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Minimally invasive procedures are a key part of ongoing pain management for spinal conditions and long-term treatment. The specialists at the Center for Comprehensive Spine Care work with a number of ancillary treatments including:

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    Acupuncture for Pain

    Accupuncture for Pain

    What Is Acupuncture for Pain Management?

    Acupuncture has been used as a treatment modality for over 3,000 years in China and throughout Asia. While acupuncture does indeed have an ancient history, it has become both accepted and prescribed as an effective treatment for many painful conditions.

    Both the National Institutes of Health and the World Health Organization has acknowledged acupuncture as an effective treatment modality for conditions involving pain and nausea.

    The principle behind acupuncture involves a type of energy called qi. The qi flows along acupuncture channels or meridians of the body. There are 12 meridians on the body that are divided into two groups-yin and yang, representing masculine and feminine. There are three yang meridians of the upper extremities, three yang meridians of the lower extremities, three yin meridians of the lower extremities, and three yin meridians of the upper extremities. There are eight additional meridians that are not designated yin or yang. Block ages and imbalances in the flow of qi result in disease and symptoms. The flow of qi can be corrected by inserting fine needles at specified points along the meridians.

    Acupuncture was first in the spotlight of the U.S. public in 1971. A New York Times reporter named James Reston was covering Henry Kissinger on a trip to China in 1971 and fell ill to acute appendicitis. His appendix was removed in a modern Chinese hospital using general anesthesia. However for his post-surgical pain he was offered and accepted acupuncture to help alleviate his symptoms. He wrote an article in the NY Times July 25th 1971 detailing his experience.

    Types of Acupuncture for Pain Management

    Single use, sterilized, disposable needles are used in acupuncture. It is important to note acupuncture needles are solid and very thin which allows them to slide into the skin without pulling epidermis or foreign material into the body. The process of the treatment is typically not painful; most patients do not even feel the hair-thin needles as they are inserted or tapped in. In fact, many find the experience relaxing. Others become energized by the treatment. There are many subtle differences in styles and point selections. Traditional stimulation of the needles involves physical tapping, rotating, or warming the needles with incense called moxibustion. Electrical stimulation of the needles dates back to the 1930s. Location of the acupuncture points typically involves some needles at the local area of involvement, but also at distal points related to the meridians that are involved. Typical treatment sessions last for about 20-30 minutes.

    Conditions Related to Acupuncture for Pain Management

    New research showed that adenosine plays a large role in the pain relieving benefits of acupuncture. Adenosine, a molecule that influences inflammation and sleep, also acts as an endogenous opiate. Using mice with injured paws, the scientists first demonstrated that adenosine was released during acupuncture. In mice that didn’t have adenosine receptors there was no relief from pain. A group of mice were given an approved leukemia drug that lengthens the amount of time that adenosine sticks around.

    With the drug, the animals experienced relief for three times as long: three hours instead of an hour.

    A 2006 Mayo Clinic study for fibromyalgia found that acupuncture significantly improved symptoms of this condition. Symptomatic improvement was not restricted to pain relief and was most significant for fatigue and anxiety. This type of treatment is also common for those suffering from sports injuries.

    Gate Control Theory is another theory behind the effectiveness of acupuncture. This theorizes that acupuncture activates sensory receptors, which will block pain receptors and thus “gate out” painful stimuli.


    The NIH Consensus Conference on acupuncture in 1997 concluded: “There is sufficient evidence of acupuncture’s value to expand its use into conventional medicine and encourage further studies of its physiology and clinical value.”

    If you are experiencing chronic pain, you may want to consider speaking to your doctor about adding acupuncture to your pain management treatment program.


    Facet Joint Injections

    Facet Joint Injections

    What are Facet Joint Injections?

    Facet Joint Injections are a minimally invasive non-surgical treatment that is used as treatment for many different causes of neck and back pain. It works by reducing the inflammation and irritation in the facet joints of the spine that is causing you pain.

    The syndromes most commonly requiring Facet Injections include:

    • Spinal Stenosis
    • Herniated Disk
    • Sciatica
    • Spondylolysis

    Facet Joint Injections - Procedure

    The facet joint of the spine is a moveable connection that connects one vertebra (bone of the spine) to another. This injection includes both a long-lasting steroid and an anesthetic (lidocaine, bupivacaine). The steroid reduces the inflammation and irritation and the anesthetic works to numb the pain. The combination medicine then spreads to other levels and portions of the spine, reducing inflammation and irritation. The entire procedure usually takes less than 15 minutes.

    The Facet Joint Injections and the Epidural Steroid Injections (ESI) are very similar and differ in the location that they inject the medicine. In an ESI, the medication is injected into the epidural space whereas in the facet injections, it is injected directly into the joint.

    Facet Joint Injections - Benefits

    The most important and greatest success achieved with the use of facet joint injections is the rapid relief of symptoms that allows patients to experience enough relief to become active again. With this they regain the ability to resume their normal daily activities that was not achieved with oral medications and physical therapy.

    Another benefit to the use of facet joint injections is that it can be used as a diagnostic test to see if the pain is actually coming from the facet joints. If your pain disappears with the injection then it is clear that the pain is originating from the joint, and it has been shown that therapeutic lumbar facet joint nerve blocks with local anesthetic, with or without steroids, may be effective in the treatment of chronic low back pain of facet joint origin. (Manchikanti 2007). However, if your pain is unresponsive then this gives your physician information that can help him in diagnosing your condition.

    A large evidence-based practice guideline for the management of chronic spinal pain with interventional techniques was developed by the American Society of Interventional Pain Physicians provide recommendations to clinicians and patients in the United States. In regards to the facet joint injections they states that the accuracy of facet joint nerve blocks is strong in the diagnosis of lumbar and cervical facet joint pain (Boswell 2007).

    Facet Joint Injections - Risks

    With a minimal amount of risks, facet joint injections are considered an appropriate non-surgical treatment for many patients who suffer from back pain. The associated risks with this procedure involve misplacement of the needle, either advancing the needle too deeply or positioning it incorrectly. The outcome of the incorrect positioning of the needle can potentially cause nerve damage, bleeding, infection, and a headache following the injection.

    As with any medication taken, there are always risks and potential side effects that may occur. The other risks of the facet injections may be directly caused by the actual medication given, however, the risk of developing these side effects are much higher in a person taking oral corticosteroids. Some of the potential side effects of the corticosteroid may include elevated blood sugars, weight gain, arthritis, stomach ulcers, and transient decrease in the immune system. All patients before receiving a facet injection should be assessed by their physician about risk assessment for the procedure.

    Facet Joint Injections - Outcome

    Lumbosacral injections have increased dramatically in the Medicare population from 1994 to 2001 and are becoming even more popular today (Friedly 2007). They are being used more frequently because they have provided very successful results in the treatment of back pain.

