Interventional pain management including percutaneous diagnostic and therapeutic techniques continue to evolve in the management of acute and chronic pain. The variety of interventional procedures are used to deliver high-quality patient care, improve diagnosis and enhance quality of life.

Several interventional pain management procedures briefly discussed on this website. The more detailed discussion will take place during the visit in the clinic.  Among the interventional procedures that are used for the treatment and not already discussed are:

• Platelet rich plasma

• Sympathetic blocks

• Vertebroplasty and kyphoplasty

• Intradiscal electrothermal therapy

• Referral blocks

• Intramuscular botulinum toxin injections

The treatment options will be discussed with the patient during the clinic visit after a comprehensive evaluation and diagnostic testing. The patient will be provided with all educational materials necessary to make a right decision which is appropriate for the patient's condition with the main goal to regain the function and life back.

Piriformis steroid injection

Spinal cord stimulator (dorsal column stimulator) is a medical device surgically placed under the patient’s skin with an lead (special electrical wire) placed in the epidural space at an appropriate level to send mild electric current to the spinal cord to produce a feeling of tingling in the area over the typical everyday pain. The pain reduction is achieved due to the suppressing of the pain signal as the main pain generator the pathologic structure.  It was found that the signal of the tingling sensation is much stronger compared to the signal of the pain and able to compete with the pain signal or even suppress it completely.

This particular treatment modality is offered only to the patients that failed conservative treatment, interventional procedures, and not a surgical candidates at that point. Patients need also to have psychological or neuropsychological evaluation to make sure that they are capable to use/operate the device and its remote control.

The procedure starts with the trial first. The spinal cord stimulator lead is placed into the epidural space at the appropriate level and the effect of the stimulation is checked by external device by the representative from the company producing the spinal cord stimulator generator kit.  Upon the appropriate placement and testing of the leads in the epidural space, the generator is temporarily placed externally. The position of the leads are secured with sutures and the generator with special dressing. The patient is sent home with a remote control to see if the spinal cord stimulator provides sufficient pain relief for the patient.  There are different modalities over the stimulation available and to be discussed with the physician and company representative during the appointment. The company representative provides the patient with education and discuss in detail with the patient how to operate the remote control and recharge the device as needed.  The patient comes back to the clinic 5 days later to discuss the effect of the spinal cord stimulator trial and assess the patient for possible side effects or complications.  The external generator with the lead is removed.  Patient will be scheduled to have surgical placement of the leads of the spinal cord stimulator into the epidural space connected to the permanent generator placed under the skin in the low back area if the trial is successful.  Patient will be provided with the further education regarding the remote control operation, maintenance and recharging the system on their own.  This spinal cord stimulator system will be frequently checked by the physician and the company representative to ensure the appropriate functioning and maintenance.

Provocative discography or discogram could be performed in the cervical or lumbar area in order to see if the intervertebral disc is the primary pain generator. This procedure is usually performed after the treatment of the facet arthropathy and radicular pain if present. Discography is the last diagnostic approach for the patient before a surgical evaluation  and should be performed after at least diagnostic blocks are performed to assure that other structures are not the main pain generator for the patient.

The procedure is performed by injecting contrast material into the nucleus pulposus of the intervertebral disc (center of the disc). Patient usually is provided with intravenous antibiotic prior to the procedure to prevent infection.  Pain is produced in the abnormal disc due to intolerance of increased intradiscal pressure or contrast material leaking through the walls of the injured disc.  The patient is asked whether he or she feels pain vs. only pressure sensation first.  The feeling of pressure only confirms that this particular intervertebral disc is not the main generator for the pain.  If patient reports having the pain with the introduction of the contrast material into the intervertebral disc, the pain needs to be specified whether it is a concordant pain ( resembling the typical daily pain for the patient and more intense at that moment) or a different new pain. The existence of the concordant pain confirms that injected intervertebral disc can possibly be the main generator for the pain.

The cervical or lumbar discogram procedure primarily serves as a prerequisite before performing a minimally invasive procedure or surgery.

Occipital nerve blocks are performed to place anesthetic and steroid medication around the greater and lesser occipital nerves that are located on the back of the head just above the neck area with the goal to reduce headaches and the pain from the involved area.

Radiofrequency ablation of the occipital nerves is the preferred treatment modality when occipital nerve steroid injections do not provide long-term pain relief and patient requires frequent injections to reduce the pain and suffering from headaches.

Hip and Shoulder Joints steroid injections are performed to deliver anesthetic and corticosteroid medications into the joint space to relieve the pain, regain range of motion and function.  The anesthetic portion of the injection may reduce pain from specific structures and corticosteroids may reduce inflammation which usually is the main source of the pain.

There are several treatments available for the sacroiliac joint dysfunction.

Sacroiliac joint diagnostic injection involves the placement of the anesthetic medication only to see if the pain is related to the sacroiliac joint pathology.  Patient’s report instant pain relief, however, the pain returns back after the anesthetic medication effect is diminished.

Sacroiliac joint steroid injection involves the placement of the anesthetic and steroid medication into the joint space or the close proximity of the joint with the goal to provide long-term pain relief.

Sacroiliac joint radiofrequency ablation is the preferred treatment modality when sacroiliac joint steroid injections do not provide long-term pain relief and patient requires more than 3-4 steroid injections annually for the pain relief.

