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Performing Surgery

Procedures

Epidural Steroid Injections


Introduction
Steroids are chemicals that are naturally present in our body. Synthetic steroids are generally used in the treatment of inflammatory conditions such as spinal disc injury and degenerative diseases among others. Epidural refers to the space outside the covering of the spinal cord and inside the spinal canal. The epidural space runs along the length of your spinal cord. Epidural steroid injection (ESI) is a minimally invasive method of delivering steroids to the spinal nerve through the epidural space. The epidural injection procedure is performed with the help of a fluoroscope (live X-ray). It is effectively used to target the direct source of the pain and reduce inflammation. The ESI can be delivered by translaminar, caudal or a transforaminal approach.
Indication
Epidural injections are potentially used as a non-surgical procedure for the treatment of inflammation and pain in patients suffering from disc herniation, spinal stenosis and degenerative disc disease. ESI can help relieve pain in the arms, neck, back and legs. It is used for the treatment of inflamed spinal nerves. Patients suffering from spondylolysis and sciatica may also find ESI to be beneficial in relieving pain. ESI is not performed in pregnant women and in people with infections, diabetes or high blood pressure. Pre-procedure
Your doctor will review your medical history thoroughly before the procedure. You may be asked to undergo an imaging test to help your doctor plan for the treatment. The doctor might recommend you stop taking blood thinning medications 3 to 5 days before an ESI. You will be advised to eat light food before the treatment. Procedure
The ESI procedure generally takes 15 to 30 minutes. Patients are awake during the procedure. If you feel anxious about the procedure, then the doctor may give you a sedative. You will lie face down on the table. A local anesthesia may be given to numb the skin before giving the injection. The doctor uses fluoroscope (live X-ray) to direct the needle to the epidural space. Steroid medication is delivered to the nerve root close to the area of inflammation. The approach of injection depends on your condition.

  • Translaminar ESI: The injection needle is placed directly from the middle of the back to the interlaminar space (between the lamina of 2 vertebrae). This allows your doctor to access the epidural space. The steroids are delivered to the nerve roots on the inflamed area.
  • Transforaminal ESI: The injection needle is placed in the neural foramen, on the side of the vertebra. This allows your doctor to access the area outside the epidural space just above the opening of the nerve root. This procedure uses X-ray to help confirm the flow of medication (combined with contrast dye) after injection. It is usually preferred for patients who previously underwent spine surgery.
Post-procedure
You will be monitored for a short while after the procedure, during your recovery period. You are encouraged to walk around immediately after the procedure. You may experience mild discomfort at the site of injection. Soreness in the injection site can be relieved by using ice packs. You will be advised to resume your normal activity on the next day after ESI. You may have to go to your doctor for a follow-up visit after a week of the procedure. Risks
The risks associated with ESI include bleeding, infection, allergic reaction and nerve damage. The steroid medication used in ESI might have some side effects such as weight gain, hot flashes, mood swings, high blood sugar levels and sleeplessness.




Hypogastric Plexus Blocks


The hypogastric plexus is a bundle of nerves present near the distal end of the spinal cord. The nerves transfer pain impulses from the organs around the pelvic region, such as the bladder, rectum, descending colon, perineum, uterus, vagina, vulva, prostate, testes and penis. Blocking these nerves from carrying pain signal helps relieve pelvic pain. Hypogastric plexus block anesthetic injections are targeted at the hypogastric plexus. It is considered when oral medications either do not help relieve the pain or cause adverse side effects. The block is indicated for pain caused by endometriosis, radiation injury or cancers in the pelvic regions. During the hypogastric plexus block procedure you will lay on your stomach on an X-ray table. Your doctor will numb the area on the back with local anesthesia. Then with the help of fluoroscopy (live X-ray), your doctor will insert 2 needles, near each hip bone. Your doctor then injects a dye to track the path of the medication. The medication (steroids, alcohol or phenol) is then injected to block the targeted nerve. This procedure usually takes about 30 minutes. You will be under observation for 30 minutes, and can then go home. Avoid driving and rigorous activities for that day. Your regular activities can be resumed the next day. As with most invasive procedures, hypogastric plexus block may be associated with certain risks that are rare; these include bruising or soreness, infection, bleeding, nerve damage, flushed face, fever, insomnia, headache, increased appetite and heart rate, abdominal cramping or water retention. These side effects usually resolve within a few days. Some patients may experience pain relief 30 minutes after the procedure; however, pain may return once the anesthetic wears off. You may experience long-term relief in 2 to 3 days after the procedure. Pain control may last from a few weeks to a few years. If pain returns the block can be repeated.