    In research study a group of patients with back pain received facet joint injections and at 8 weeks of treatment 53% of people reported improvement of their pain and by 6 months of treatment over 68% reported the same (Anand 2007). The duration of pain relief varies from each individual but if the first facet injection provides relief then the procedure can be repeated up to 3 times a year.


    Evaluation of lumbar facet joint nerve blocks in the management of chronic low back pain: preliminary report of a randomized, double-blind controlled trial: clinical trial NCT00355914. Manchikanti L, Manchikanti KN, Manchukonda R, Cash KA, Damron KS, Pampati V, McManus CD. Pain Physician. 2007 May;10(3):425-40 PMID: 17525777

    Increases in lumbosacral injections in the Medicare population: 1994 to 2001 Friedly J, Chan L, Deyo R. Spine. 2007 Jul 15;32(16):1754-60 PMID: 17632396

    Patients’ response to facet joint injection. Anand S, Butt MS. Acta Orthop Belg. 2007 Apr;73(2):230-3 PMID: 17515236

    Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Boswell MV,Trescot AM, Datta S, Schultz DM, Hansen HC, Abdi S, Sehgal N, Shah RV, Singh V, Benyamin RM, Patel VB,Buenaventura RM, Colson JD, Cordner HJ, Epter RS, Jasper JF, Dunbar EE, Atluri SL, Bowman RC, Deer TR, Swicegood JR, Staats PS, Smith HS, Burton AW, Kloth DS, Giordano J, Manchikanti L; American Society of Interventional Pain Physicians. Pain Physician. 2007 Jan;10(1):7-111 PMID: 17256025

    Hardware Blocks

    Hardware Blocks

    What are Hardware Blocks?

    A Hardware Block is a procedure that helps with pain in the cervical, lumbar or spinal fusion. When an individual experiences chronic pain it is often caused by several factors and has endured over an extended period of time. If you have had a fusion but are continuing to experience pain, it is important to determine if the hardware is the cause or if something else is creating the chronic condition.

    A study by the Global Burden of Disease in 2010 showed that back pain is the leading cause of disability for American workers. More than one half of the population will experience chronic pain in their lifetimes. Chronic pain is defined by experts as any pain that persists for longer than three months.

    Proper treatment is important, but has also proven to be expensive for Americans, costing more than $50 billion annually in the United States.

    Experts have seen that most back pain is not caused by cancer, bone breaks or arthritis. Most chronic pain is caused by a mechanical injury to the muscle tissue or joint. Often, individuals who suffer chronic pain will opt for surgery, which includes hardware. Occasionally this will cause additional pain, and hardware blocks can determine the right way to treat the issue.

    Talk to your doctor about hardware blocks. In the procedure the patient is given a nerve block via injection of an anesthetic near the hardware in your spine. At that time the patient is asked to recreate his or her general range of motion. If the patient continues to experience pain then the doctor can determine that the hardware is not the cause of the pain, and will begin to assess treatments for the new areas of chronic pain.

    If the hardware block does prove that the screws in your fusion are causing the increased pain, you can discuss possible options with your physician.

    In addition to hardware blocks, it is important to make some lifestyle changes to improve your overall quality of life. Someone experiencing chronic pain should give up smoking and work on eating healthier and exercising. Good posture, good shoes and the right bed can also help improve symptoms. You may also wish to make changes to your workstation to make it more ergonomic and comfortable.

    Chronic pain after a cervical, lumbar or spinal fusion is not abnormal, but it doesn’t have to limit your mobility or your quality of life. Often chronic pain can have more of an effect on your mental well-being than simply your physical health. It is extremely important to keep your physician up to date on your experiences.

    While a hardware block may be able to isolate the problem, the treatment for your chronic pain may need to be a more holistic approach. Treatment for depression as well as physical therapy can help alleviate symptoms.

    Chronic pain doesn’t cause only physical symptoms - it is also one of the leading causes of depression. Talk with a chronic pain specialist to understand the ways you can find pain relief, which may include hardware blocks to diagnose the specific issue. If you’ve had a fusion with hardware, consult your doctor about hardware blocks to see if you can isolate the pain.

    Hip Injection

    Hip Injection

    What is a Hip Injection?

    A hip injection is a cortisone shot administered in the hip joint to reduce pain and inflammation. A relatively simple and straightforward procedure, it can be performed at the doctor’s office in just a few minutes.

    Hip pain does not automatically mean a patient would benefit from a hip injection, although this kind of treatment has been effective for patients suffering from hip pain, either due to injury or disease.

    Examples of conditions that cause pain in the hip joint include osteoarthritis, rheumatoid arthritis, hip bursitis, hip fractures, tendinitis, dislocation, sacroiliitis, sciatica, spinal stenosis and osteoporosis. Cancer may also cause hip pain that can be managed with a hip injection.

    Doctors typically recommend that patients stop using any kind of blood-thinning medications prior to receiving a hip injection, as these medications will prevent clotting, thus increasing the risk for excessive bleeding or bruising at the time of the injection.

    Usually the patient will be asked to change into a gown. Then the doctor will clean the hip area to make it sterile before applying a topical anesthetic to numb the outermost nerves in the area.

    At the time the needle is inserted through the skin and into the joint area, the patient may feel mild discomfort and/or a little pressure. Once the doctor has reached the desired depth, he or she will release into the hip joint the prescribed medications - usually a combination of an anesthetic and a corticosteroid. While the anesthetic provides immediate pain relief, the corticosteroid will work gradually to relieve pain and inflammation over time.

    Following the hip injection it will be very important to monitor the injection site for any signs of prolonged inflammation, infection or excessive bleeding. The area around the injection site may feel somewhat sore for a few days following the procedure, and the doctor may recommend using cold therapy on the area to reduce swelling.

    The patient may also be directed to limit activities for a few days immediately following the hip injection. This is important not only for limiting the chance of infection, but also to minimize potential post-injection pain and inflammation, and get an accurate idea of how the injection has affected the patient’s pain levels.

    Potential complications and risks of a hip injection include: weakening or deterioration of bone, joint infection, nerve damage, temporary pain, temporary inflammation, temporarily elevated blood sugar levels.

    Because cortisone injections might affect bone health, muscle strength and the health of the cartilage around the joint, a hip injection is usually not recommended to be performed with frequency, or over a long period of time. Doctors usually limit their patients to just a few injections per year and do not increase a patient’s dosage for the injection unless absolutely necessary.

    However, for those patients who have exhausted other forms of therapy without the results they want, the injections can provide some relief.


    Intercostal Nerve Blocks

    Intercostal Nerve Blocks

    What are Intercostal Nerve Blocks?

    An intercostal nerve block is an injection of an anesthetic, and often steroids, in the intercostal nerve in order to relieve pain. This injection inhibits pain signals and reduces inflammation, thereby decreasing the pain involved.

