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Patient Information - Epidural

What is an Epidural?

An epidural is a form of a regional anesthesia involving injection of drugs through a catheter placed in to the epidural space. The injection leads to a loss of sensation (anesthesia) and a loss of pain (analgesia), in accordance with the medication administered.

The epidural space is a part of the human spine inside the spinal canal separated from the spinal cord and its surrounding cerebrospinal fluid by the dura mater.

Today, epidurals are widely accepted as an integral part of the non-surgical management of lower back pain. While the effects might be temporary, ranging from one week upto one year, an epidural can be very beneficial for patients suffering from an episode of severe back pain.

What is an epidural used for?

Pain relief is the most important purpose for which an epidural might be administered.

Here we list some of the most important and common uses of an epidural:

1. For pain relief, when surgery is not contemplated.
2. As an adjunct to general anesthesia. The anesthetist may use epidural analgesia in addition to general anesthesia.
3. For temporary pain relief, to facilitate rehabilitation.
4. As the only technique for surgical anesthesia. A Caesarean section for childbirth is the most common example in this category.
5. For post-operative pain relief, analgesics might be given in the epidural space for a few days after the surgery, in cases where a catheter has been inserted.
6. For relief from back pain. This is normally done with an injection of analgesics and steroids into the epidural space.
7. For the treatment of chronic pain or palliation of symptoms in terminal care, usually for short or medium term.

The most common local anesthetics used for the above listed purposes include:

• Lidocaine
• Bupivicaine
• Ropivicaine
• Chloroprocaine

Research shows that an epidural is most useful for analgesia for the abdomen, pelvis or legs as compared to the analgesia for the chest, neck or arms.

When a catheter is placed into the epidural space, the effects of the analgesia may be prolonged for several days, if required.

What is the procedure?

An epidural should be administered only by specialists, qualified and trained to do the procedure, such as an anesthesiologist, radiologist, neurologist, physiatrist and surgeon.

The entire procedure takes between 15 and 30 minutes. Here we list the main steps involved:

1. The patient lies flat on an x-ray table on the abdomen.
2. Before the injection is administered, the skin is numbed with lidocaine.
3. Using fluoroscopy.i.e. live x-ray for guidance, the physician directs a needle toward the epidural space.
4. Once the needle is in the exact position, the epidural solution is injected.
5. The patient is then kept under observation for 15 to 20 minutes.

What are the risk factors?

Thought quite infrequent, but this procedure also has certain potential risks and side effects, including:

• Infection
• Bleeding
• Nerve damage
• Dural puncture
• High blood sugar
• Stomach ulcers
• Cataracts
• Increased appetite

Patient Information - Lumbar Facet Joint Block

What is a lumbar facet joint block?

A lumbar facet joint block is a surgically invasive procedure performed by injecting in to the lumbar (lower back) facet joint or injecting close to the nerves supplying the joint.

Facet joints are small joints at each segment of the spine that provide stability and help guide motion. These joints can become a source of pain due to arthritis of the spine, a back injury or a mechanical stress to the back.

Why is the lumbar facet joint block performed?

A lumbar facet joint block injection is normally performed to achieve one of the two below listed goals:

• Diagnostic goals: The immediate pain relief experienced by the patient by placing the numbing medicine into the joint confirms the joint as the source of pain.

• Pain relief goals: A lumbar facet joint block also includes injecting time-release cortisone into the facet joint to reduce inflammation, often providing long-term pain-relief.

What is the procedure?

A lumbar facet joint block is most commonly performed using fluoroscopy (live x-ray) for guidance, to properly target and place the needle.     

As laid down, the general injection procedure follows the below steps:

• An IV line will be started so that adequate relaxation medicine can be administered, if required.
• The patient is then required to lie face down on an x-ray table and the skin over the area to be treated is cleaned properly.
• The physician numbs a small area of the skin with an anesthetic. This is likely to sting for a few seconds.
• Using x-ray guidance (fluoroscopy), the physician directs a small needle into the joint. Several drops of contrast dye are then injected to confirm that the medicine only goes into the joint.
• A small mixture of anesthetic and anti-inflammatory medication is slowly injected into the joint.

