Interventional Pain Management is a medical subspecialty that uses cutting-edge technology and invasive procedures to treat pain and other functionally limiting conditions. See more info at aapmr.org
MEDIAL BRANCH BLOCK
A medial branch nerve block is a procedure in which an anesthetic is injected near small medial nerves connected to a specific facet joint. Typically several levels of the spine are injected in one procedure.
If the patient experiences marked pain relief immediately after the injection, then the facet joint is determined to be the source of the patient’s pain.
The procedure is primarily diagnostic, meaning that if the patient has the appropriate duration of pain relief after the medial branch nerve block, then he or she may be a candidate for a subsequent procedure – called a medial branch radiofrequency neurotomy (or ablation) – for longer term pain relief.
FACET JOINT INJECTION
Facet joints are small joints at each segment of the spine that provide stability and help guide motion. The facet joints can become painful due to arthritis of the spine, a back injury, or mechanical stress to the back. Both facet joint injections and medial branch blocks are used to diagnose and treat pain stemming from facet joints. While treating pain, typically steroids or steroids mixed with anesthetics are used.
The mechanism of pain control is different for facet joint injections and medial branch blocks.
A cervical, thoracic or lumbar facet joint injection involves injecting a small amount of local anesthetic (numbing agent) and/or steroid medication, which can anesthetize the facet joints and block the pain. The pain relief from a facet joint injection is intended to help a patient better tolerate a physical therapy routine to rehabilitate his or her injury or back condition.
Facet joint injections usually have two goals: to help diagnose the cause and location of pain and also to provide pain relief:
- Diagnostic goals: By placing numbing medicine into the facet joint, the amount of immediate pain relief experienced by the patient will help determine if the facet joint is a source of pain. If complete pain relief is achieved while the facet joint is numb, it means that joint is likely a source of pain.
- Pain relief goals: Along with the numbing medication, a facet joint injection also includes injecting time-release steroid (cortisone) into the facet joint to reduce inflammation, which can sometimes provide longer-term pain relief.
The injection procedure may also be called a facet block, as its purpose is to block the pain.
Radiofrequency ablation (or RFA) is a procedure used to reduce pain. An electrical current produced by a radio wave is used to heat up a small area of nerve tissue, thereby decreasing pain signals from that specific area. RFA can be used to help patients with chronic (long-lasting) low-back and neck pain and pain related to the degeneration of joints from arthritis
The degree of pain relief varies, depending on the cause and location of the pain. Pain relief from RFA can last from six to 12 months and in some cases, relief can last for years. More than 70% of patients treated with RFA experience pain relief.
SACROILIAC JOINT INJECTION
Dysfunction in the sacroiliac joint, also called the SI joint, can sometimes cause lower back and/or leg pain. Leg pain from sacroiliac joint dysfunction can be particularly difficult to differentiate from radiating leg pain caused by a lumbar disc herniation (sciatica) as they can feel quite similar. For decades, the sacroiliac joint was suspected as a common cause of low back and/or leg pain, although difficulty in accurate diagnostic testing left many in the medical profession skeptical. Today it is estimated that the sacroiliac joint is responsible for 15% to 30% of lower back pain cases. The sacroiliac joint connects the hip bones (iliac crests) to the sacrum, the triangular bone between the lumbar spine and the tailbone (coccyx). The primary function of the sacroiliac joints is to absorb shock between the upper body and the pelvis and legs.
The sacroiliac joint typically has little motion. Small movements at the joint help with shock absorption and forward/backward bending. The joint is reinforced by strong ligaments surrounding it, some of which extend across the joint in the back of the pelvis. This network of soft tissues provides support, limits movement at the joint, and assists with absorbing pressure.
Other muscles that support sacroiliac joint function include the gluteus maximus and the piriformis muscle.
COOLED RADIOFREQUENCY ABLATION
This advanced procedure uses cooled radiofrequency energy to safely target the sensory nerves responsible for sending pain signals.
A radiofrequency generator transmits a small current of RF energy through an insulated electrode, or probe, placed within tissue. Ionic heating, produced by the friction of charged molecules, thermally deactivates the nerves responsible for sending pain signals to the brain.
RF energy heats and cools the tissue at the site of pain.
Unlike other RF procedures, COOLIEF* circulates water through the device while heating nervous tissue to create a larger treatment area, increasing the opportunity to help with pain. This combination targets the pain-transmitting nerves without excessive heating, leading to pain relief.
Botulinum toxin injections are used to reduce the excess muscle activity caused by dystonia. Botulinum toxin is produced naturally by a bacterium called Clostridium botulinum which is also associated with causing botulism, a rare form of food poisoning. However, although botulinum toxin is exceptionally toxic, when it is purified and used in tiny, controlled doses, it can be used safely and effectively to relax excessive muscle contraction.
The injection enables the botulinum toxin to be targeted directly into the muscles affected by dystonia. The toxin has an effect on the nerves at their junction with the muscles. It acts as a blocker preventing release of the chemical messenger acetylcholine which is responsible for making the muscle contract. As a result, the signals that would normally be telling the muscle to contract are halted and the muscle spasms are reduced or eliminated.
Because each muscle affected by dystonia has to be injected separately, and also because there is a limit to the total quantity of toxin that can be injected into the body at one time, botulinum toxin is more suitable for treating dystonia which are focal to one or two areas of the body rather than generalized dystonia. However, sometimes the toxin is used to treat a specific part of the body in generalized dystonia as part of a wider treatment regime.