    Intercostal blocks are administered through the ribs in the thoracic region. Typically, the procedure is performed during chest or abdominal surgery, though it is also done as an outpatient procedure for acute pain.

    How Intercostal Nerve Blocks Work

    The intercostal nerve is responsible for carrying pain messages from the muscles, bones and skin to the brain. By blocking certain regions of this nerve, physicians can diagnose where pain is originating and inhibit further pain. The first intercostal nerve block is normally used for diagnostic purposes only, with subsequent intercostal nerve blocks used to block pain signals.

    For some patients, a single procedure may result in permanent pain relief.

    Intercostal nerve blocks are also a relatively safe procedure for patients with little risk of side effects. Physicians can easily access the intercostal nerve by injecting the area between two ribs where the nerve is located. When successful, the procedure also frees patients from the side effects of opioid medications.

    Intercostal Nerve Block Procedure

    Patients are injected with an anesthetic, and often steroids, in the intercostal nerves. The block itself only takes a few minutes. The physician first applies a local anesthetic to the area. With the patient sitting on his or her side or back, the physician then administers the injection into the intercostal nerves.

    After the procedure, the patient is normally monitored for a few minutes and then allowed to return home. If there is no pain relief in the weeks following the procedure, a new treatment plan must be considered. If the treatment was successful, the patient will begin to feel pain relief immediately after the surgery, due to the local anesthetic, and another level of pain relief three to five days after the procedure once the steroid component has taken effect.

    Intercostal Nerve Block Diagnosis and Treatment Benefits

    While intercostal nerve blocks can be very helpful for relieving pain, it is difficult to predict exactly how and if they will help. The first injection is often used to diagnose the actual area in pain. When successful, the patient may experience pain relief for weeks or months after the procedure, or the relief may become permanent.

    More often, patients return for repeat injections to treat the pain after the effects of the initial intercostal nerve block wears off. A permanent ablation can eventually be performed to provide long-term pain relief. Patients with acute, recent pain often respond better to intercostal nerve blocks than patients experiencing chronic pain.

    Intercostal nerve blocks can be used to treat:

    • Pain in the chest associated with herpes zoster or shingles
    • Post-operative pain in the chest or abdomen
    • Chronic pain after a mastectomy
    • Pain from a rib fracture
    • Pain related to scar tissue formation after surgery
    • Pain associated with metastatic cancer to the ribs

    Intercostal Nerve Block Risks and Side Effects

    In general, intercostal nerve blocks are extremely safe. There may be some temporary discomfort from the needle insertion, however, the local anesthetic should prevent this. The most common side effect is temporary pain at the injection site. More serious side effects include infection, bruising, bleeding, or worsening of these symptoms.

    Since intercostal nerve blocks are performed in the area surrounding the lungs, there is a relatively small chance that the lung could be damaged, resulting in a collapsed lung. If patients experience shortness of breath after the procedure, they should contact their physician.

    Intra-Articular Steroid Injection

    Intra-Articular Steroid Injection

    What is Intra-Articular Steroid Injection?

    Intra-articular steroid injections (IASI) can be an effective method for treating a variety of joint pain, including pain arising from osteoarthritis, a condition in which the cartilage that protects and cushions the joints breaks down over time.

    With osteoarthritis, the bones formerly separated by the cartilage start rubbing directly against each other, resulting in damage to the bone and causing painful joints. Osteoarthritis is the most common form of arthritis and is a major cause of disability in older adults, most often affecting the spine, fingers, thumbs, hips, knees or toes.

    Initially, this condition is typically treated with analgesics to control the pain, such as acetaminophen (also called Tylenol) and non-steroidal anti-inflammatory drugs (NSAIDs) to reduce the inflammation, such as aspirin, ibuprofen and naproxen. However, if you have not experienced sufficient pain relief with these treatments, an injection of corticosteroid into the joint can sometimes be helpful for short-term pain relief and to increase mobility or movement in the joint.

    Steroids or corticosteroids are medications designed to mimic natural hormones produced by the body that help reduce inflammation. Steroids may be used to reduce inflammation in tendons and ligaments in osteoarthritic joints. Corticosteroids may relieve pain caused by osteoarthritis for a short amount of time (weeks to months), or they may provide longer-lasting relief.

    Intra-articular steroid injections can be an effective treatment option for some patients. The procedure is minimally invasive and uncomplicated. Before the actual steroid injection, the doctor will inject a local anesthetic in the treatment area to numb the skin. The doctor will then inject the steroid, typically using ultrasound or other guided X-ray for proper placement.

    Following the intra-articular steroid injection, it is often helpful to ice the area, as the injection itself will cause some swelling. Immediately following the procedure you will likely feel quite comfortable because the area will be numb from the first injection of the local anesthetic.

    Generally the effects of the anesthetic will wear off about two hours following the procedure. At this time it’s normal to experience increased pain that may initially be worse than the pain experienced before the injection. This type of discomfort is called a post-injection flare and is the result of injection a steroid directly into the joint. The pain will subside in a day or two, and it’s recommended to treat the area with ice and over-the-counter analgesics during this time period.

    The injection of any substance into a joint or tendon carries risks, although the chances of complications resulting from intra-articular steroid injections are low. Risks include damage to a tendon, ligament or nerve; bleeding into the tissue; and infection. It’s crucial that the injection site be closely monitored in the days following the injection for signs of redness, unusual swelling or infection.

    Some patients have reported long-term relief of up to six months or longer from intra-articular steroid injections. In general doctors limit steroid injections into a single joint area to three or four times per year, as there is some concern that repeated long-term use can cause damage to the joint and surrounding tissues.

    Lumbar Epidural Steroid Injection

    Lumbar Epidural Steroid Injection

    What is a Lumbar Epidural Steroid Injection?

    A lumbar epidural steroid injection is administered to reduce pain in the lumbar spine, also known as the low back. This type of injection is not a cure, but rather a treatment, and can temporarily alleviate discomfort in the area extending from the lower spine to the hips and possibly even down the leg.

    Patients who have not already found significant relief from low back pain with non-invasive therapies such as medications or physical therapy are good candidates to benefit from a lumbar epidural steroid injection.

    The injection, which usually consists of a corticosteroid and a local anesthetic, is administered in the outer part of the spinal canal, also called the epidural space. The pain specialist will make the injection as close to the affected nerves as possible to reduce inflammation and pain for the patient.

    To administer the lumbar epidural steroid injection as precisely as possible, the doctor will order an MRI scan of the patient’s back. By studying this, he or she will be able to determine exactly where the problems are located, as well as the injection site that will deliver the patient the greatest amount of pain relief.

    Prior to the procedure patients are also recommended to stop taking medications that prevent clotting, such as aspirin, ibuprofen, naproxen and others. This is to limit the possibility of excessive bleeding at the injection site.

