
  • Advanced age
  • A family history of osteoporosis
  • Being past menopause
  • Abnormal absence of menstrual periods
  • Anorexia or bulimia
  • A diet low in calcium
  • Long-term use of medications such as corticosteroids or anticonvulsants
  • Lack of exercise
  • Smoking
  • Excessive use of alcohol

[/box]

Bone tumors and metastatic bone disease also lead to vertebral compression fractures. Diseases such as multiple myeloma and hemangioma (types of tumors) place patients at great risk for these painful fractures. High doses of steroids for the control of auto-immune diseases such as lupus and rheumatoid arthritis, as well as asthma or chronic pulmonary disease can also increase the risk of reduced bone mass and resulting fractures.

 

Percutaneous vertebroplasty may be done either as an inpatient or outpatient procedure, depending upon the severity of the fracture and the health of the patient.  After suitable sedation is given, a needle is placed into the affected vertebra and fills the damaged area with bone cement.

 

 

The bone cement is a plastic paste, similar to glue used to hold artificial joints in place. The cement holds the fragile bones in place making the vertebra stronger. A special imaging machine that allows the pain doctor to see the exact placement of the needle throughout the procedure. It also shows the cement as it fills the vertebra.

In many patients, the pain is lessened or even gone within 24 hours. There are few side effects or problems. In some cases, increased pain and fever may occur for a short time. This is treated with anti-inflammatory drugs.

 

Other risks to the patient include infection and allergic reactions to x-ray dye or other medications. There is a very small risk that the cement could leak into areas outside of the vertebra at the time of the procedure, causing spinal cord or nerve damage. If leakage occurs, surgery could be required and the patient could have permanent nerve and organ injury.

 

Pre-Operative Preparation

For proper and thorough treatment, review your current medical history with your physician.  Your physician may ask you to modify your current medication schedule.  Be sure to tell your physician if you are taking blood thinners or have a history of a bleeding disorder, or if you are allergic to any medications, or if you have an infection in any part of your body

 

Rest well the night before the procedure.  It is routine for patients undergoing outpatient surgery to be asked not to eat the night before the procedure. Due to the sedative medications given during the procedure, you will probably be asked to arrange to have someone drive you to and from the medical facility.

 

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 clinic facility or hospital for approximately 2-3 hours for your procedure. You will need to bring a driver with you.

 

During the Procedure

It is standard procedure to have an IV needle placed in your arm, and to be given a light sedative. After you are in position on the operating table, your back will be numbed with a local anesthetic.  Under x-ray guidance, your physician will place an access needle into your vertebral body. You may experience mild discomfort during this part of the procedure.  When the cement is injected you will have recreation of your regular back pain.

 

After the procedure

You must lay flat after the procedure. You will need to follow-up in the clinic after five to ten days.

 

Keep the area clean and dry to help prevent skin infection. Do not do any heavy lifting for 3 months (i.e. nothing heavier than a carton of milk). After that, you can gradually increase your lifting to normal. Walking is encouraged and you can bend within the restrictions of your brace.

 

You may experience some muscle discomfort where the needles were placed. This may be treated with a mild pain reliever such as Tylenol.  Do not drive for the remainder of the day. Please have an adult drive you home or accompany you in a taxi or other public transportation. Depending on how you feel, you may resume normal activities and return to work the next day.

 

Benefits: Immediate Relief from Pain, Improved Quality of Life

Following vertebroplasty, most patients (>90%) find a marked improvement in their pain, improved mobility and other quality of life improvements. Within a few days, many patients are able to reduce their pain medications significantly and return to the normal daily activities that had been inhibited by their painful vertebral compression fractures. Most patients report sustained pain relief, even years later.

 

What are the risks of Vertebroplasty?

The risks are minimal and in fact, few complications have been reported involving less than five percent of cases.   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
  • Cement leakage is possible.  The cement used in vertebroplasty is in a liquid form and is squeezed into the fractured vertebra under high pressure. Some of the cement commonly leaks out of the vertebra, but this usually doesn’t cause any problems. Only rarely does a cement leak cause pressure on the spinal cord or nearby nerves. In these cases, surgery may be required to remove the pressure.
  • Ongoing pain may occur. Many patients get nearly complete relief of symptoms from vertebroplasty. As with any procedure, however, you should expect some pain afterward. If the pain continues or becomes unbearable, talk to your doctor about treatments that can help control your pain.

