Non- Surgical Treatments
Non- Surgical Treatments definition here
Trigger Point Injections
Trigger point injections are used for the treatment of myofascial pain syndromes. In these patients, taut bands of muscle or areas of muscle spasm are injected to release the area of tightness. Most physicians use local anesthetic for this procedure, although some physicians may use other substances such as, saline, steroid, sarapin, or nothing at all (which is called a ‘dry needle’ technique). I prefer to use local anesthetic because of the short term analgesic effect. This provides an almost immediate increased range of motion which then allows the patient to stretch the affected areas; stretching is the key to obtaining long term results. Therefore, following trigger point injections it is extremely important that the patient perform a home stretching program in order to maximize their benefit from this therapy. Trigger point injections are often used in conjunction with other therapeutic interventions especially when there is a residual muscular spasm component after treatment of another underlying condition.
Botox may be used to treat chronic muscular spasm that responds on a short term basis to trigger point injections to try and achieve more lasting benefit. Botox injections are also used for the treatment of various headache syndromes, most commonly migraine type headaches. Chronic muscle spasms can be the primary cause of a patient’s pain or it can be the result of another condition. Botox will be limited in its benefit if the underlying conditions are left untreated. Requirements for insurance coverage of Botox are typically very specific and strict and will vary by indication.
Epidural Steroid Injections (Cervical, Thoracic, Lumbar and Caudal)
Epidural steroid injections can be performed in almost any area of the spine, from the neck (cervical) to the mid back (thoracic), all the way to the lower back (lumbar), and even as low as just above the tailbone (caudal). The specific location is chosen based on the area of injury or damage. Epidural injections can be used to treat many conditions including nerve compression, nerve injury, disc related pain, Complex Regional Pain Syndromes, and a variety of other indications. The specific type of epidural will be based on the underlying condition that is being treated and the patient’s injury. There are four basic types of epidural injections:
- A Midline or interlaminar approach in which the needle is inserted into the center of the spine through a small window between bones of adjacent spinal levels. This can be done in the neck, mid-back, or low back regions. This is typically used for central disc herniations or central canal stenosis and is also used when catheters or spinal cord stimulators are inserted into the epidural space.
- In a Transforaminal approach, a needle is inserted into an opening on the side of the spine, between the spinal bones, in the area where the nerve exits the spine. This bony opening between spinal levels is also called the foramen. In this case the injection is placed in close proximity to the nerve; injection in this location will typically cause reproduction of arm or leg symptoms. When the area of compression is within the foramen, a transforaminal approach tends to provide greater relief than an interlaminar approach.
- Caudal epidural injections are performed through a small opening in the spine called the sacral hiatus, which is located just above the tailbone at the base of the spine. Caudal injections can be used for the treatment of a variety of conditions including peripheral neuropathy and pathology or injury at the lowest lumbar levels. This approach is also commonly used with epidural lysis of adhesions procedures.
- Catheter guided – In this situation a needle is inserted via a mid-line or interlaminar approach into the epidural space. Through the needle, a catheter is guided into the area of damage. Once the catheter tip is properly positioned, and verified by contrast injection (to demonstrate that the medication will go to the intended location), medication is injected through the catheter. .
Lysis of Epidural Adhesions (Scar Tissue)
Epidural Lysis of Adhesions is used to treat scar tissue that has formed in the epidural space from surgery or inflammation. While typically scar tissue follows surgical intervention, it may also develop as an inflammatory response, such as when a disc is chronically leaking from a tear in its outer wall (or annulus). Scar tissue is broken up and disrupted both mechanically through the direct insertion of the catheter, but also through hydrostatic pressure created by the injection of large volumes of fluid to distend the epidural space. The goal of this procedure is to break up this scar tissue and free up the nerve structure which is trapped within the scar tissue. This treatment is most commonly used to treat chronic leg pain following low back surgery.