    For the procedure, which typically lasts about 15 to 20 minutes, the doctor will ask the patient to lie face-down on an elevated table. After sterilizing the patient’s back, the doctor will then guide the needle into the epidural space using X-ray guidance for the most precision. When the needle is in the correct position, the doctor will release the medications. The patient may feel some pressure during the positioning of the needle and the injection.

    Immediately following the injection a patient may feel some pain resulting from the injection itself, or his or her symptoms might temporarily become worse. The effects of the corticosteroid develop gradually over a period of a few days, and then a patient can typically expect the pain relief to last for several weeks to several months.

    All procedures carry some risk, although the risks associated with lumbar epidural steroid injections are relatively few and most are not serious. Potential complications and negative side effects a patient may experience with this type of injection include: nerve damage, nausea, allergic reaction, excessive bleeding or infection at or around the injection site, and internal bleeding.

    Because lumbar epidural steroid injections affect bone health, muscle strength and hormonal balances, it’s usually not recommended that lumbar epidural steroid injections are administered with frequency, or over a long period of time. Doctors usually limit their patients to two or three injections per year and do not increase a patient’s dosage unless absolutely necessary.

    However, for those patients who have exhausted other forms of therapy without the results they want, the injections can provide some relief.


    Lumbar Facet Block

    Lumbar Facet Block

    What is a Lumbar Facet Block?

    A lumbar facet block is an injection of corticosteroid (steroid) medications into the facet joints of the low back. The facet (zygapophysial) joints, formed by the articular processes of the vertebrae, facilitate motion of the spinal column. The facet joints can become painful for a variety of reasons.

    Inflammation is a principle cause of joint pain. One common inflammatory condition of the facet joints is osteoarthritis. As a person ages, degeneration of the spine leads to spinal collapse and wear-and-tear within the facet joints, which produces inflammation and pain in facet joint tissues. Injection of corticosteroids, which are potent anti-inflammatory drugs, can help to reduce painful inflammation in these spinal joints.

    Another common reason for facet joint pain is trauma. Damage to the joints through physical accidents can lead to joint inflammation. Blockade of the painful joints can relieve pain associated with this inflammation.


    A facet block is a quick procedure performed on an outpatient basis. The skin over the area to be injected is cleaned with antiseptics and numbed with local anesthesia. The practitioner then injects corticosteroid medications into the facet joint under fluoroscopic guidance. Use of fluoroscopy, or real-time x-ray) guidance, permits the practitioner to see internal structures in detail.

    The patient is released shortly thereafter, following a brief period of monitoring. If the treatment successfully reduces the patient’s pain, future facet blocks may be scheduled. Alternatively, other forms of treatment may be discussed with the patient.


    Facet blocks:

    • Are minimally invasive.
    • Are convenient, as they are given on an outpatient basis and require little procedural and recovery time.
    • May make the patient a candidate for other treatment options.


    The facet block is associated with a low rate of post-procedural complications. However, like any medical treatment, the risk of unwanted outcomes exists. Some of the reported complications of facet blocks include:

    • Infection.
    • Damage to neighboring tissues, such as blood vessels and nerves.
    • Temporary soreness at the injection site.
    • Side effects from use of corticosteroid medications, particularly if several facet blocks are used within a short time span.

    Lumbar Medial Branch Block

    Lumbar Medial Branch Block

    What is a Lumbar Medial Branch Block?

    A lumbar medial branch block is an injection of numbing medication into the medial branches, or nerves that give feeling to the facet joints in the spine. Due to its numbing capabilities, the lumbar medial branch block can be used to diagnose and treat pain in medial branches in the lumbar region of the spine, or low back.

    The facet joints (zygapophysial joints), located where the vertebral bones touch, provide motion between vertebrae. Pain in the medial branches of the facets is often a consequence of degenerative processes associated with aging, such as osteoarthritis and spinal disc degeneration. The spine may begin to collapse, reducing the space between neighboring vertebrae. Such processes increase inflammation and friction in the facet joints, and may lead to buildup of scar tissue, all of which have the potential to irritate and compress the medial branch nerves.

    By numbing a medial branch, the practitioner can assess whether the pain is originating from the nerve, and determine whether continued nerve blocks would be of benefit. A successful medial branch block may also make the patient eligible for longer-lasting pain relief procedures, such as radiofrequency ablation.

    Lumbar Medial Branch Block Procedure

    A medial branch block is an outpatient procedure that takes only minutes to perform. First, the skin over the area to be injected is cleansed with antiseptics, and treated with local anesthesia. Then, the physician injects numbing medication into the medial branch nerve(s) using fluoroscopic (real-time x-ray) guidance to ensure accuracy.

    After a short recovery period, the patient is released the same day. The patient will be asked to rate his or her pain after the procedure and in follow-ups.

    A successful medial branch block is characterized by a pain reduction of at least 50%. Since the effects of the block are temporary, the patient’s pain relief can be maintained with a series of these injections. At that time, the practitioner may also offer the patient longer-lasting treatments that produce longer-lasting pain relief.

    Lumbar Medial Branch Block Benefits

    Medial branch blocks:

    • Are minimally invasive.
    • Are conducted on an outpatient basis.
    • Require very little recovery time.
    • Serve as a screening method for longer-lasting pain relief procedures.

    Lumbar Medial Branch Block Risks

    The medial branch block is a relatively safe and common procedure. However, like any medical treatment, it can lead to complications, such as:

    • Infection.
    • Damage to surrounding tissues, such as spinal membranes.
    • Temporary soreness around the injected area.

    Lumbar Sympathetic Block

    Lumbar Sympathetic Block

    What is a Lumbar Sympathetic Block?

    A lumbar sympathetic block is an injection of medications into or around one or more sympathetic nerves in the low back. Sometimes, these nerves can transmit pain signals from peripheral tissues in the lower body to the central nervous system. The pain-relieving and anti-inflammatory medications contained in a lumbar sympathetic block can inhibit the ability of lumbar sympathetic nerves to transmit pain signals from the lower body.

    Lumbar sympathetic nerves, which extend from both sides of the lumbar spine, belong to the sympathetic nervous system, which is involved in maintaining homeostasis. Sympathetic nerves begin as preganglionic neurons in the middle and lower regions of the spine. They synapse, or terminate, in a bundle of neurons called a ganglion, where they send their signals across a gap to a second group of neurons that travel to peripheral body tissues.

    Injection of medications into lumbar sympathetic nerves may alleviate lower-body sympathetically mediated pain and other symptoms characteristic of sympathetically mediated conditions, such as swelling, numbness, skin discoloration, poor circulation and impaired mobility. Examples of such conditions include Reflex Sympathetic Dystrophy, Complex Regional Pain Syndrome and herpes zoster (shingles) affecting the lower limbs. Other conditions treated with this type of block are neuropathy and peripheral vascular disease.