Intrathecal Pump Placement


Back pain and leg pain will often resolve either on their own, with medical intervention or with surgical treatment to decompress the nerves. Sometimes, however, back and leg pain cannot be resolved such as with leg and back pain from a condition called arachnoiditis, a pain disorder caused by inflammation and scarring around the nerves. Failed back syndrome is another situation where leg and back pain continue despite previous surgical attempts to resolve. In situations where your neurosurgeon feels an open surgery would not be helpful for you, an intrathecal pain pump is considered. An intrathecal morphine pain pump is a drug delivery system that involves implanting a small reservoir under the skin to deliver pain medication directly to the spinal nerves.This helps attain pain relief at much lower doses than through oral administration of pain medications. An intrathecal pain pump is indicated in patients with severe, chronic lower extremity or back pain. Procedure The procedure is performed in an operating room with the patient under general anesthesia. The patient is placed on their abdomen and a catheter is inserted through a small back incision into the spinal canal. The catheter is then passed under the skin, around your torso, and connected to a reservoir also placed under the skin, usually over the rib cage. Postoperative Care Patients are usually discharged home on the same day or the next day of the procedure. The wound needs to be kept clean and dry. Risks Risks related to the implantation of an intrathecal pain pump are minimal. However, potential risks associated with the surgery include infection, bleeding, nerve injury, spinal cord injury, paralysis, and rarely, death.




Kyphoplasty


Kyphoplasty is a surgical procedure employed in the management of a compression fracture in the spine secondary to osteoporosis. Vertebral compression fractures result in a reduction in the normal vertebral height. The compression of the vertebrae results in pain, restriction of mobility, height loss, and spinal deformity. Conventionally, pain medications, rest, and bracing were commonly used for the nonsurgical management of vertebral compression fractures. Kyphoplasty is a relatively new surgical procedure introduced for the management of vertebral compression fractures of the spine. The aim of the surgery is to relieve pain, stabilize the vertebra, and to restore normal height of the vertebral body. Procedure The patient is sedated before the procedure and then placed on the operating table, on their abdomen. The skin over the back is cleansed and prepared. The procedure is performed under X-ray (fluoroscopy) guidance. In this procedure a tube or probe is introduced into the vertebral body through a tiny incision in the back. After proper positioning is confirmed by X-ray, a drill is introduced into the tube and the vertebral body is drilled. This creates a path for the insertion of a deflated balloon which is inflated once inside the vertebra to the desired height. After a space has been created in the vertebral body by the balloon, this space is filled with orthopedic cement called polymethylmethacrylate (PMMA). The cement hardens in a few minutes, after which the probe and deflated balloon is withdrawn. This procedure restores the normal height of the vertebrae and minimizes the deformity. The skin incision is closed with surgical glue. Vertebroplasty is very similar to kyphoplasty with the only difference being the absence of the use of a balloon. In vertebroplasty, the orthopedic cement or PMMA is inserted into the bone of the collapsed vertebra through a needle and syringe, under fluoroscopic guidance. This technique is performed to stabilize the fracture and prevent further collapse. Postoperative Care Patients are usually discharged home an hour or two after the surgery. You should have a companion to drive you home. At home, you can resume your normal routine activities but should avoid lifting heavy weights. The incision needs to be kept clean and dry. Risks As with any major surgery there may be certain potential risks and complications associated with balloon kyphoplasty and vertebroplasty which include bleeding, infection, bone cement leakage, damage to the spinal cord or spinal nerves, and rarely, cement embolization in the veins that can travel into the lungs, leading to coma and death.