 

 

 

 

 

 

 

Electrodiagnostics EMG NCS (dermatomes and myotomes)

 

Electrodiagnostics (EDX) testing is used to evaluate the integrity and function of the peripheral nervous system (most cranial nerves, spinal roots, plexi, and nerves), NMJ, muscles, and the central nervous system (brain and spinal cord). EDX testing is performed as part of an EDX consultation for diagnosis or as follow-up of an existing condition. EDX studies can provide information to:

 

 

 

 

  • Identify normal and abnormal nerve, muscle, motor or sensory neuron, and NMJ functioning.
  • Localize region(s) of abnormal function.
  • Define the type of abnormal function.
  • Determine the distribution of abnormalities.
  • Determine the severity of abnormalities.
  • Estimate the date of a specific nerve injury.
  • Estimate the duration of the disease.
  • Determine the progression of abnormalities or of recovery from abnormal function.
  • Aid in diagnosis and prognosis of disease.
  • Aid in selecting treatment options.
  • Assists in following response to treatment by providing objective evidence of change in neuromuscular function.
  • Localize correct locations for injection of intramuscular agents (e.g., botulinum toxin).

 

Electromyography (EMG) is a technique for evaluating and recording the electrical activity produced by skeletal muscles.  An EMG detects the electrical potential generated by muscle cells when electrically or neurologically activated.  Often, EMG testing is performed with another test that measures the conducting function of nerves, called a nerve conduction study (NCS). These electrodiagnostics tests (EMG and NCS) are often performed at the same office visit and by the same personnel, the risks and procedures generally apply to both tests.

 

In some medical conditions the electrical activity of the muscles or nerves is not normal. Finding and describing these electrical properties in the muscle or nerve may help diagnose your condition.  EDX may aid with the diagnosis of nerve compression or injury (such as carpal tunnel syndrome), nerve root injury (such as sciatica), and with other problems of the muscles or nerves. Less common medical conditions include amyotrophic lateral sclerosis, myasthenia gravis, and muscular dystrophy.  EMG is most often used when people have symptoms of weakness, and examination shows impaired muscle strength. It can help to tell the difference between muscle weakness caused by injury of a nerve attached to a muscle and weakness due to neurologic disorders.

Dorsal (back) of spinal cord transmits sensory information from sensory units to brain, Ventral (front) of cord transmits motor information from brain to muscle
Needle electrode stimulation allows evaluation of nerve to muscle function

 

Electrical impulses are recorded for detailed analysis after the EMG test is completed.

 

 

Risks

People usually have a small amount of discomfort during EMG testing because of pin insertion. Disposable needles are used so there is no risk of infection.

 

During nerve conduction studies, small electrodes are taped to the skin or placed around fingers. You typically experience a brief and mild shock, which may be a bit unpleasant. Most people find it only slightly annoying.

 

It is very important to note that most EMG/NCV tests are not 100% accurate. Most physicians will admit that the tests have at least a 10% margin of error. Very often individuals with nerve damage will have normal EMG/NCV tests even though they are experiencing nerve damage.

 

During the Procedure

During EMG, small pins or needles are inserted into muscles to measure electrical activity. The needles are different than needles used for injection of medications. They are small and solid, not hollow like hypodermic needles. Because no medication is injected, discomfort is much less than with shots.

 

You will be asked to contract your muscles by moving a small amount during the testing.

 

With nerve conduction studies, small electrodes will be taped to your skin or placed around your fingers. You typically will experience a mild and brief tingling or shock, which may be a bit unpleasant.

 

The person who administers the test will explain the procedure. Often muscle activity is monitored through a speaker during the test, which may make a popping or soft roaring noise. The EMG technician will be looking at an oscilloscope, which looks like a small TV set during the procedure.