    Lumbar Sympathetic Block Procedure

    The lumbar sympathetic block is an outpatient procedure that takes less than an hour to perform. The patient is given light sedation and the skin over the area to be injected is cleaned and numbed with local anesthetic. Using fluoroscopy (real-time x-ray) for guidance, the physician directs the injection into or around the target nerve. Then, after a short period of observation, the patient is released.

    A successful lumbar sympathetic block is characterized by relief of pain and other symptoms of sympathetically mediated disorders. The duration of symptom relief varies between patients.

    Since the block is impermanent, the patient will need another injection when symptoms return. The patient may also become a candidate for more complex treatments that quell pain and other symptoms over longer periods.

    Lumbar Sympathetic Block Benefits

    The lumbar sympathetic block:

      • Can provide relief of pain and other symptoms in sympathetically mediated disorders, which are often difficult to treat.
      • Can be conducted quickly, on an outpatient basis, due to the minimally invasive nature of the treatment.
    • Involves very little, if any, recovery time.

    Lumbar Sympathetic Block Risks

    Since a lumbar sympathetic block is a minimally invasive procedure, it is safer than more invasive interventions such as surgery. However, even minimally invasive procedures can produce complications. Some of the reported complications associated with this procedure include:

    • Infection.
    • Damage to surrounding tissues, such as blood vessels and spinal membranes.
    • Temporary tenderness around the injection site.

    Lumbar Spondylosis Radiofrequency Ablation

    Lumbar Spondylosis Radiofrequency Ablation

    What is Lumbar Spondylosis Radiofrequency Ablation?

    Your lumbar spine, also known as your low back, is located between your ribcage and your pelvis and comprised of the five largest vertebrae in your spine.

    Throughout your lifetime, your spinal discs endure normal wear and tear. The term for this normal deterioration is spondylosis. When it refers specifically to the lumbar discs, it is called lumbar spondylosis.

    As you age, your spinal discs dehydrate, shrink, develop bone spurs or show other signs of osteoarthritis. You may or may not experience associated symptoms, such as a stiff low back, pain, tingling sensations, numbness or weakness in your extremities, and loss of control over your bladder or bowels. The condition and symptoms usually worsen as a person ages.

    Treatment for lumbar spondylosis may include medications such as muscle relaxants, anti-seizure drugs, narcotics and steroid injections. Physical therapy may also serve to strengthen the muscles in your back to better support the spine.

    If the symptoms are unbearable and the condition shows no signs of improvement following conservative treatment, your doctor may recommend a more invasive treatment, for example, surgery, to relieve the pressure in your spinal area.

    As the spinal discs develop bone spurs or other abnormalities, the bones may pinch nerves, creating a lot of pain. Surgery allows the doctor to remove a herniated disc, bone spur or other piece of bone from a patient’s spine to make more room for the spinal cord and nerve roots.

    Radiofrequency ablation is a minimally invasive procedure that can be used to treat lumbar spondylosis. With this type of therapy, the doctor first applies a local anesthetic to an area on your low back. Then, typically using X-ray, the doctor will guide a thin needle through the skin and into the spinal area. The X-ray is to help ensure correct placement.

    High-frequency electrical current is carried via the needle into the spinal area, where the heat from the needle can destroy bone spurs or other parts of discs that are putting a lot of pressure on the spinal cord or nerve roots.

    Usually the patient does not feel pain during this portion of the procedure, although some patients report a tingling sensation. Generally the tingling feeling is desired, since it helps the doctor know that the placement of the needle is correct.

    The procedure is safe and effective, with most patients tolerating the treatment very well. As with any procedure, however, there are risks and potential complications, including a risk of infection or excessive bleeding at the injection site.

    Prior to the procedure your doctor may ask you to stop taking any medications that have blood-thinning effects. You will also have to keep an eye on the injection site for infection in the days after the procedure.

    Patients are typically not allowed to drink or eat anything in the hours leading up to the procedure, so following the treatment you will be asked to remain in a recovery room for a few hours so that your vital signs can be monitored and you can rehydrate, usually by drinking some water.

    The injection site will be bandaged and a medical professional will give you your discharge instructions. Then you will be allowed to be taken home by a responsible adult.

    Side effects of lumbar spondylosis radiofrequency ablation include normal swelling and discomfort, but these usually subside a few days after the treatment. If you experience any pain beyond two to three days following the procedure, or if you notice swelling or redness near the injection site, contact your doctor immediately.

    Cervical Facet Radiofrequency Neurotomy

    Cervical Facet Radiofrequency Neurotomy

    What is Cervical Facet Radiofrequency Neurotomy?

    Radiofrequency neurotomy is a treatment that involves the division or destruction of one or more nerves through the use of heat to relieve neuralgia, or nerve-related pain.

    Facet joints, sometimes also called synovial joints, are very small - each one is about the size of a thumbnail. They are located in pairs in the spine, with two facet joints extending from each vertebra in such a way as to be positioned somewhat between that vertebra and the vertebra directly above it. Fulfilling a very important role as motion limiters, facet joints prevent the spine from over-flexion, over-rotation or over-extension.

    The cervical spine comprises seven vertebrae located in the neck, and the facet joints in this area of the body are called cervical facet joints.

    Sometimes facet joints become damaged, either due to injury, disease or other condition or event, and can become very painful for the person. For those individuals who still experience significant discomfort following the use of medications and other therapies, cervical facet radiofrequency neurotomy may offer a higher level of temporary pain relief.

    The procedure itself uses heat in the form of radio waves. The doctor will sterilize the skin on the patient’s neck, then apply an anesthetic to numb the area where the needle will be inserted. Prior to the day of the procedure the doctor will have performed a series of tests to determine not only which nerves should be targeted by the cervical facet radiofrequency neurotomy, but also exactly where the needle should be placed.

    With the patient lying down on an X-ray table, an IV will be started, to deliver medication that will keep the patient calm and comfortable for the duration of the procedure. Using a type of X-ray called fluoroscopy, the physician will guide the needle into the cervical spine, where heat generated by radio waves can damage specific nerves.

    Following the procedure, the damaged nerves will be unable to transmit pain signals, although this effect will be temporary. The nerves will gradually regenerate and eventually be able to transmit pain signals again; however, this does not necessarily mean that the patient’s pain will return. If the pain does return, the patient and doctor may elect to repeat the procedure.

    The procedure generally lasts anywhere from 30 to 90 minutes, depending on the number of nerves the doctor will be targeting. The recovery period is usually short, typically just a few hours, with the patient being discharged the same day. While a person may experience some pain at the procedure site afterward, this will usually improve within a few days.

    The level of pain relief a person can expect to achieve from a cervical facet radiofrequency neurotomy treatment varies from patient to patient, with some experiencing greater relief than others. The duration of the procedure’s effects may last a few months, or about a year. If the patient’s pain does not reoccur following nerve regeneration, then the effects may be enjoyed much longer.