The injection takes only a few minutes. However, the entire procedure usually takes between thirty and sixty minutes.

What happens after the procedure?

After the procedure is over, the patient is required to rest on the table for twenty to thirty minutes and is then asked to move the affected area. This is done in order to provoke the usual pain.

Some patients might not experience pain relief in the immediate first few hours after the injection, depending upon whether or not the joints that were injected are the main source of pain.

Occasionally, the patient might feel some numbness or experience a slightly weak or odd feeling in the upper back for a few hours after the injection. 

Should I take any precautions?

Patients about to undergo a lumbar facet joint block are generally advised to take the following precautions:

• To avoid strenuous activities on the day of the injection
• To avoid driving on the day of the injection without the doctor’s permission
• To avoid driving for at least 24 hours after the injections if sedation was given

What are the risk factors?

The general risk involved with a lumbar facet joint block is relatively quite low. However, a patient might experience one of the below reactions or side effects:

• Allergic reaction
• Bleeding
• Infection
• Worsening of pain symptoms
• Discomfort at the point of injection
• Hot flashes
• Fluid retention
• Elevated blood pressure
• Mood swings
• Cataracts
• Severe arthritis
• Nerve or spinal cord damage

Patient Information - Thoracic Facet Joint Blocks

What are thoracic facet joint blocks?

A thoracic facet joint block is an invasive procedure carried out on the affected thoracic facet joints.

Thoracic (mid back) facet joints are small joints about the size of thumbnails, located in pairs on the back of the spine. The main purpose of these facet joints is to provide stability and guide motion in the mid back.

Due to certain reasons, these joints can become painful and lead to a pain in the mid back, ribs, chest or abdomen.

Why is a thoracic facet joint block given?

A thoracic facet joint block is administered to achieve either or all of the below goals:

1. To confirm or deny the joint as a source of pain by placing the numbing medicine into the joint. Immediate pain relief received from this signals towards the joint as being the source of pain.
2. To facilitate a chiropractor or physical therapist to treat the joint by providing a temporary relief from pain.
3. To help reduce inflammation and pain, sometimes for long-term.

What is the procedure?

The procedure for administering a thoracic facet joint block generally follows the below listed steps:

1. An IV is started so that a relaxation medication can be given when required.
2. You will be asked to lie on the x-ray table, face down so that the doctor can best visualize the joints in the mid back.
3. The skin on your back will be then scrubbed using two types of sterile scrub.
4. Once done, the physician will then numb a small area of skin with a numbing medicine, which might sting for a few seconds.
5. After the numbing medicine has produced the desired effect, the doctor will use x-ray guidance to direct a very small needle into the joint space.
6. Finally, a small mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) will be injected.

What happens after the procedure?

Once over, you will be asked to move around and try to imitate something that would have normally brought about the usual pain. This is done so that you can report the percentage of pain relief and record the relief during the next few weeks on a post injection evaluation sheet.

You will not be in a condition to drive on the day of your procedure. Your chest or mid back may also feel numb or weak for a few seconds. While the numbing medicine is still working, you may also be referred to a chiropractor or a physical therapist.

Do I have to take any precautions?

There are certain amounts of precautions you need to take when about to undergo a thoracic facet joint block. Here we list the main amongst them:

• Eat only a light meal within a few hours before the procedure.
• In case you are an insulin dependent diabetic, do not change your eating pattern prior to the procedure.
• Do not take any pain medications or anti-inflammatories on the day of the procedure.
• Inform your doctor if you are on any of the blood thinners (such as aspirin) or a diabetic medication such as Glucophage.

Patient Information - Cervical Facet Joint Blocks

What are Cervical Facet Joints?

Cervical (of the neck) facet joints are small joints, about the size of the thumbnail located in pairs on the back of the neck.

The main aim of these joints is to provide stability and guide motion in the neck. When these joints become painful, they may lead to pain in the head, neck, shoulders, down between the shoulder blades or in the arms.

Why is the Cervical Facet Joint Block given?