 

How long does EDX take?

Testing may take 30-60 minutes. The nerve conduction part of the test usually takes longer than the needle exam because one needs to make calculations and measurements during it. On average, if one extremity is studied, the nerve conductions take anywhere between 15 and 30 minutes. The needle exam for one extremity usually takes 15 to 20 minutes. You can count on being in the examination room for about one hour if only one extremity is requested; longer if more extremities need to be tested.

Carpal Tunnel Syndrome

For suspected carpal tunnel syndrome (CTS), bilateral median motor and sensory NCSs are often indicated. The studies in the contralateral asymptomatic limb serve as controls in cases where values are borderline and may establish the presence of bilateral CTS, which is a frequent finding. Two to 4 additional sensory or mixed NCSs can be compared to the median sensory NCSs to increase the diagnostic sensitivity of the testing. The additional sensory NCSs and an additional motor NCS (usually ulnar) are indicated to exclude a generalized neuropathy or multiple mononeuropathies. If 2 sensitive sensory NCSs are performed to start, additional sensory testing on the same limb is rarely needed. For suspected bilateral CTS, bilateral median motor and sensory NCSs are indicated. Up to 2 additional motor and 2 additional sensory NCSs are often indicated. The extent of the needle EMG examination depends on the results of the NCSs and the differential diagnosis considered in the individual patient.

Delayed conduction due to entrapment syndromes such as carpal tunnel and tarsal tunnel are best evaluated with NCS. If atrophy of muscles occurs it will also be evident as denervation by EMG.

Additional testing may be indicated in patients with a differential diagnosis which includes peripheral neuropathy, cervical radiculopathy, brachial plexopathy, or more proximal median neuropathy.

 

Radiculopathy

A minimal evaluation for radiculopathy includes 1 motor and 1 sensory NCS and a needle EMG examination of the involved limb. However, the EDX testing can include up to 3 motor NCSs (in cases of an abnormal motor NCS, the same nerve in the contralateral limb and another motor nerve in the ipsilateral limb can be studied) and 2 sensory NCSs. Bilateral studies are often necessary to exclude a central disc herniation with bilateral radiculopathies or spinal stenosis or to differentiate between radiculopathy and plexopathy, polyneuropathy, or mononeuropathy. H reflexes and F waves can provide useful complementary information that is helpful in the evaluation of suspected radiculopathy and can add to the certainty of electrodiagnostic information supporting a diagnosis of root dysfunction.

 

 

Mononeuropathy and Polyneuropathy/ Mononeuropathy Multiplex

Mononeuropathy and polyneuropathy/mononeuropathy multiplex are entirely different conditions and must be considered separately. Mononeuropathy comprises focal lesions of a single peripheral nerve. Polyneuropathy comprises diseases in which there is a bilaterally symmetric disturbance of peripheral nerve functions. Mononeuropathy multiplex comprises multifocal isolated lesions of more than 1 peripheral nerve.

 

Mononeuropathy

To determine the level of the lesion in a focal mononeuropathy, and in order to exclude radiculopathy, plexopathy, or polyneuropathy, it may be necessary to study 3 motor and 3 sensory nerves including the clinically affected nerve, the same nerve on the contralateral side, and an unaffected ipsilateral nerve. F-wave studies provide additional diagnostic information. A needle EMG examination in the affected limb is indicated.

 

Polyneuropathy/MononeuropathyMultiplex

In order to characterize the nature of the polyneuropathy (axonal or demyelinating, diffuse or multifocal) and in order to exclude polyradiculopathy, plexopathy, neuronopathy, or multiple mononeuropathies, it may be necessary to study 4 motor and 4 sensory nerves, consisting of 2 motor and 2 sensory NCSs in 1 leg, 1 motor and 1 sensory NCS in the opposite leg, and 1 motor and 1 sensory NCS in 1 arm. H-reflex studies and F-wave studies from 2 nerves may provide additional diagnostic information. At least 2 limbs should be studied by a needle EMG examination. Studies of related paraspinal muscles are indicated to exclude some conditions such as polyradiculopathy.