Lumbar Sympathetic Block


Sympathetic nerves are located in the lower spine, control basic functions such as regulating blood flow. They also carry pain signals from tissues to the spinal cord. Lumbar sympathetic block is an injection containing a local anesthetic and steroid, which is injected into or around the sympathetic nerves to block the transmission of pain impulses from the legs or lower back, thereby relieving pain. The lumbar sympathetic block is usually indicated as a treatment for conditions such as reflex sympathetic dystrophy (pain and dysfunction of an extremity), Herpes zoster infection, vascular insufficiency (impaired blood flow) and peripheral neuropathy (nerve damage). You are contraindicated for this procedure if you are allergic to the medications being injected, are taking blood thinning medications, have an active infection, or you have diabetes or heart disorders. The lumbar sympathetic block is performed under local anesthesia and sedation, in an outpatient setting. You will lie flat on your stomach. Your doctor will numb the area of your lower back to be treated. With the help of live X-rays, your doctor will insert a needle into your back. A dye is then injected to check the correct path of the medication. When this is confirmed, the steroid medication and anesthetic is injected into the target site. The entire procedure usually takes less than 30 minutes. After the procedure you may feel warmth in your lower back and your legs may feel numb or weak. You may have pain relief immediately after the injection, but pain may return after a few hours as the anesthesia wears off. Relief from the medication is observed in 2 to 3 day, as the steroid begins to work. Most often you will need 2 to 10 injections at regular intervals to get continued pain relief. As with most therapeutic procedures, lumbar sympathetic block may be associated with certain side effects such as temporary pain or soreness at the site of injection, bleeding and infection. This procedure is usually safe and the risks are rare.




Medial Branch Block Cervical/Thoracic /Lumbar


Medical branch block is an injection of a local anesthetic near the medial branch nerves to temporarily block the pain signal carried from the facet joints of the spine to the brain. It is used to assist your physician in diagnosing the cause of your back pain. Facet joints are the joints connecting the different vertebrae of the spine to each other. Medial branch nerves are small nerves that supply the facet joints of the spine. If a medial branch block is successful in confirming the patient’s back pain is originating from the facet joints, Radiofrequency Rhizotomy is indicated to provide longer pain relief. Indications and contraindications Medial branch block injections are usually indicated in patients with back pain originating from arthritic changes in the facet joints or from mechanical stress to the back. A medial branch block can be performed for the diagnosis or treatment of pain arising from the facet joints. The procedure cannot be performed on patients taking blood-thinning medications or who have an active infection. Also inform your doctor if you are allergic to medications used for the procedure. Be sure to discuss these situations with your physician before the procedure. Procedure A medial branch block procedure is performed under fluoroscopy ( X-ray) guidance for accurate placement of the needles and to avoid nerve injuries. The basic steps involved in the injection procedure include:

  • The patient lays on their stomach on an x-ray table. The area of the skin to be injected is cleansed properly and a local anesthetic is administered to numb the skin. A stinging or burning sensation may be felt for a few seconds.
  • A small needle is then directed into the medial branch nerve area, under X-ray (fluoroscopy) guidance.
  • Contrast dye is used to confirm the location of the needle over the medial branch nerves.
  • Following this, a small mixture of the numbing agent and steroid medication, is then slowly injected over the targeted nerves.
The whole procedure takes about 20-30 minutes and patients can go home on the same day. After the medial branch block your pain may either:
  • go away for a few hours
  • go away for a few days or
  • not reduce at all
If the pain is relieved after the medial branch block, this indicates that the origin of the pain is the medial branch nerves supplying the facet joints. Based on the amount of pain relief observed during the first 6-12 hours after the injection, the patient may be considered suitable for a Radiofrequency Neurotomy procedure to relieve the pain for a longer period of time. In Radiofrequency Neurotomy, an electrical current is passed through a needle to the selected medial branch nerves causing pain in order to interrupt the pain signals. Post-procedural care Patients are advised to avoid driving and doing any vigorous activities on the day of the injection. You should arrange for someone to drive you home after the procedure. The patient may experience localized pain at the injection site in the first 2-3 days for which ice packs can be applied to ease the discomfort. Patients may continue their routine prescribed medications after a gap of 4-6 hours following the procedure, in order to avoid incorrect assessment of diagnostic results related with pain relief. Patients can return to their regular activities, a day after the procedure. In cases where improvement in the pain is seen, patients are advised to perform moderate activities, with regular exercises. Risks and complications Although medial branch block injection is a safe procedure, the possible risks and complications associated with the procedure include:
  • Allergic reaction, usually with x-ray contrast dye
  • Bleeding from the site of injection
  • Infection at the site of injection
  • Discomfort at the site of injection
  • Increased pain
  • Nerve or spinal cord damage and rarely, paralysis