    Occipital Nerve Block

    Occipital Nerve Block

    What is Occipital Nerve Block?

    Essentially an Occipital Nerve block is numbing of the greater and lesser occipital nerve. The block is an injection composed of an anesthetic and a corticosteroid next to the greater and lesser occipital nerves, which are located just beneath the scalp, superficial to the skull, in the back of the head. It is most often used in the diagnosis and treatment of Occipital Neuralgia and Cervicogenic headache (Afridi 2006). Occipital Neuralgia will typically follow a trauma to the nerves over the occiput (back of the head) and is characterized by an acute onset of pain in the distribution of the occipital nerves.

    Cervicogenic headache is more chronic, with an insidious onset, characterized by pain in the same distribution. Most patients with Cervicogenic headaches have associated spondylosis or problems of the cervical facet joints in the neck and therefore may need an additional block in the cervical facet joint to completely alleviate their symptoms.

    A group of people suffering from Cervicogenic headaches was split into two categories, one of which received the Occipital Nerve Block. The study found that analgesic consumption, duration of headache and its frequency, nausea and vomiting, photophobia (fear of light), phonophobia (fear of noise), decreased appetite, and limitations in functional activities were significantly less in the blocked group compared to control group. The study therefore concluded “the nerve stimulator-guided occipital nerve blockade significantly relieved cervicogenic headache and associated symptoms at two weeks following injection.” (Naja 2006)

    The greater occipital nerve arises from the second cervical nerve root and travels deep to the cervical paraspinous musculature and becomes superficial just below the superior nuchal line and lateral to the occipital protuberance of the skull, just lateral to the occipital artery. The lesser occipital nerve is a terminal branch of the superficial cervical plexus and arises from the second and third cervical nerve roots. It then travels through the cervical paraspinous musculature and become superficial over the inferior nuchal line of the skull. The lateral section of the posterior scalp is supplied by the lesser occipital and great auricular nerves. These nerves are commonly involved in patients suffering from Cervicogenic headaches and Occipital Neuralgia.

    Interventional nerve blocks have become an important therapy in the treatment of certain types of acute and chronic pain, particularly where management with medications is unsuccessful. With nerve blocks, medication consisting of an anesthetic and a steroid is injected directly into a nerve to reduce inflammation and block the transmission of pain signals to the brain1. An occipital nerve block (ONB) specifically blocks the occipital nerve, a carrier of pain signals from the head and neck to the brain1, 3. ONB’s can be used to treat several conditions:

    • Occipital neuralgia is a condition which leads to headaches in the occipital region at the back of the head where the skull meets the neck. It is a neuropathic pain that typically manifests as an intermittent, brief episode of shocking pain around the back of the head3. The cause of occipital neuralgia is uncertain, but it often develops spontaneously. They can also occur with whiplash injuries or other impacts to the back of the head. Headaches may occur intermittently throughout the week, and have been known to lead to nausea and vomiting. Because of the similarity of symptoms, occipital neuralgias are commonly confused with migraines3. Local ONB is the treatment of choice for occipital neuralgias. In one study, an ONB provided headache relief for 90% of patients, lasting an average of 28 days1
    • Trigeminal autonomic cephalagias are a group of headache disorders that preset with similar characteristics4, 5, 6. These headaches tend to be severe and affect only one side of the head, while presenting with symptoms of the autonomic nervous system malfunction including sweating, flushing, tearing and a runny nose on the affected side. Trigeminal autonomic cephalagias include cluster headaches, paroxysmal hemicrania headaches, and SUNCT (short-lasting uniform neuralgiform headache attacks with conjunctival injection) and SUNA (short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms)4, 5, 6. Despite their similarities, each of these headache types differs in duration, frequency and response to therapy6. However, each type of headache, especially when chronic and unresponsive to medication treatment, may benefit from ONB4

    The Procedure

    Of the nerve blocks, the ONB is one of the easiest and safest to perform. During the procedure, and neurologist or interventional pain specialist will feel for the protrusion of the occipital bone of the skull behind the ear, and identify the pulsing, nearby occipital artery which runs alongside the greater occipital nerve1. The physician can then inject an anesthetic/steroid solution into the area to provide pain relief and reduce inflammation1, 2. A lesser occipital nerve can also be targeted by injecting an area just below and to the outside of the greater occipital nerve2.

    ONB has very few complications when performed by a trained physician. The primary complication is inadvertent injection into the occipital artery which can cause a number of systemic symptoms, including diffuse numbness of an area, dizziness or an allergic reaction. This is easily avoided by suctioning the syringe and checking for blood before injecting the solution2, 3.

    The procedure involves inserting a small fine needle through the skin beneath the scalp in order to get the anesthetic and corticosteroids around the area of the nerve. In order to minimize this discomfort your pain specialist may numb the skin in the injection area with an even smaller needle with a local anesthetic before inserting the block needle. The injection blocks both the greater and lesser occipital nerves. There are two major benefits to using this block. Not only is it useful in treating Occipital Neuralgia, relieving or reducing pain in the back of the head in the scalp, but if symptoms improve after the injection then the block is also useful in diagnosing Occipital Neuralgia. Typically if you respond well to the injection and have pain relief then it is recommended that you return and receive repeat injections.

    Usually, a series of block injections is needed to treat the problem adequately, however the response to the block varies from patient to patient. Also, if you respond well to the Occipital Nerve block then you will most likely benefit even more with the addition of Occipital Nerve Stimulation. A 2006 study reported that if a patient receives repeated nerve stimulator guided Occipital Nerve blockade for the treatment of Cervicogenic headache, the patients experienced significant reduction of symptoms with no recurrence for at least six months in addition to alleviation of associated symptoms. Eighty-seven (87%) of the patients who experienced relief required more than one injection to achieve a six-month period of pain relief (Naja 2006).


    Occipital Nerve Block injections are considered safe, however, with every procedure there are associated risks, side effects, and possible complications. With nerve blocks in general, the most common is the superficial pain from the scalp where the needle was inserted. This pain comes after the local anesthetic wears off, but this pain is temporary and typically mild. Another frequently seen occurrence is bleeding, since the scalp is highly vascular (there is an abundance of tiny blood vessels near the surface of the skin). Bleeding is common but is easily stopped and temporary. This risk is significantly reduced if ice is placed at the injection site immediately after the procedure. The other less common risks involve excessive bleeding, infection, and nerve damage. Patients with an allergy to any of the anesthetics used, are on blood thinning medications, have an active infection, or are pregnant should consult with your pain physician before receiving the procedure.