 

Myopathy

To diagnose a myopathy, a needle EMG examination of 2 limbs is indicated. To help exclude other disorders such as polyneuropathy or neuronopathy, 2 motor and 2 sensory NCSs are indicated. Two repetitive motor nerve stimulation studies may be performed to exclude a disorder of neuromuscular transmission.

 

Motor Neuronopathy

In order to establish the diagnosis of motor neuronopathy (for example, amyotrophic lateral sclerosis [ALS or Lou Gehrig’s disease]) and to exclude other disorders in the differential diagnosis, such as multifocal motor neuropathy or polyneuropathy, up to 4 motor nerves and 2 sensory nerves may be studied. Needle EMG of up to 4 extremities (or 3 limbs and facial or tongue muscles) is often necessary to document widespread denervation and to exclude a myopathy. One repetitive motor nerve stimulation study may be indicated to exclude a disorder affecting neuromuscular transmission.

 

Plexopathy

To characterize a brachial plexopathy and to differentiate it from cervical radiculopathy and mononeuropathies, it is often necessary to study all major sensory and motor nerves that can be easily studied in both upper extremities (radial, median, ulnar, and medial and lateral antebrachial cutaneous sensory; radial, median, ulnar, and possibly axillary and musculocutaneous motor) and to perform a needle EMG examination in both upper extremities. To characterize the lumbosacral plexopathy and to differentiate it from lumbar radiculopathy and mononeuropathies, it is often necessary to study all major sensory and motor nerves that can be easily studied in both lower extremities (superficial peroneal and sural sensory; peroneal and posterior tibial motor) and to perform a needle EMG examination in both lower extremities. F-wave studies in the motor nerves and soleus H reflexes also provide useful information.

 

Neuromuscular Junction

To demonstrate and characterize abnormal neuromuscular transmission, repetitive nerve stimulation studies should be performed in up to 2 nerves and SFEMG in up to 2 muscles. If any of these are abnormal, up to 2 motor and 2 sensory NCSs may be performed to exclude neuropathies that can be associated with abnormal neuromuscular transmission. At least 1 motor and 1 sensory NCS should be performed in a clinically involved limb, preferably in the distribution of a nerve studied with repetitive stimulation or SFEMG. At least 1 distal and 1 proximal muscle should be studied by a needle EMG examination to exclude a neuropathy or myopathy that can be associated with abnormal repetitive stimulation studies or SFEMG. At least 1 of the muscles should be clinically involved and both muscles should be in clinically involved limbs.

 

Timing of Testing After an Injury

In combination, NCSs and a needle EMG examination may be most helpful when performed several weeks after the injury has occurred. However, NCSs are often useful acutely after nerve injury, for example, if there is concern that a nerve has been severed. In fact, if studies are delayed, the opportunity to precisely identify the region of injury or to intervene may be lost. In some cases, even needle EMG testing performed immediately after a nerve injury may demonstrate abnormal motor unit action potential (MUAP) recruitment and/or provide baseline information that can be helpful to document preexisting conditions, date the injury, or serve as a baseline for comparison with later studies.

 

Because of the variability of different nerve injuries, a standard rule on the timing of EDX testing cannot easily be established and the AAEM does not have specific recommendations in this regard. In all instances, the AAEM encourages dialogue between physicians and payors and encourages the appropriate use of the physician’s clinical judgment in determining when studies are most appropriately performed and what studies should be conducted.

 

Frequency of Electrodiagnostic Testing in a Given Patient

There are many clinical situations where good medical management requires repeat testing, such as in the following examples:

 