Facet Blocks (Cervical, Thoracic, Lumbar)
The term facet block refers to a group of injections used to treat arthritic conditions within the spine. Facet blocks can be performed in the neck, mid back, and lower back. Facet joints are the paired joints on each side of the spine that run from the top of the neck to the base of the spine where it joins with the pelvis. The facet joints are in the back of the spine, the discs are in the front of the spine. These joints can become arthritic related to age and degeneration and they commonly become irritated and damaged from trauma. When the disc at a particular level starts to degenerate or herniate, the facet joints simultaneously degenerate and often become another painful part of the problem. Facet blocks are performed via two different techniques. The first type is referred to as a facet joint injection and is performed by placing medication directly into the joint. The second type is called facet mapping and this injection maps the nerves that go to the joint.
- Facet joint injection – In this approach a needle is placed directly inside the joint, dye is injected in the joint to confirm placement, and then local and steroid is injected within the joint. The local anesthetic provides some temporary relief and the steroid reduces inflammation in the area, hopefully providing long term relief.
- Facet mapping – In this situation, the nerves that innervate the joint are blocked with local anesthetic to see if there is a change in symptoms (and typically steroid is added to try and achieve a prolonged effect by reducing the inflammation in the area). This approach frequently provides extended relief similar or better than intra-articular joint injections. A mapping procedure must always be performed prior to performing a more long lasting treatment to the facet joints, radiofrequency ablation. This provides confirmation that the nerves causing the patient’s pain are correctly identified before they are blocked on a more long term basis. Today most facet blocks are done via a mapping approach.
Sacroiliac Joint Injection
The sacroiliac or SI joint is a joint within the pelvis that is frequently injured in falls and motor vehicle accidents. When an individual falls and lands on their buttocks (either square on, or to one side) the sacroiliac joint can sustain damage. Specifically the ligaments and tendinous structures overlying and supporting the SI joint become damaged. In a motor vehicle accident when the injured person’s foot is placed forcibly on the floor at the time of impact, it transmits forces up the leg into the pelvic region and sacroiliac joint; hence the common association of SI joint injury and motor vehicle accidents. Treatment of the sacroiliac joint requires specific image guided injections. There are two choices for injection of the sacroiliac joint, one involves the placement of a needle into the joint and the other involves mapping of the nerves that innervate the joint. Both of these are effective approaches and can provide sustained benefit. When sustained benefit is not obtained, longer lasting procedures such as radiofrequency denervation can be considered (please see radiofrequency denervation for further information of this procedure). It is important to note that sacroiliac problems frequently occur in combination with facet problems; when these two conditions are present simultaneously it is referred to as a posterior joint syndrome. Incomplete relief will occur if both structures are not treated. Both facet and sacroiliac joint problems also frequently follow surgical intervention in the lumbar region.
Radiofrequency (RF) denervation is also referred to as radiofrequency ablation and is a treatment used to provide longer lasting relief of facet joint and sacroiliac joint injuries. In this procedure a needle is placed near the innervating nerves of the joint (each joint has multiple nerves) and those nerves are then blocked for a prolonged period of time using radiofrequency energy. These nerves are precisely identified with electrical stimulation at low currents. Once the nerve is identified it is then lesioned. This procedure typically takes 6-8 weeks in order to see full results and is associated with 1-2 weeks of postoperative discomfort. Pulsed Radiofrequency treatments deliver less energy and utilize lower temperatures can be applied to the dorsal root ganglions when there is a specific spinal nerve that has been injured (or peripheral nerve). Very few carriers cover Pulsed RF today.
Damage to the joints can come from trauma, arthritis, or a latent effect from infection. Initial treatment should be conservative with anti-inflammatories and physical therapy (unless there is an active infection which would require treatment first). The treatment options for joint injections include steroid injections, viscosupplementation (basically the injection of a lubricant into the joint), and regenerative medicine techniques. Many joint injuries can be treated conservatively but some may require surgery or even replacement. Stem cell therapy is being used today to regenerate cartilage tissue within the joint in order to avoid further surgery including joint replacement.