Occipital Nerve Root Blocks


A greater occipital nerve block involves injecting medication around the greater occipital nerve to relieve pain. The greater occipital nerve travels through the muscles at the back of the head and into the scalp providing sensation to the back and top of the scalp. Greater occipital nerve blocks are commonly used for patients with a unilateral headache, mainly at the back of the head. This block may also be used in patients with occipital neuralgia experiencing shooting, zapping, stinging, or burning pain in the back of the head. Patients with migraines, cluster headaches, and other painful conditions may also obtain temporary relief with this block. Procedure During the procedure, you will lie down on an examination table. Then your doctor locates the greater occipital nerve by palpation of the scalp. The skin is cleansed with alcohol and your doctor injects a local anesthetic and steroid mix with a fine needle over the area of the trunk of the nerve.. The injected region becomes numb, often relieving pain. The anesthetic effect wears off over several hours and the steroid begins to act over the next few days. This helps provide pain relief for several days to a few months. Risks Risks and complications are rare but can include infection, nerve or blood vessel injury, and allergic reaction to medications. You may also feel dizzy for a short period of time.




Peripheral Nerve Injections – Celiac


The peripheral nervous system carries signals of movement and senses, such as hot, cold and pain, from different parts of your body to the spinal cord and brain. Injecting an anesthetic at a peripheral nerve can block the transfer of pain signals from the region it supplies to the brain. This is called a peripheral nerve block. A celiac plexus block is a peripheral nerve injection administered at the celiac plexus, a bundle of nerves that surrounds the aorta, to block pain impulses originating from organs in the abdomen. A celiac plexus block is indicated to relieve chronic pain in the abdominal region, most often due to pancreatic cancer or pancreatitis. It is carried out under local anesthesia and sometimes sedation. You will lie on your stomach on an X-ray table, and your blood pressure, oxygen and heart activity is monitored. The region of skin to be injected is cleaned with an antiseptic solution and local anesthesia is given. X-ray images are taken to guide the needle to the correct position of the nerve plexus. A test dye is injected to ascertain the correct location. Then the anesthetic is injected gradually over a couple of minutes. Sometimes, the anesthetic is combined with a steroid to prolong pain relief, or alcohol or phenol to destroy damaged nerves. Once the medication has been injected completely, the needle is removed and a bandage is placed. The entire procedure takes about 10 to 30 minutes. After the procedure, you may feel warmth in your abdomen, and experience pain relief that will last for a few days. For better outcomes, you will be advised to have a series of 2 to 10 injections at varying intervals. The duration of relief tends to get longer after each injection. Although it is a safe procedure, celiac nerve block may be associated with certain side effects and risks such as temporary pain and soreness at the injection site, temporary weakness or numbness near the abdominal wall or leg, bleeding, infection, or injection of the anesthetic at other regions of the spine, blood vessels and surrounding tissues.