  • Second diagnosis. Where a single diagnosis is made on the first visit, but the patient subsequently develops a new set of symptoms, further evaluation is required for a second diagnosis.
  • Inconclusive diagnosis. When a serious diagnosis (e.g., ALS) is suspected but the results of the needle EMG/NCS examination are insufficient to be conclusive, 1, or even more, follow-up studies are needed to establish or exclude the diagnosis.
  • Rapidly evolving disease. Initial EDX testing in some diseases may not show any abnormality (e.g., Guillain-Barré syndrome) in the first 1 to 2 weeks. An early diagnosis confirmed by repeat electrodiagnosis must be made quickly so that treatment can begin. Follow-up testing can be extremely useful in establishing prognosis and monitoring patient status.
  • Course of the disease. Certain treatable diseases such as polymyositis and myasthenia gravis follow a fluctuating course with variable response to treatment. The physician treating such patients needs to monitor the disease progress and the response to therapeutic interventions. The results of follow-up evaluations may be necessary to guide treatment decisions.
  • Unexpected course or change in course of the disease. In certain situations, management of a diagnosed condition may not yield expected results or new, questionably related problems may occur (e.g., failure to improve following surgery for radiculopathy). In these instances, reexamination is appropriate.
  • Recovery from injury. Repeat evaluations may be needed to monitor recovery, to help establish prognosis, and/or to determine the need for and timing of surgical intervention (e.g., traumatic nerve injury).

 

 

Repeat EDX consultation is therefore sometimes necessary and, when justifiable, should be reimbursed. Reasonable limits can be set concerning the frequency of repeat EDX testing per year in a given patient by a given EDX consultant for a given diagnosis. The following numbers of tests per 12-month period per diagnosis per physician are acceptable:

 

  • Two tests for carpal tunnel-unilateral, carpal tunnel-bilateral, radiculopathy, mononeuropathy, polyneuropathy, myopathy, and NMJ disorders.
  • Three tests for motor neuronopathy and plexopathy.

 

 

 

Spinal nerves have motor fibers and sensory fibers. The motor fibers innervate certain muscles, while the sensory fibers innervate certain areas of skin. A skin area innervated by the sensory fibers of a single nerve root is known as a dermatome. A group of muscles primarily innervated by the motor fibers of a single nerve root is known as a myotome. Although slight variations do exist, dermatome and myotome patterns of distribution are relatively consistent from person to person.

 

The ventral (anterior) gray matter of the spinal cord contains nerve cells that send axon fibers out, through the nerves, to their end points on the muscles that they activate. Sensory information from the body and arriving instructions from the brain all cause movement by giving instructions to these “motor neurons” in the spinal cord gray matter.

 

Spinal Cord Segmental Myotomes and Dermatomes

Sensory dermatomes in blue, motor myotomes in yeallow

 

 

Myotomes – Relationship between the spinal nerve & muscle and are best evaluated with EMG

Dermatomes – Relationship between the spinal nerve & skin and a combination of EMG and NCS is used to define pathology.

 

Myotomes

Each muscle in the body is supplied by a particular level or segment of the spinal cord and by its corresponding spinal nerve. The muscle, and its nerve make up a myotome. This is approximately the same for every person and are as follows:

Myotome muscle EMG

 

  • C3,4 and 5 supply the diaphragm (the large muscle between the chest and the belly that we use to breath).

 

  • C5 also supplies the shoulder muscles and the muscle that we use to bend our elbow

 

  • C6 is for bending the wrist back.

 

  • C7 is for straightening the elbow.

 

  • C8 bends the fingers.

 

  • T1 spreads the fingers.

 

  • T1 –T12 supplies the chest wall & abdominal muscles.

 

  • L2 bends the hip.

 

  • L3 straightens the knee.

 

  • L4 pulls the foot up.

 

  • L5 wiggles the toes.

 

  • S1 pulls the foot down.

 

  • S3,4 and 5 supply the bladder. bowel and sex organs and the anal and other pelvic muscles.

 

Spinal Cord Segmental Dermatomes

Dermatome is a Greek word which literally means “skin cutting”. A dermatome is an area of the skin supplied by nerve fibers originating from a single dorsal nerve root.  The dermatomes are named according to the spinal nerve which supplies them. The dermatomes form into bands around the trunk but in the limbs their organisation is more complex as a result of the dermatomes being “pulled out” as the limb buds form and develop into the limbs during embryological development.

 

In diagrams or maps, the boundaries of dermatomes are usually sharply defined. However, in life there is considerable overlap of innervation between adjacent dermatomes. Thus, if there is a loss of afferent nerve function by one spinal nerve sensation from the region of skin which it supplies is not usually completely lost as overlap from adjacent spinal nerves occurs: however, there will be a reduction in sensitivity.