Peripheral Nerve Blocks
Your central nervous system is made up of your brain and your spine. Your peripheral nervous system encompasses every other nerve in your body. Clearly, there are many different peripheral nerves in the body. These nerves can be injured by trauma or can become entrapped in musculoskeletal structures causing compression and irritation of the nerve. Diagnosing a damaged nerve is a process requiring a thorough history and physical examination. The diagnosis is confirmed with either nerve conduction testing and/or injection of the peripheral nerve. If the pain resolves when the peripheral nerve is blocked with local anesthetic, this proves the diagnosis. Common nerve blocks that are performed include occipital nerve blocks, which are performed to treat headaches, ilioinguinal and/or iliohypogastric nerve blocks which are used to treat pain following a hernia operation, and genitofemoral nerve blocks, which are performed on another nerve that can be damaged during a hernia operation, or pelvic surgical interventions. Intercostal nerve blocks are used to treat pain in the chest wall; typically related to post-herpetic neuralgia or following thoracic surgery (lung surgery). There are many other peripheral nerve blocks that can be performed. Each particular peripheral nerve has its own set of symptoms and proper diagnosis is based on knowledge of these specific nerve distributions and matching these to the patient’s symptoms. It is not uncommon for peripheral nerves to be damaged following surgery or trauma which in extreme cases can result in the development of a Complex Regional Pain Syndrome, Type II (please see CRPS, Type II). Injured Peripheral nerves can be treated with an injection of local anesthetic and steroid and if that fails to provide lasting relief, neurolysis procedures can be performed to obtain more lasting pain control (cryoneurolysis or Pulsed RFD). More invasive interventional treatments that can be considered for recalcitrant peripheral nerve pain include peripheral nerve stimulation and peripheral nerve field stimulation. In these interventions the goal is to try to stimulate the nerve tissue and replace the pain with a soothing tingling sensation.
Sympathetic blocks are used to treat sympathetically mediated pain syndromes such as CRPS Type I and Type II. Sympathetic nerves exist throughout the entire body and pain syndromes associated with these tend to be regional involving an entire extremity or quadrant of the body. Sympathetic blocks are also used for the treatment of cancer pain, visceral pain, interstitial cystitis and other pelvic pain syndromes.
- Stellate ganglion block – an injection used for pain involving the head and neck.
- Sphenopalatine nerve block – used for treatment of headaches and other facial pain syndromes.
- Splanchnic nerve block typically used for pancreatic cancer and other abdominal malignancies.
- Celiac plexus block – the most common injection for pancreatic cancer related pain. Neurolytic or destructive injections are often performed to the celiac plexus to block the innervation or sensation coming from the pancreas to alleviate pain on a long term basis. These injections are typically highly effective for Pancreatic Cancer, a condition associated with very severe abdominal pain.
- Lumbar sympathetic block – lumbar sympathetic blocks are typically used for Complex Regional Pain Syndromes involving the lower extremity.
- Superior hypogastric plexus block refers to a group of nerves which provide sensation in the pelvic region. Patients with bladder and pelvic pain syndromes such as interstitial cystitis may benefit from superior hypogastric plexus blocks.
- Ganglion of impar block – represents the lowest aspect of the sympathetic chain. Impar blocks are typically used to treat rectal pain from cancer, surgery, or radiation damage.
Discography is a diagnostic test used to determine which specific disc(s) are causing the patient’s pain. It is NOT a therapeutic procedure. During the procedure, needles are placed into the center of multiple discs and then the discs are injected with fluid or dye to pressurize or distend the disc. By adding pressure to the inside of the damaged disc, the disc is stimulated and the nerves that are normally causing the patient’s pain will be activated, in other words the patient’s pain will be reproduced. Discs which are not causing the patient’s pain will not have a painful response to this pressure. Following the injection the patient will undergo a CT scan and this will show how the dye that was injected spread through the disc. By examining what has happened to the dye following injection, we are able to see the size and location of tears (and herniations) in the disc. Discography helps the physician to plan minimally invasive spine surgery and surgical fusion procedures. Many patients will have already undergone an MRI and often wonder why this procedure is necessary. MRIs provide a good picture of the disc; but discography tells us which of the discs is causing the pain as sometimes discs appear damaged on an MRI, but they are not actually causing the patient’s pain.