A cervical facet joint block is administered to serve one or more of the below listed purposes:

1. The amount of immediate pain relief experienced by placing the numbing medicine will help in denying or confirming the joint as the source of pain.
2. The temporary relief provided by the numbing medicine may facilitate the work of a chiropractor or a physical therapist who is supposed to treat the joint.
3. The time-release cortisone (steroid) will help in reducing any inflammation that might exist within the joint.

What happens during the procedure?

A procedure for the cervical facet joint block generally follows the below listed steps:

1. To begin with, the patient is explained all the aspects of the treatment clearly. He is then asked to sign a consent form, confirming his approval.
2. An IV is started so that a suitable relaxation medicine can be given.
3. The patient is placed on the x-ray table and positioned in such a way that the physician can best visualize these joints in the neck, using x-ray guidance.
4. Once done, the skin on the back and side of the neck is scrubbed, using two types of sterile scrub.
5. The physician will then numb a small area of the skin with a numbing medicine, which might sting for a few seconds.
6. Once the numbing medicine produces the desired result, the physician will direct a very small needle, with x-ray guidance, inside the joint space.
7. Finally, a small mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) is injected.

What happens after the procedure?

Once the procedure is over, your physician will ask you to move your neck, shoulders and arms around and try to imitate something that would bring about the earlier pain.

After this, you will be asked to record the percentage of pain relief experienced immediately and over the next week on a post injection evaluation sheet.

In addition, your arms may feel weak or numb for a few hours. In some cases, the physician will refer the patient to a chiropractor or a physical therapist immediately after the injection, while the numbing medicine is still working.

What precautions should I take?

Here we list a general set of precautions you need to take when about to undergo a cervical facet joint block:

• Do not change your normal eating pattern if you are an insulin dependent diabetic.
• Do not take any pain medications or anti-inflammatory medications on the day of the procedure.
• Inform your doctor if you are on Warfarin, Heparin, Plavix or other blood thinners (including aspirin)

Patient Information – Sacroiliac Joint Blocks

What is a Sacroiliac Joint Block?

Sacroiliac (SI) joint blocks are injections that are typically used for diagnosing and treating the low back pain associated with sacroiliac joint dysfunction, more common in young and middle-aged women.

The SI joint lies next to the spine and connects the sacrum (bottom of the spine) with the pelvis (hip). The sacroiliac joint is the largest joint in the spine.

Research shows that the sacroiliac pain is very often confused with back pain from the spine.

When is the Sacroiliac Joint Block required?

The SI joint block is performed to relieve pain caused by arthritis in the sacroiliac joint, where the spine and hipbone meet.

In general, a sacroiliac joint block is performed to achieve one or both of the below goals:

• Diagnostic: Diagnostic blocks are administered with the purpose of trying and establishing the exact structural abnormality, which is causing the symptoms. This is also known as finding the ‘pain generator’.

• Therapeutic: In this type of an injection, corticosteroids are injected to reduce the inflammation at the source of the problem that is causing the symptoms.

What is the procedure?

Used for sacroiliac pain syndromes, the procedure for a sacroiliac joint block is aimed at placing the medication into the sacroiliac joint, either on left or on right.

In the SI joint block injection approach, a physician uses fluoroscopic guidance (live x-ray) and inserts a needle into the sacroiliac joint. He then inserts a needle into the sacroiliac joint with a mixture of lidocaine, which is a numbing agent and a steroid (an anti-inflammatory medicine). 

An SI joint block injection can be repeated up to three times per year. However, for the treatment to be successful, the injection should be followed by physical therapy and/or chiropractic manipulations to provide mobilization and range of motion exercises.

Do I need to take any precautions?

If you are about to undergo a sacroiliac joint block, it is important that you follow the below listed pre-test instructions:

• Stop blood-thinning medication 2 days prior to the test.
• Do not consume any form of an aspirin product 5 days before the test.
• Stop all anti-inflammatory medication at least 5 days prior tot the test (with the exception of VioxxTM and CelebrexTM .
• Do not drink or eat 6 hours before the test.
• Arrange for someone to drive you home post-test.