    • Zhou, Y. (2008). Principles of Pain Management. Bradley: Neurology in Clinical Practice, 5th Ed. MD Consult Web site, Core Collection.
    • Amsterdam, J., Kilgore, K. (2009). Regional Anesthesia of the Head and Neck. Bradley: Roberts: Clinical Procedures in Emergency Medicine, 5th Ed. MD Consult Web site, Core Collection.
    • Garza, I. (2010). Occipital neuralgia. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA.
    • May, A. (2010). Cluster headache: Epidemiology, clinical features and diagnosis. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA.
    • Matharu, M. (2011). SUNCT and SUNA headache syndromes: Treatment. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA.
    • Matharu, M.; Cohen, A. (2009). Paroxysmal hemicranias: Clinical features and diagnosis. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA.
    • Occipital nerve blockade for cervicogenic headache: a double-blind randomized controlled clinical trial Naja ZM, El-Rajab M, Al-Tannir MA, Ziade FM, Tawfik OM. Pain Pract. 2006 Jun;6(2):89-95 PMID: 17309715
    • Repetitive occipital nerve blockade for cervicogenic headache: expanded case report of 47 adults. Naja ZM, El-Rajab M, Al-Tannir MA, Ziade FM, Tawfik OM. : Pain Pract. 2006 Dec;6(4):278-84 PMID: 17129309
    • Greater occipital nerve injection in primary headache syndromes-prolonged effects from a single injection Afridi SK, Shields KG, Bhola R, Goadsby PJ. Pain. 2006 May;122(1-2):126-9. Epub 2006 Mar 9 PMID: 16527404 Textbooks: Atlas of Interventional Pain Management Author(s): Waldman, Steven D. Pub. Date: 7/1/1998 Publisher (s): Elsevier Science Health Science division.

    Platelet Rich Plasma Injections

    Platelet Rich Plasma Injections

    What Is Platelet Rich Protein Injections?

    A quickly emerging medical breakthrough, platelet rich protein injections are becoming popular not only among elite professional athletes, but among the general population.

    According to an article in the New York Times, sports medicine experts have high hopes for this therapy. Should it prove to have the results it has shown early signs toward, it could be instrumental in aiding in the pain relief of persistent injuries such as tendinitis of the knee and tennis elbow for both the professional and recreational athlete. Famous athletes such as Tiger Woods have touted the efficacy of this groundbreaking procedure, calling quite a bit of attention to it in the media.

    Indications of Platelet Rich Protein Injections

    PRP is a relatively new method of treatment for several orthopaedic conditions such as muscle, ligament, and tendon injuries; arthritis; and fractures. PRP injections can help alleviate painful symptoms, promote healing and delay joint replacement surgeries.

    This is not a complete list. Please call our office at XXXX if your condition is not listed to find out if this treatment may be an option for you.

    Types of Platelet Rich Protein Injections

    Most commonly known as platelet rich plasma therapy, this injection uses the patient’s own blood to help heal their injuries. Since it is autologous, meaning it comes from the patient’s own body, there is very low risk for transmissible infection or allergic reaction.

    Additionally, early research has shown such positive results that it may be a way to avoid surgery and a lengthy recovery.

    The procedure is fairly simple. A small sample of blood is taken, and then placed into a machine that creates a centrifuge, separating the platelets or plasma from red blood cells. Once this process is completed, a concentration of ten times the normal amount of platelets is left, leaving super-concentrated platelets rich in healing properties. These concentrated platelets are then injected into the injured area, promoting healing and regeneration of injured tissue.

    Conditions Related to Platelet Rich Protein Injections

    When the body sustains soft tissue injury, platelets go to the site of injury and begin to regenerate and heal. However, some areas of the body receive a poor blood supply, thus making it difficult for the body to repair any tears or internal scarring. One such example would be tendinitis or rupture of the Achilles or tendonitis of the knee or elbow. It is now thought that because of the low blood supply, these areas of the body can never fully heal. With the advent of plasma rich protein injections, this problem may become a thing of the past.

    Expanding past what is considered routine sports injuries, platelet rich plasma therapy is now being used to treat muscle sprains, arthritis, bone fractures, and surgical wounds. However, as the therapy is still in research and has not been proven medically, insurance companies have yet to reimburse the procedure. Patients are trusting in the procedure and the outcome they have seen in the news with prominent athletes such as Tiger Woods that they are paying for the procedure out of pocket.


    While the therapy shows much early promise, patients should take care to research all options and discuss the therapy fully with their pain physician before going ahead with the treatment.

    Sacroiliac Joint Injections

    Sacroiliac Joint Injections

    What are Sacroiliac Joint Injections?

    Sacroiliac Joint (SIJ) Disease is one of the major causes of low back pain. The sacroiliac joint is located at the junction between the spine and the pelvis. The sacroiliac joint is a weight baring joint as the weight from the upper body is transmitted down the spine, through the sacroiliac joint and into the pelvis, hips, and lower extremities. The sacroiliac joint is supported by many muscle groups and ligaments that are richly innervated by free nerve endings and spinal nerve roots. When there is inflammation to the sacroiliac joint, the abundance of nerves become irritated and patients experience intense low back pain. Patients typically complain that pain associated with sacroiliac joint worsens when sitting for long periods of time or performing twisting motions and will usually resolve with exercise.

    The sacroiliac (SI) joint connects the spine with the pelvis, and is a significant source for low back, buttock, groin and lower extremity pain. Dysfunction of the joint has been estimated to affect between 15-38% of the general population1. The most common painful condition of the sacroiliac joint is known as sacroiliac joint dysfunction, which is often caused by direct impact to the buttocks, motor vehicles accidents, or via ballet or ice skating injuries2. It can also be caused by arthritis, infection, or simply as the result of age-associated degeneration. With SI joint dysfunction there is a structural change within the joint with the nearby pelvic and/or sacral bones that induces pain in nearby cartilage or ligaments1.

    The sacroiliac joint (SI) is often overlooked as a source of low back pain, especially since there are relatively few techniques to diagnose SI joint pain2. The SI joint can receive referred pain from other locations, further complicating diagnosis1. Thus, diagnosis of SI joint dysfunction tends to occur after excluding other possibilities. The gold standard to definitively confirm a diagnosis of SI joint pain is through provocative injection of the SI joint, in which an injection of fluid into the joint causes distention and reproduces painful symptoms1, 2. If symptoms are reproduced and SI joint pain is confirmed, the diagnostic injection can be followed with a therapeutic injection for pain relief.

    The Procedure

    Before considering an injection, a doctor will perform a thorough neurological and musculoskeletal examination focusing on the lower back, hips, pelvis and lower extremities1. There are a variety of special maneuvers available to the physician to identify SI joint pathology, and the physical examination can also rule out other potential sources of pain other than the SI joint.

    If a SI joint injection is deemed appropriate, a patient will lie face down on a table while the site of injection is cleaned with an antiseptic agent such as alcohol. The injection site is selected a few centimeters below the bottom of the joint over the buttocks2. The skin of the injection site is then anesthetized before a needle is guided through the skin and into the SI joint. Trained physicians use a technology called fluoroscopy, a real-time x-ray, to safely guide the needle through internal tissues without damaging adjacent nerves, blood vessels or other critical structures. Once the needle is properly positioned in the SI joint, an anesthetic/steroid solution is delivered to reduce inflammation and relieve pain.