Facet joints (zygapophyseal joints, Z-joints) intra-articular steroid injections are performed with the goal of long-term pain relief. However, according to the evidence base medicine, these particular injections do not provide significant and long lasting pain relief compared to other modalities like radiofrequency ablation. This approach is currently used if instant pain relief required or radiofrequency ablation therapy is contraindicated.

Medial branch blocks are diagnostic injections with intent to block or numb the medial branch nerves of the dorsal rami for the facet joint to see if the zygapophyseal joint is the primary pain generator. This is a diagnostic procedure and not a treatment.  The test is considered positive if patient reports 50% or more of the pain relief.  The best results are usually evident when the pain relief is in 80-100% range.  The pain will come back several hours or sometimes days later.  This diagnostic injection is a prerequisite to performing a radiofrequency ablation.  A second diagnostic injection with different anesthetic medication is required to be confident with the results of testing prior to the radiofrequency ablation therapy.

Radiofrequency ablation therapy is the therapeutic treatment phase involving the placing of Teflon-coated electrode on the region of the medial branch nerve preferably in parallel to and along the nerve in close proximity. The radiofrequency waves energy is transformed to heat energy to provide long-term pain relief by prohibiting the treated facet joints from sensing pain after coagulation its neuronal innervations.  According to the evidence base medicine, this procedure provides significant pain relief for the period of 6-12 months.  According to our own experience, it is very unusual if we consider repeating the treatment in less then 12 months.

Epidural steroid injections are performed to provide long-term pain relief from radicular pain. During the procedure the anesthetic and corticosteroid solution is introduced into the epidural space.  The epidural space is the area around the spinal cord or its extension inside of the spinal canal which consists of fat and small blood vessels.

Different approaches are used to perform epidural steroid injections:

• Interlaminar epidural steroid injection

• Transforaminal epidural steroid injection

• Caudal epidural steroid injection

Joints and bursa steroid injections performed to deliver anesthetic and corticosteroid medications into the joint or bursa to relieve the pain, regain range of motion and function. The anesthetic portion of the injection may reduce pain from specific structures and corticosteroids may reduce inflammation which usually is the main source of the pain.

Common Injection techniques and areas are:

• Shoulder joint

• Acromioclavicular joint

• Subacromial bursa

• Lateral epicondyle

• Medial epicondyle

• Olecranon bursa

• First carpometacarpal joint

• De Quervain’s tendinitis injection

• Trigger finger

• Hip joint

• Knee joint

• Greater trochanteric bursa

• Pes Anserine bursa

• Tibiotalar joint

• Morton’s neuroma

• Plantar fasciitis

Myofascial trigger points are hypersensitivity areas with a circumscribed area of tenderness with palpable tense band of muscle fibers that cause pain resembling the existing typical daily pain in the specific region and with specific travel further from the area of the intense pain with associated local twitch response upon palpation. Patients complain of having decreased range of motion, spasms and subjective weakness.  Poor sleep patterns and fatigue are also common.

The treatment will focus on flexibility, strengthening and aerobic exercises. If conservative management fails, anesthetic spray and stretch or trigger point injections with anesthetic medication and steroids or botulism toxin injections may be required.

A trigger point injection is an injection of local anesthetic with or without steroid medication into the trigger point of the muscle.  Patients usually report instant relief of the pain, also sometimes the effect of the steroid medication could be seen several days later.

Physical therapy refers to passive and a combination of passive and active treatments performed using special equipment to break through the cycle of pain. Physical therapy consists of manual therapy, physical therapeutic exercises, physical modalities, special modalities, traction, electrical stimulation and home exercises.

Physical modalities include:

• Thermotherapy using heat packs, ultrasound, short wave diathermy, microwave diathermy and also cold

• Light therapy using ultraviolet radiation

• Electrotherapy using transcutaneous nerve stimulation (TENS), neuromuscular electrical stimulation (NMES) and iontophoresis

• Traction

If you find that you have an acute pain, it is reasonable to start with conservative methods of pain management to see if the pain symptoms could be elevated naturally. Conservative pain management consists of nonsurgical and noninterventional modalities for the acute pain.

Among the first steps to consider are short-term rest, applying heat or ice, anti-inflammatory medications like Advil and Aleve, over the counter pain patches, also home exercises program if were already established during the prior physical therapy sessions.

You need to seek an evaluation by your primary care physician (family doctor, general practitioner) if the pain persists. This time conservative management includes a short course of muscle relaxers like Flexeril or Skelaxin, prescription of anti-inflammatories like Mobic and Relafen, local anesthesia patches like Lidoderm patches, possibly short course of oral steroids and even opioids pain medications as Tylenol with codeine and tramadol. It is very important to consider lifestyle changes, yoga, massage therapy, acupuncture, chiropractic care and physical therapy at this point.

Low-grade pain that does not affect the function and quality of life may be easily managed with just conservative treatments. However, if the pain persists or becomes worse, an evaluation by a pain specialist is required.

During the evaluation in the pain clinic, you will be provided with comprehensive physical exam along with appropriate diagnostic imaging performed to find the source of the pathology responsible for your pain. Diagnostic imaging usually starts with plain x-ray views which will be discussed during the visit.  The next step will be MRI or CT scan to look further for the pathology and correlate the findings with the clinical examination.  According to the clinical findings confirmed by diagnostic imaging, you will be offered an appropriate interventional treatment to reduce the pain levels and help you to regain the function and life back.