What are the risk factors involved?

Though minimal, but the SI joint blocks can lead to a certain set of side effects and complications. Here we list the main amongst them:

• Side effects may occur due to steroids, including blurred vision, frequent urination, increased thirst and change in blood sugar levels, especially in diabetic patients.
• If fever, chills, increased pain, weakness or loss of bowel/bladder function occurs, you should immediately seek medical attention.
  

Patient Information - Cervical Nerve Root Blocks

What is a nerve root block?

A nerve root block is a surgically invasive procedure, administered for pain relief associated to the nerve roots.

A nerve root exits the spinal cord and forms nerves that travel into the arms or legs. These nerves allow movement of the arms, chest wall and legs and may become inflamed and painful due to irritation, from causes such as a damaged disc or a bony spur.

When is a cervical nerve root block required?

Cervical (of the neck) nerve root blocks (CNRBs) play a very important role in the conservative treatment of patients with cervical radicular pain.

A cervical nerve root block is generally advised for the patients in the following circumstances:

• Therapeutic effects are required to delay or prevent surgery
• Imaging studies are normal
• Imaging studies show multiple levels of pathology

Generally, a cervical nerve root block will be performed to determine if a specific nerve root is the source of pain. Another important aim is to reduce inflammation around the nerve root, thus decreasing or relieving the pain.

A research by Strobel et al strongly suggest that patients with disk herniation, foraminal nerve root compromise and no spinal canal stenosis appear to have the greatest pain relief after this procedure.

What is the procedure?

After all the aspects of the procedure have been explained to the patient, along with its risks and side effects, a consent form is signed seeking the patient’s formal approval. Once done, the procedure will generally follow the below steps:

• An IV will be started to ensure that a relaxation medicine can be started.
• The patient is then placed on the x-ray table and positioned in a way to facilitate the best-desired view, using the x-ray guidance.
• The skin is then scrubbed using two types of sterile scrub.
• Once done, the physician will numb a small area of the skin with a numbing medicine, which might sting for a few seconds.
• After the numbing medicine has had the desired effect, the physician directs a very small needle with x-ray guidance, near the specific nerve being tested.
• To ensure proper needle position, a small amount of contract (dye) is injected, somewhat increasing the usual pain for 30 minutes.
• Finally, a small mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) is injected.

Once the procedure is over, the arms, chest wall or legs may feel weak or numb for a few hours. This a very common after-effect of a selective nerve root block, such as the CNRB.

What are the risks involved?

A series of risks might be involved in relevance to the cervical nerve root block procedure, including:

• Hematoma
• Pain
• Allergic reaction
• Infection
• Nerve damage
• Transient weakness or paralysis
• Injury to carotid or vertebral arteries
• Spinal cord stroke (rare)
• Death (rare)

Should I follow any precautions?

A patient about to undergo a cervical nerve root block is advised to observe the following precautions:

• Eat a light meal before the procedure.
• Do not change your eating pattern if you are an insulin dependent diabetic.
• Do not take any pain medications or anti-inflammatory medications on the day of the procedure.

Patient Information – Thoracic Nerve Root Blocks

What is a Nerve Root Block?

A nerve root block is typically an injection onto the sheath surrounding a nerve root in the spine. The aim of a nerve root block is to decrease the pain temporarily and then define it more precisely.

A selective nerve root block is primarily used to diagnose the specific source of nerve root pain and secondarily, for therapeutic relief of low back pain and/or leg pain.

Pain relief from the procedure of a nerve root block varies from minimal to long-term, depending on the specific symptoms.

When is a Thoracic Nerve Root Block used?

A thoracic (of mid back) nerve root block is carried out to indicate towards the nerve causing pain by placing temporary numbing medicine over the nerve root of concern.

If the usual pain improves after the injection, the nerve in concern is most likely causing the pain. By confirming or denying the exact source of pain, it provides information facilitating proper treatment that may further include additional nerve blocks or surgery at a specific level.

What is the procedure?