Sacroiliac and Peripheral Joint Injections


Sacroiliac Joint Injection The sacroiliac joint connects the lowest part of the spine, the sacrum, to the adjoining bones of the pelvis, the iliac bones, which are present on either side of the sacrum. In an adult there is minimal movement at these joints. However in a female, they play an important role during delivery where they relax and increase the flexibility of the pelvis. An injury or arthritis can cause inflammation of the sacroiliac joints, causing pain. Sacroiliac joint injections, containing cortisone and a local anesthetic, can reduce the inflammation and decrease the intensity of pain. The benefits of sacroiliac joint injections vary. In most patients, the pain subsides within 10-15 minutes after the injection and may provide pain relief for up to 6 months or more. In some patients, it may not provide much pain relief. In cases of recurring pain, the injection may be repeated or alternative pain management techniques will be discussed with you. Preparation before the injection You should inform the doctor if:

  • You have any cough, cold or any systemic or skin infection such as a wound, boil or rash as infection could spread to the spine. If necessary, the doctor will reschedule the injection for a later date once the infection resolves.
  • You are a diabetic. Cortisone injections may cause transient elevation in blood sugar and may require a temporary adjustment of your blood sugar medication.
  • You are on any blood thinning medication
  • You think you are pregnant
Procedure Sacroiliac joint injection is an outpatient procedure performed by a radiologist. The patient would lay face down in a CT scanner. The injection site is sterilized and local anesthetic is injected to numb the area. A fine needle is then inserted through the skin and tissues into the sacroiliac joint, under guidance from CT Fluoroscopy imaging. Once the position of the needle has been confirmed, a mixture of cortisone and local anesthetic is injected into the inflamed sacroiliac joint through the needle. After the injection Some patients may experience mild discomfort in the back while most patients are free from pain. Patients are able to walk freely and are observed for 10 minutes following the procedure. You should avoid driving for the rest of the day, after the injection. You may return to work the following day but strenuous activity should be avoided for the initial few days. The intensity of activities can be gradually increased over time. Risk and Complications Sacroiliac joint injections are safe but as with other medical procedures there are risks involved. Some of the risks associated with sacroiliac joint injection include infection and nerve damage. Bleeding at the injection site is rare but can occur in patients with bleeding disorders and those on blood thinning medications.




Selective Nerve Blocks


A selective nerve block is the injection of an anesthetic and steroid medication around the spinal nerve root to diagnose or treat pain. It is indicated to relieve pain, weakness, numbness and tingling sensation in your neck, back and extremities due to nerve injuries such as a pinched nerve and spinal stenosis (narrowing). A selective nerve block is an outpatient procedure during which you will lie on your stomach on an X-ray table and your doctor will administer a sedative intravenously to help you relax during the procedure. Your vitals will be constantly monitored. Your doctor locates the target site with the help of X-ray imaging. A contrast dye is used to ensure that the needle is accurately placed and the medication is then delivered to the target site to help relieve pain and inflammation. If the nerve block is performed as a diagnostic procedure, you will be instructed to note any changes in the levels of pain at different intervals. This helps your doctor evaluate which nerve is causing pain. The entire procedure takes approximately 15 to 30 minutes. You may have pain relief immediately after the injection, but pain may return after a few hours as the anesthesia wears off. The effects of the treatment will be usually noticed 2 or 3 days after the treatment. If you respond well to the first injection, you may be advised to have another injection after a period of time for better relief. With any procedure there may be risks, complications or side effects. The most common side effects of selective nerve block are pain (temporary), bruising, infection at the site of the injection and nerve damage.




Spinal Cord Stimulation


Spinal cord stimulation is used for the management of chronic pain in arms and legs that has not responded to conventional modalities of treatment. Specific segments of the spinal cord are stimulated through electrical signals, generated by a spinal cord stimulator, which may be associated with a slight prickling or tingling sensation. There are different types of stimulation systems but the most common among them is an internal pulse generator with battery. A SCS system comprises of:

  • An implantable pulse generator with battery that generates electrical signals
  • A lead with many electrodes which delivers the electrical impulses to the spinal cord
  • An extension wire connecting the pulse generator to the lead
  • A manually operated remote for adjusting the electrical signals
A spinal cord stimulator (SCS) is surgically implanted in the subcutaneous tissue of the lower back, beneath the skin, and is also known as a dorsal column stimulator. A SCS comprises of a small wire that transmits the electrical signals from a pulse generator to the leads. These signals interrupt the transmission of pain signals from the spinal nerve fibers to the brain, thus relieving the pain. SCS only provides symptomatic relief and does not cure the root cause of pain. There is interindividual variation in the extent of pain relief with a SCS. Therefore, before implantation of the permanent device, trial stimulations are performed to evaluate the patient’s response. A SCS provides significant relief in performing routine activities and decreases the requirement for pain medications. A SCS is effective in the management of chronic pain in the lower extremities or back and also in various other disorders such as sciatica, failed back surgery syndrome, complex regional pain syndrome (CRPS), and arachnoiditis. Procedure There are different techniques for the implantation of a spinal cord stimulator. Before implantation of the permanent device, a trial implantation is done by placing the stimulator at the appropriate segment of the spinal cord. In a trial implantation a paddle lead is placed over the spinal cord either by removal of the lamina covering the spinal cord or by percutaneous insertion of the lead through the skin. If there is a significant reduction in the intensity of pain with a trial stimulator, permanent implantation is performed after a few days. Postoperative care After the implantation of a spinal cord stimulator you may be discharged on the same day or next day after the procedure. Patients are instructed to keep their wound clean and dry. Risks The risk and the complications associated with the procedure are generally low. However, some of the possible risks include bleeding, infection, nerve damage, spinal cord injury, paralysis and death.




Stellate Ganglion Block


The stellate ganglion is a set of nerves located at the last two vertebra of the neck which supply the face and arm. Trauma, injury or infection to these nerves can cause pain. A stellate ganglion block is an injection containing local anesthesia and a steroid, which blocks pain signals from reaching the brain. The injection can be used for the following:

  • Manage pain in your neck, head, arm or chest due to nerve injury, infection or angina (reduced blood flow to heart muscles)
  • Reduce sweating in the head, face, arms and hands
  • Diagnose the cause for pain
The procedure of administering a stellate ganglion block is performed under local anesthesia and intravenous sedation. You will lie on your back. The area of injection in front of your neck is cleaned with antiseptic. Your doctor will gently press your neck to identify the spot for the placement of the needle. During this time, you are instructed to remain still and not talk, cough or swallow. The medication is gradually injected through the needle. After the procedure is complete the needle is removed. The entire procedure takes about 5 to 10 minutes. You will remain in the recovery area after the procedure. You may feel warmth in the treated area and may have a hoarse voice, red eyes and swallowing difficulties. If you respond to the 1st injection, you will be recommended for a repeat injection. A series of such injections is needed to treat this condition. Though the risks of the procedure are infrequent, they may include seizures, bleeding at the site of injection, epidural or spinal block (numbness or temporary weakness from the neck and below), collapsed lung, allergic reaction to the medication, or damaged nerves.




Trigger Point Injections


Trigger point injection (TPI) are used to treat intense pain in the muscles containing trigger points. Trigger points are tight bands or knots that are formed when the muscle fails to relax after the contraction. A trigger point may also cause referred pain (pain in another part of the body) by irritating the adjacent nerves. Trigger point injections can be used to relieve pain in conditions such as myofascial pain syndrome when other treatments are a failure, fibromyalgia, and tension headaches. During this procedure, nerve block will be administered by the orthopedist or pain specialist to numb the area of needle penetration and keep you comfortable during the procedure. Further, a small needle containing local anesthetic (lidocaine, procaine) which may or may not containing corticosteroid is directly injected to the trigger point. This makes the trigger point inactive and the pain is relieved. This is a short procedure and may just take a few minutes. The injection may cause mild pain for a short time. If you are allergic to the local anesthetic medication, a dry-needle technique (without medications) is used. Numbness at the site of injection may persist for about an hour after the procedure. A bruise may even form at the site of injection. Applying moist heat and ice alternatively to the area for two days relieve the pain. Your orthopedist may also recommended stretching exercises and physical therapy after trigger point injections.