Sometimes injections performed to treat peripheral nerve pain only provide temporary relief. In order to achieve longer lasting relief, Cryoneurolysis may be performed. This procedure involves freezing the peripheral nerve that is causing the patient’s chronic pain. This is most commonly used for peripheral nerves in an extremity, an occipital nerve for treatment of headaches, or an intercostal nerve for treatment of a post-thoracotomy syndrome (pain following thoracic surgery). In cryoneurolysis a large probe is inserted near the peripheral nerve. Once the peripheral nerve has been identified with electrical stimulation, the nerve is frozen to -70oC. This results in an effective block of the nerve for approximately a 4-8 month period during which time hopefully the initial nerve problem will heal so the pain will not recur.
Minimally Invasive Procedures
Percutaneous Discectomy (PLDD, LASE, Nucleoplasty)
This is a generic description of a variety of different minimally invasive techniques used to decompress a herniated disc as an alternative to an open surgical procedure. Typically these procedures are performed through a needle or a very small cannula and do not involve a significant incision of the skin. There are multiple different surgical techniques which have been described for percutaneous discectomy. Percutaneous Laser Disc Decompression (PLDD) is one of the minimally invasive surgical approaches for removal of a disc herniation. This treatment involves the placement of a cannula into a damaged disc and through it tissue is removed. The cannula is a small tube, similar to a straw that houses the tools needed to fix the disc. These tools can include a means of seeing inside the disc, as well as the tools used to remove the disc materiel. The basic idea behind this treatment is that by removing a small amount of tissue from the inside of the disc we can reduce the internal pressure within the disc, thereby decreasing the force pushing the disc material through the defect or weakened portion of the disc outer wall. .
Annuloplasty is a generic description for repair of the outer wall of the disc which can be damaged from trauma or degeneration. IDET is one potential approach, but there are a number of other modalities today that may potentially repair the outer wall of the disc. Some physicians have experimented with the use of PRP injections and others are working with the injection of natural sealants to repair the outer wall of the disc. Annuloplasty does not address the increased pressure within the disc, which can result in a disc herniation or re-tearing of the disc wall.
Intradiscal Electrothermal Annuloplasty (IDET)
IDET or intradiscal electrothermal annuloplasty is used to treat tear in the outer wall of a disc. When a disc tears, some of the fluid or disc material can leak out and irritate the nerves in your spine. This fluid can cause inflammation and thereby pain. To control the pain the tear needs to be sealed so the irritant is once again contained within your disc. In addition, when the disc tears, small blood vessels and more importantly nerves begin to grow in and around the tear, causing the back pain associated with this condition. This treatment, which is an alternative to open back surgery, involves the insertion of a needle into the center of the disc. We use the needle to introduce a coil that is steered to the location of the tear. A small section of this coil or wire can be heated using radiofrequency energy. Heating of the outer wall of the disc causes controlled scarring, which will seal the tear in your disc. The heating of the disc may also destroy the nerve endings that your body grew into the tear. In general the results with IDET have been good in properly selected patients. One of the major benefits to this procedure is that if it doesn’t work, you still have the option of open back surgery.
Unfortunately this therapy has been often misused and therefore many physicians do not believe in its effectiveness. Instead of only offering the treatment to patients who fit the strict criteria, patients were given this option even when they weren’t ideal candidates.
Patients who have both a disc herniation and an annular tear typically require treatment of both portions of this injury for an optimal outcome. Dr. Kloth feels strongly that to prevent the disc from re-tearing, any coexisting disc herniation should be removed to reduce the pressure on the outer wall of the disc. In addition, once the disc herniation is decompressed, using a percutaneous discectomy approach, strengthening of the outer wall with IDET, can help prevent re-herniation or recurrent injury of the disc. Combining these minimally invasive procedures can treat both the patient’s herniated disc and annular tear, and thereby enhance the results of each treatment.