Different parts of the spinal cord provide innervation to the body, organized as dermatomes.
Lumbar radiculopathy, commonly referred to as sciatica.
Neck injury can cause pain in the hands and arms, referred to as cervical radiculopathy.

 

 

 

 

 

 

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

 

 

 

 

Whiplash Injury (Nagging neck pain after an accident)

Following a car accident, your nagging neck pain may not be just “soft tissue.”  Neck pain is one of the most common chronic pain conditions in modern medicine and can lead to depression, sleep disturbance, and inability to work.  Even though there may be minimal damage to your car, you can still sustain significant whiplash.  In fact, even at low speeds, occupants can experience severe whiplash, the video above demonstrates whiplash injury with a 5 mph collision.

 

 

 

 

 

The rapid motion of the neck during a crash can result in a number of injuries, with the majority of these injuries involving “soft tissue”:

  • Muscles
  • Tendons
  • Ligaments
  • Nerves
  • Discs
  • Micro fractures
  • Facet subluxation
  • Hemorrhage or edema of the pariarticular tissues (facet joints)
Soft tissue ligaments involved in whiplash

The term “soft tissue” is frequently tossed around as if it is an insignificant injury; this could not be farther from reality, as even the brain, liver, and heart are soft tissue, and it doubtful you could survive long with any of these structures damaged.

Nerves involved in whiplash injury

Soft tissue injuries are difficult to see on x-rays or MRI, and frequently require a diagnostic interventional workup to define.  Soft tissue injuries can lead to significant permanent impairments, and should be treated in a timely and medically appropriate manner in order to mitigate long-term consequences.

 

Injuries to bony structures are less common, but are usually apparent on x-rays

  • Rim Lesions
  • Endplate avulsions
  • Tears of the anterior longitudinal ligament
  • Uncinate process
  • Articular subchondral fractures
  • Articular pillar
  • Articular processes

 

 

 

Whiplash affects the cervical vertebrae of the neck as well as the first few upper thoracic vertebrae, and is most commonly caused by car accidents when the force of a blow from the rear causes the head to whip backward and forward.  The most common facets to be injured are at C2/C3 and C5/C6, which frequently results in referred pain at the locations indicated. As a result of facet joint injury, whiplash patients frequently encounter, headaches, back and shoulder pain in addition to neck pain.

Referred pain from facet injury

This action can cause tears in the muscles, tendons or ligaments of the neck. It can also cause a nerve to become pinched between two vertebrae, resulting in pain or numbness that may radiate down to the shoulder, arm and hand.

 

The neck is a particularly vulnerable part of the spine because:

  • The head is a free floating weight attached to the fixed thorax like a pendulum
  • The neck has relatively little muscular support
  • During an accident the head is moved with tremendous force back and forth, concentrating the biomechanical forces to just a few cervicothoracic vertebral bodies and their limited support

 

 

When the neck is moved quickly and forcefully, it places tremendous strain on the facet joints of the spine — which are located at the rear of the spine. The facet joints normally allow the spine to move in a very flexible manner through flexion, extension and rotation.

 

Xray of facet joints, range of motion
Normal motion of cervical facets
Damage to facet with whiplash

 

Injured people with cervical facet syndrome usually present with severe posterior neck pain and muscle spasms. Outpatient to the neck produces pain over the cervical facets. The pain typically increases with extension of the neck with symptoms of pain overlying the cervical facet joints or regionally to the head, neck or shoulder region.

 

Unfortunately radiographic diagnoses of these injuries are very difficult. Cervical spine x-rays may reveal focal or diffuse cervical spondylosis or loss of normal lordosis, but will not reveal the facet injury itself. The medial branch of the dorsal ramus transmits the pain from inflamed facet joints. Stimulation of the facet nerves often results in referred pain.