Botulinum toxin injections are administered by trained medical professionals (usually a doctor, physiotherapist or dystonia nurse) and most commonly delivered at a local hospital. Some people find the injection hurts a little but others are not concerned about it at all. Depending on the location of the muscle spasm, doctors will either select the muscles by observing the abnormal postures or movements and feeling for the muscle spasm or will use an EMG (electromyography) machine which measures muscle activity.
The number of injections will vary depending on the severity of your dystonia. Talk to your doctor about the number of injections you will need.
After the injection, the treatment takes effect gradually over 4–7 days, sometimes longer. Where it is a suitable treatment, botulinum toxin provides significant relief for the majority of people but it is not perfect – usually mitigating symptoms rather than completely eliminating them. The positive effects of botulinum toxin injections can last up to 16 weeks, sometimes longer; although many people find that the injections need repeating before this and usually attend a clinic around every 12 weeks.
Botox for Migraine
If you undergo Botox treatments for migraines, your doctor will typically administer them once every three months. Depending on your response to Botox, your doctor will recommend a length of time for your treatment plan. Each session will last between 10 and 15 minutes. During the sessions, your doctor will inject multiple doses of the medicine into specific points along the bridge of your nose, your temples, and your forehead, the back of your head, your neck, and your upper back. Botox treatments can help reduce symptoms of migraine headaches, including nausea, vomiting, and sensitivity to lights, sounds, and smells. After you receive Botox injections, it may take as long as 10 to 14 days for you to experience relief. In some cases, you may not experience any relief from your symptoms following your first set of injections. Additional treatments may prove more effective.
Although blood is mainly a liquid (called plasma), it also contains small solid components (red cells, white cells, and platelets.) The platelets are best known for their importance in clotting blood. However, platelets also contain hundreds of proteins called growth factors which are very important in the healing of injuries.
PRP is plasma with many more platelets than what is typically found in blood. The concentration of platelets — and, thereby, the concentration of growth factors — can be 5 to 10 times greater (or richer) than usual.
To develop a PRP preparation, blood must first be drawn from a patient. The platelets are separated from other blood cells and their concentration is increased during a process called centrifugation. Then the increased concentration of platelets is combined with the remaining blood.
To speed healing, the injury site is treated with the PRP preparation. This can be done in one of two ways:
PRP can be carefully injected into the injured area. A mixture of PRP and local anesthetic can be injected directly into this inflamed tissue. Afterwards, the pain at the area of injection may actually increase for the first week or two, and it may be several weeks before the patient feels a beneficial effect.
PRP may also be used to improve healing after surgery for some injuries. For example, an athlete with a completely torn heel cord may require surgery to repair the tendon. Healing of the torn tendon can possibly be improved by treating the injured area with PRP during surgery. This is done by preparing the PRP in a special way that allows it to actually be stitched into torn tissues.
Joint injections are used to deliver steroids directly into a joint, such as a knee, ankle, hip or wrist. Sometimes fluid is removed from the joint before the steroid is injected.
Steroid joint injections can help with pain and swelling by treating the underlying joint inflammation – improvement is often with a several days.
Joint injections are performed in an office or hospital setting, often with a cold spray or other local anesthesia. After the skin surface is thoroughly cleaned, a needle in injected directly into a joint. At this point steroids can be injected into the joint. The steroid treats the inflammation inside the joint, leading to decreased swelling and pain.
Commonly injected joints include the knee, shoulder, ankle, elbow, wrist, base of the thumb, and small joints of the hands and feet. Hip joint injection may require the aid of an ultrasound or X-ray called fluoroscopy for guidance. Some small joints may also be more easily aspirated or injected with aid of ultrasound.
TRIGGER POINT INJECTIONS
A trigger point injection can help soothe muscle pain, especially in your arms, legs, lower back and neck. It also can be used to treat fibromyalgia, tension headaches and myofascial pain.
Trigger points are painful “knots” in your muscles. They form when a muscle can’t relax. Sometimes you can feel these knots when you rub your muscle.
Injecting small amounts of anesthetic and steroid into the trigger point can help alleviate the pain. You will sit or lie down for the procedure. Your doctor will press on your muscle to locate the area where you have pain. Then, he or she will insert a small needle into the area and inject a mixture of anesthetic and steroid.
You can have several trigger points injected during one visit to your doctor’s office. The procedure only takes a few minutes.
The risk of complication from a trigger point injection is very low. Complications such as bleeding and infection at the injection site are uncommon. However, you may have temporary soreness or numbness at the injection site.
Trigger point injection may be right for you if your muscle pain has not improved with other treatment, including pain medication and physical therapy.
Osteoarthritis of the knee is one of the leading causes of disability in the United States. It develops slowly and the pain it causes worsens over time. Although there is no cure for osteoarthritis, there are many treatment options available to help people manage pain and stay active.
A treatment option is a procedure called viscosupplementation. If you have tried all other nonsurgical treatment methods and your pain continues to limit your activities, viscosupplementation may be an option.
In this procedure, a gel-like fluid called hyaluronic acid is injected into the knee joint. Hyaluronic acid is a naturally occurring substance found in the synovial fluid surrounding joints. It acts as a lubricant to enable bones to move smoothly over each other and as a shock absorber for joint loads. People with osteoarthritis have a lower-than-normal concentration of hyaluronic acid in their joints. The theory is that adding hyaluronic acid to the arthritic joint will facilitate movement and reduce pain.