of spinal pain
The majority of the patients we see have chronic spinal pain.
The spine is a complicated structure. Its primary components are
the bones, joints between the bones, discs, and nerves. In addition
to these primary components, there are a variety of structures
that support the spine, including the muscles. Injury or irritation
of any of the primary components of the spine has the potential
to cause chronic spinal pain. Once a painful condition occurs,
muscles go into spasm to defend the spine from further injury.
Although this muscle spasm is also painful, in most patients with
chronic pain the muscles are not the primary cause of pain. In
some patients the situation is complicated by stress and depression,
which frequently accompany pain, and can even make pain worse.
Chronic spinal pain is not a life-threatening condition. However,
it can disable patients from work and other activities and prevents
many people from fully enjoying their lives.
of spinal pain
The key tools that doctors use to diagnose the cause of spinal
pain are patient history, physical examination, and x-ray studies,
including MRI scans. Often the source of pain can be diagnosed
using these tools, particularly in patients who have primarily
nerve root pain (pain or weakness along the course of a nerve).
However, in many patients, particularly those with primarily back
or neck pain, it is difficult to localize the exact source of
pain. MRI scans are frequently not helpful in these patients.
They may show only the normal age-related changes that occur in
most people, whether they have pain or not. The nerve supply to
the spine is diffuse and overlapping, so a particular pain could
have one of several possible causes. Diagnosing the exact source
of pain may be difficult, but if your doctor knows the source
of your pain, he or she may be able to treat you more effectively.
This is particularly true if surgery is being considered.
Using diagnostic injections to diagnose the source of pain is
an effective alternative to relying on only clinical evaluation
and x-ray studies. These may be useful both in patients with nerve
root pain and patients with back or neck pain. At the time of
a diagnostic injection, individual structures of your spine are
selectively injected with contrast dye and/or local anesthetic.
Then the effect this has on your pain is carefully observed. If
reproduction of your typical symptoms is experienced, that may
be an indication that the structure injected is the source of
your pain. If your pain goes away, even for a short period of
time, that may also be an indication that the structure injected
is the source of your pain. The degree of pain relief you experience
immediately after a diagnostic injection is very important. So
following the injection, you may be asked to perform certain maneuvers
that usually increase your pain to determine if your pain level
has changed. In addition to contrast dye and/or local anesthetic,
we often include a small amount of cortisone with diagnostic injections.
The cortisone used may provide prolonged relief beginning one
to two weeks after the injection. If you have such pain relief
following a cortisone injection, that may also be important diagnostically.
Examples of diagnostic injections include disc, facet, sacroiliac,
sympathetic, and selective epidural or nerve root injections.
Using injections, in conjunction with clinical information and
imaging studies, we are able to diagnose the source of pain in
approximately 75% of our patients.
of spinal pain
In general, there are four treatment options for patients with
chronic spinal pain. Physical therapy can be effective for many
people, particularly physical therapy that emphasizes activity
and return to function. For patients who have pain in spite of
physical therapy, surgery can sometimes be effective. The success
of surgery is highly dependent on an accurate diagnosis as to
the source of pain. Another option for patients is to simply live
with their pain as best as they can, sometimes with the assistance
of pain medications or other methods such as acupuncture.
Another alternative for treating spinal pain is using therapeutic
injections. If your doctor knows where your pain is coming from,
he or she may recommend a therapeutic injection. Therapeutic injections
differ from diagnostic injections in that they are intended to
treat pain, rather than diagnose its cause. Most therapeutic injections
use local anesthetic and cortisone medications, although sometimes
other substances or even heat can be applied. Examples of therapeutic
injections include epidural, facet, sacroiliac, sympathetic injections,
facet rhizotomy, and intradiscal electrothermal therapy.
Therapeutic injections have two potential benefits. The first
is that they have the potential of providing long-term pain relief.
After a therapeutic injection, the likelihood of significant and
lasting pain relief will vary according to the source of pain
and the specific injection, but typically is in the 50% - 60%
range. The second potential benefit of a therapeutic injection
is that even though it only provides short term pain relief (e.g.
two to three weeks), other treatments such as physical therapy
will be much more effective during that time. The combination
of the injection and additional treatments, as ordered by your
doctor, may then eventually lead to long-term pain relief.
and side effects
When done properly, spinal injection procedures are very safe.
All of our procedures are done under x-ray guidance, both for
safety reasons and to provide the greatest likelihood of success.
However, with any medical procedure or treatment come possible
risks. Any time a needle is placed into the body, there is a risk
of bleeding. Usually, any bleeding that occurs after an injection
is very minor. However, in rare circumstances bleeding can lead
to serious complications. To minimize this risk, we have instructed
you to stop taking anti-inflammatories for 3 days prior to your
procedure, aspirin for seven days prior, and to notify us if you
take blood-thinning medications. Another complication that can
occur with needle procedures is infection. The chance of getting
a significant infection after any needle procedure is very low.
However, with certain procedures involving disc injections, including
discograms and intradiscal electrothermoplasty, a minor infection
could lead to a serious complication. For that reason, if you
are having a disc injection, antibiotics will be administered
to you both intravenously and directly into the disc at the time
of the procedure.
All of our procedures are performed using local anesthesia and
intravenous sedation. It is possible to have allergic or other
reactions to the medications used during the procedure, including
the contrast material or "dye" used to make the x-ray
images clearer and make sure the injected medication will go to
the correct site. Most reactions that occur are minor, although
serious complications are possible. For that reason, it is important
that you notify us of any medication allergies you may have, prior
to the procedure. For your safety, oxygen will be administered
during the procedure, while your blood pressure, heart rate, and
oxygen levels will be constantly monitored.
Minor side effects are common after injection procedures. The
sedative medications that are used may impair your coordination,
so you should not drive or do other activities requiring coordination
for at least 12 hours after the procedure. The local anesthetic
injected into the spine may cause regional numbness or weakness
for up to 6 hours after the procedure, which is another reason
to limit your activity on the day of the injection. You may have
local soreness at the injection site for one or two days, which
usually responds to application of ice packs. Some patients, especially
those having discograms, may have an increase in their usual pain
for up to 10 days following an injection. If you experience this,
you should try resting and taking your regular pain medication,
then call us if your pain persists. If you received cortisone
in your injection, you may notice an improvement in your usual
pain within two to three days, although it may take as long as
10-14 days for the medication to fully take effect. Although most
patients do not have any side effects from cortisone, the following
side effects may be possibly experienced: sweating, flushing,
palpitations, increased heart rate, insomnia, anxiety, hiccoughs,
headache, menstrual changes, upset stomach, frequent urination,
and slight fever with flu-like symptoms. If any of these side
effects become significant or persists longer than three days,
please contact us.
Although serious complications are rare, they can occur. Possible
serious complications include: increased pain, headache, temporary
or permanent nerve damage, hip (bone) damage caused by steroids,
seizures, difficulty breathing, collapsed lung, death, paralysis.
It is possible that serious complications, especially those related
to bleeding and infection, could occur in the recovery period,
at home, after you have left the clinic. For that reason, if you
develop fever, progressive weakness or numbness, loss of bowel
or bladder control or any other symptoms that you find concerning,
please notify us immediately.