 

 

Cervical facet blocks at the appropriate level are frequently necessary in the accurate diagnosis of cervical facet pain. The cervical facet block at the appropriate level usually brings immediate relief to the injured person, with pain relief lasting four to six hours after injection being diagnostic.  If successful diagnosis with facet blockade is made, then a more permanent solution may be radiofrequency neurolysis.

 

Low back pain with lumbar facet involvement can also be diagnosed similarly. However, lumbar facet joint injuries are far less likely to occur following an auto accident; because the lower back (lumbar spine) is generally supported and not subject to fast and extreme range of motion following a rear end car accident. This is different than the neck (cervical spine), which can only rely on a headrest for protection from these quick acceleration injuries (whiplash).

 

 

Facet Joint Radiofrequency (RF)

A patient with primary facet pain, proven with either one or more blocks, may be a candidate for a facet rhizotomy using radiofrequency (RF). The patients selected for rhizotomy are those who are not surgical candidates and who have failed other conservative measure.

By using the radiofrequency rhizotomy, the surgeon denervates the medial branch nerve which runs along the posterior spine near the facet joints.

Radiofrequency ablation or lesioning is a term used when radio waves are used to produce heat to destroy tissue, usually a nerve. It has been used for several years with great success in patients who have abnormally fast heartbeats. More recently, it is being used to destroy tumors. It is also a non-surgical option to treat your spine pain.

Spine pain is the second most frequent pain complaint. It occurs in 65 to 80 percent of the population at one time or another, and can be disabling and frightening. Its costs to society are great.

In the case of spinal pain, radiofrequency waves are transmitted through a needle placed into the facet joint under x-ray guidance. This procedure is also known as rhizotomy.

 

 

 

 

 

Radiofrequency (RF)

For chronic cases of facet joint syndrome, where the pain relief from the injections is short lived a procedure called Radiofrequency Rhizotomy or facet neurotomy or simply RF can be performed.  There are nerves that arise from the facet joints that carry the painful impulses to the brain. Heating these nerves by radiofrequency waves can block this transmission.

 

What is RF?

Facet neurotomy is a procedure which results in interruption of the nerve supply to a facet joint. A radio-frequency probe that heats the 2 small nerve branches to each facet joint accomplishes this interruption known as denervation. These nerves are called the medial branches.

 

How is RF done?

With the patient in a prone position [laying on your stomach] and under local anesthesia and fluoroscopic guidance, a radio-frequency needle is advanced to the base of the transverse processes. The needle is placed along the course of the medial branch. The needle is heated to 80° C for 90 seconds. At least 2 branches for each joint are treated in this same manner.  Sometimes a cold radio frequency is done, especially for cervical facets, which does not involve heating, but does involve a special pulsed radio wave.  Frequently, a small does of IV anesthesia medication is given for sedation.  However, this medication is not intended to make you unconscious.  You must be awake and responsive during the procedure.

 

How long does RF take?

The neurotomy takes 10 to 45 minutes, depending on the number of levels to be done. The patient is then recovered in the observation area for 30 minutes to 1 hour.

 

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.

 

Risks of RF?

Increased localized back pain and/or leg pain can be expected from several days to several weeks and rarely several months. Destabilization of the facet joint is a risk and post injection training to strengthen the extensor muscles can prevent 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 RF 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 an unexpected motor or sensory nerve in the path of the radiofrequency needle
  • Bleeding, nerve injury, organ injury and death are rare but possible
  • Neuritis with inflammation of the nerve with pain and tenderness that lasts three to six weeks. This can occur in 10 to 15 percent of patients.
  • Neuroma is a tumor from a nerve made of nerve cells and fibers. It forms around the area destroyed during radiofrequency ablation and can itself cause pain.
  • Numbness-nerve damage
  • Lack of pain relief  even though a test block was beneficial.

 

 

Expected Outcome of RF?

Following the neurotomy, there is a 60 to 80% chance of pain relief. This typically last for 3 months to 2 years. The nerve eventually grows back and the procedure can be repeated. While the patient is experiencing pain relief, vigorous physical therapy is necessary to try and strengthen the involved facet joint(s).  You should expect no pain relief for the first 72 hours, with peak relief occurring 6 weeks later.

 

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