A procedure for thoracic nerve root block generally follows the below listed steps:

1. An IV will be started in order to administer the relaxation medicine.
2. The patient will be asked to lie down on the x-ray table and positioned in a manner, which will allow the physician to best visualize the bony openings in the spine, where the nerve roots exit the spine.
3. The skin on the back is then scrubbed using two types of sterile scrub.
4. The physician numbs a small area of skin with a numbing medicine, which might sting for a few seconds.
5. Once the numbing medicine has had the desired effect, the physician directs a very small needle, using x-ray guidance near the specific nerve being tested.
6. A small amount or contrast (dye) is injected to insure proper needle insertion, which might increase the pain for about 30 minutes.
7. Finally, a small mixture of a numbing medicine (anesthetic) ad anti-inflammatory (cortisone/steroid) is injected.

What happens after the procedure?

Once the procedure is over, the physician will ask the patient to imitate something that would normally bring about the usual pain. The patient is then asked to report the percentage of pain relief and record the relief experienced during the next week on a post injection evaluation sheet.

In addition, the arms, chest wall or legs may also feel weak or numb for a few hours after the procedure.

Should I follow any precautions?

The following set of precautions is normally advised for a patient about to undergo a thoracic nerve root block:

1. Eat only a light meal within a few hours before the procedure.
2. Do not change your normal eating pattern, if you are an insulin dependent diabetic.
3. Do not take any pain medications or anti-inflammatory medications on the day of the procedure.
4. Notify your physician if you are on Coumadin, Heparin, Plavix or the diabetic medication Glucophage.

Patient Information - Radiofrequency Nerve Blocks

What is a Radiofrequency Nerve Block?

Radiofrequency nerve block or radio frequency lesioining is a procedure using a specialized machine to interrupt nerve conduction on a semi-permanent basis. The nerves are usually blocked for a period of 6-9 months.

The basic principle of radio-frequency lesioining is placement of an insulated electrode probe into the target tissue.

When is the radiofrequency nerve block used?

Radiofrequency nerve block is generally used for patients with whom all forms of conservative treatment and etiologic treatments such as surgery, have failed.

In addition, the patient should be free of any significant psychological problems and drug dependency.

Radiofrequency nerve blocks are generally advised for patients experiencing one of the below listed medical conditions:

• Mechanical neck or low back pain due to facet joint disease
• Occipital neuralgia
• Coccygodynia and rectalgia
• Abdominal (visceral) pain responsive to splanchnic nerve blocks
• Sympathetically mediated pain
• Rhizotomy
• Ganglionotomy
• RSD/CRPS/SMP involving upper or lower extremities.

In addition, to be a candidate for radiofrequency nerve block, you must have responded well to the local anesthetic blocks.

What is the procedure?

The radiofrequency nerve ablation uses radio waves to produce heat directed at a specific facet joint nerve. The heat destroys the nerve and thus relieves pain.

The patient is required to lie on the stomach when working on the facet joints, low back for lumbar sympathetic nerves and in a sitting position when lesioining the cervical area.

The radiofrequency nerve ablation procedure is similar to a spinal joint injection. However, the only difference is that two needles are inserted. Fluoroscopic guidance is used to correctly position each needle. Once done, the radiofrequency ‘radio waves’ are directed through each needle.

While the ablation process takes about two minutes, the entire procedure takes about 2 hours.

What are the benefits of Radiofrequency Nerve Block?

The radiofrequency nerve block has a series of benefits as compared to the other forms of pain relief. Here we list the main benefits:

• The lesion size can be accurately controlled, thus allowing lesioning of small nerves without damaging nearby motor and other sensory nerves.
• Recovery is rapid and usually uneventful, allowing the patient to return to normal activity very soon.
• Nerve lesion is usually long lasting and heals without neuroma formation.
• The rate of side effects and complications is relatively low.
• When pain recurs, nerve lesion can be repeated as necessary.

What are the risk factors involved?

There is a potential of a series of side effects after the procedure. Here we list the main amongst them:

• Muscle soreness for up to a week afterwards.
• Deep sunburn type feeling.
• Hypersensitivity, burning pain or numbness for a few weeks.