Minimally Invasive Lumbar Decompression (MILD)
Minimally Invasive Lumbar Decompression is used to treat a painful condition called spinal stenosis. Spinal stenosis describes a condition of when there is narrowing of the spinal canal which can cause pain in the back and lower extremities. Traditional decompression of this stenosis via an open surgical technique can lead to instability of the spine. This instability must be fixed by performing a surgery known as a fusion (often these two open surgeries are performed simultaneously with markedly increased risks). Minimally invasive lumbar decompression was invented to provide a more conservative, less invasive approach for decompression of spinal stenosis. The MILD procedure removes overgrown ligament in the back of the spine (which is called the ligamentum flavum), and to a lesser degree, overgrown bone. This procedure does not aim to treat all of the damage seen at that spinal level but is instead meant to provide just enough decompression of the stenotic area to decrease the chronic pain that these patients suffer from. By limiting what is removed from the area, the risk of instability is minimized and patients are hopefully able to avoid more invasive fusion surgery. Studies to date have shown good results with very low risk.
Spinal Cord Stimulation
Spinal cord stimulation involves the placement of small leads (or catheter with metal contacts) into the epidural space to electrically stimulate the nerves within the spinal cord. This does not cure the underlying injury but rather treats the pain associated with the injury. This treatment is typically reserved for patients who have undergone extensive treatment but are left with chronic pain. The goal of this therapy is to change the sensation the patient is feeling from a painful one to a soothing tingling sensation. It is a distraction therapy, giving the patient a different sensation to feel rather than the pain.
After your physician has determined that you are an appropriate candidate for this treatment, they will schedule you for a trial. A trial is required to determine the best position for the leads (at which spinal level) and to determine whether this therapy will result in symptomatic relief before the final implant is performed. During the trial the leads will be inserted and then attached to an external programmer (remote) that you will wear for the duration of the trial. The average trial lasts approximately 5-7 days, and during that period you will come into the office frequently for evaluation and when necessary, the stimulation pattern will be adjusted to provide optimum results. At the end of the trial period, the leads will be removed and you and Dr. Kloth will decide whether or not the trial was successful. In some cases, trial leads are sewn into position for later permanent implantation; this approach is typically used when a longer trial is desired.
If the trial is deemed a success, you will be scheduled for permanent implantation of the stimulator device. This will include implanting the leads and a generator. The trial, the removal of the trial leads, and the permanent implant are all typically done on an outpatient basis. Spinal cord stimulation is an effective treatment for many conditions including chronic radiculopathy, failed back syndrome, complex regional pain syndromes, and a variety of nerve injuries or other neuropathic pain conditions.
There are three major companies that produce spinal cord stimulators. For additional information on each company please see their websites.
Boston Scientific http://www.bostonscientific.com/us/patients/chronic-pain.html
St. Jude Medical http://www.poweroveryourpain.com/
Peripheral Nerve Stimulation
Peripheral nerve stimulation involves the stimulation of a peripheral nerve via a percutaneously inserted lead or a surgically implanted lead sewed directly to the nerve. The purpose, similar to spinal cord stimulation, is to replace the pain with a soothing tingling sensation. Peripheral nerve stimulation also requires a trial before permanent implantation. For more information, please see the section on Spinal Cord Stimulation.
Peripheral Nerve Field Stimulation
Peripheral nerve field stimulation is a relatively new technique and involves placement of stimulator leads into the subcutaneous tissue (just underneath the skin) to stimulate the distal nerve endings and provide a “field” of stimulation in the area of pain. Many patients find this to be highly effective and in fact for some conditions this appears to provide greater relief than traditional spinal cord stimulation (i.e. – groin pain). Peripheral nerve field stimulation is controversial because of the limited evidence associated with this therapy at this time. Peripheral nerve field stimulation also requires a trial before permanent implantation.
Spinal Drug Delivery Systems
Spinal drug delivery systems, otherwise known as intrathecal pumps (or more simply pumps), are implanted devices that deliver medications directly into the spinal fluid. Before undergoing a permanent implant of this device, patients must undergo a successful trial. Once the permanent pump is in place, patients will come to the office every 30-90 days for refills of the implanted device (depending on the medication and dosage).
The pumps major advantage is that by delivering medication directly into the spinal fluid, the patient receives a much lower dosage than is required orally and this is associated with lower side effects and improved pain control for many patients. These devices can be used for more severe and chronic forms of pain that do not respond to more conservative treatment. These pumps can also deliver spinal medications which helps to reduce the spasticity associated with multiple sclerosis, brain injury, or spinal cord injury. They are also extremely helpful in treating cancer pain.