    Although a relatively safe procedure, injections are not without some risk. Steroid injections can be associated with a temporary increase in pain before any relief is experienced1. Further, local and systemic side effects can occur with steroid injections such as high blood pressure, skin color changes at the site of injection and elevated blood pressure.


    Sacroiliac Joint Steroid Injections: involve injecting a steroid into the joint space of the SIJ, where the irritated nerve roots are located. This injection includes both a long-lasting steroid and a local anesthetic (lidocaine, bupivacaine). The steroid reduces the inflammation and irritation and the anesthetic works to numb nerves in the area. The combination medicine then spreads throughout the joint and surrounding areas, reducing inflammation and irritation. The entire procedure usually takes less than 15 minutes.

    SIJ Traumeel Injections: Traumeel is a homeopathic natural anti-inflammatory medication that has very few side-effects and can be injected into the SIJ when steroid medications are not desired.

    Medial and Lateral Branch Blocks: The medial and lateral branches innervate the sacroiliac joint and blocking these nerves is diagnostic and therapeutic. If your pain is better after the injections, than you may be a candidate for radiofrequency procedure.

    Radiofrequency Ablation: The medial and lateral branches innervate the sacroiliac joint and can be destroyed with radiofrequency. The nerves typically grow back, but people report pain relief from ranging from 3 months to 3 years.

    Spinal Cord Stimulation: A small electrode is typically placed in the epidural space and electrical current is directed through the electrode. If pain relief is attained, a permanent system with battery and electrodes can be placed under the skin.

    Chiropractic Manipulation: The sacroiliac joint can sometimes be manipulated into place if it is believed to be out of alignment.

    TENS unit: Electrical current is directed over the skin to the most painful area. The brain cannot perceive the pain it previously felt, but now feels the “tingling or buzzing” sensation that is commonly used to describe TENS therapy. TENS therapy may also cause the brain to release endorphin (the body’s natural pain fighters).

    Physical Therapy: Is extremely important to increase range of motion and continue to maintain strength in a painful shoulder.

    Acupuncture: Acupuncture is an alternative treatment that was originally started in China over 2000 years ago and is quickly gaining acceptance and popularity in Western Medicine for the treatment of many conditions (Facco 2007). Research continues to explore the use of acupuncture in the treatment of many chronic pain conditions.


    Chronic lower back pain is one of the most difficult conditions for physicians to treat. Commonly seen, the pain may go into remission with periods of decreased or absent symptoms, however, more frequently than not, the pain returns and causes a chronic pain syndrome in most people. Sacroiliac Joint Injections are a minimally invasive, low risk procedure that can cause a significant decrease in symptoms without disrupting your daily activities. In patients suffering from chronic sacroiliac joint pain, sacroiliac joint injections are preferred to the more conventional methods of treatment (Pereira 2000).


    SIJ injections are considered an appropriate non-surgical treatment for many patients who suffer from lower back pain. The associated risks, although rare, include nerve damage, bleeding, and infection. Some of the potential side effects of the corticosteroid may include elevated blood sugars, weight gain, arthritis, stomach ulcers, and transient decrease in the immune system.


    Patients have reported that sacroiliac joint pain began spontaneously or had an insidious onset, while others recognize a specific event that triggered the occurrence of the pain. Frequently the pain can be due to a traumatic injury to the spine resulting in residual sacroiliac joint inflammation. While conservative treatment, such as NSAID’s and physical therapy may be effective, Murakami and Tanaka reported in 2007 that the effect of periarticular injection into the SIJ was 96% effective in pain improvement in patients with sacroiliac joint complaints with minimal complications (2007 Murakami).


    Williams, K.; Park, A. (2007). Injection Studies. Canale and Beaty: Campbell’s Operative Orthopaedics, 11th Ed. MD Consult Web site, Core Collection.

    Isaac, Z.; Devine, J. (2008). Sacroiliac Joint Dysfunction. Frontera: Essentials of Physical Medicine and Rehabilitation, 2nd Ed. MD Consult Web site, Core Collection.

    Murakami E, Tanaka Y, Aizawa T, Ishizuka M, Kokubun S. J Effect of periarticular and intraarticular lidocaine injections for sacroiliac joint pain: prospective comparative study. Orthop Sci. 2007 May;12(3):274-80. Epub 2007 May 31

    Pereira PL, Günaydin I, Duda SH, Trübenbach J, Rémy CT, Kötter I, Kastler B, Claussen CD. Corticosteroid injections of the sacroiliac joint during magnetic resonance: preliminary results J Radiol. 2000 Mar;81(3):223-6

    Selective Nerve Root Blocks

    Selective Nerve Root Blocks

    What are Selective Nerve Root Blocks?

    Selective Nerve Root Blocks can help with chronic pain caused by sciatica or other nerve issues. This type of pain can be debilitating. It can produce a lower quality of life and even depression as you deal with incurable and unmanageable pain. Too frequently, adults don’t seek treatment for this type of pain. If you are experiencing chronic back pain you should consult a physician and consider selective nerve root blocks or SNRBs to isolate the cause of the pain and determine treatment.

    According to studies by the American medical association, back pain is the leading cause of disability for American workers. More than one half of adults in the United States will experience chronic pain at some time in their lives.

    The difference between chronic and acute pain is typically the duration. If pain lasts more than three months it is typically diagnosed and treated as chronic. Seeking treatment will not only alleviate the symptoms of pain but will also improve the overall quality of life. Chronic pain is also a cause of depression so it is important to understand all the possible effects.

    Selective nerve root blocks are a way to determine the exact location and cause of the chronic pain. An injection of steroids and an anesthetic is given to the area believed to be the cause of the discomfort. At this point the patient is asked to perform his or her normal range of motions and the ones that typically cause pain. If there is no pain then the location of the inflammation can be determined.

    Beyond diagnostic tools such as selective nerve root blocks, it is important to make lifestyle changes to improve symptoms and alleviate depression. Not smoking and maintaining a healthy diet and exercise routine is imperative. You may also wish to improve your posture, invest in comfortable shoes and the right firm mattress to help with symptoms.

    Determining the cause of the chronic pain is an important first step toward treatment. Treatments can come in a number of forms, including physical therapy and anti-inflammatory medications. If these less invasive procedures do not provide relieve for your symptoms of chronic pain, you and your specialist may seek additional treatments, such as long-term nerve blocks or surgery.

    Selective nerve root blocks can provide the answers you’re seeking concerning your chronic pain.

    Before visiting your doctor to discuss treatments, assess the severity of your pain, conduct your own research and determine the best ways to communicate your symptoms. You may wish to start keeping a pain journal to chronicle your experiences and share with your specialist at your first consultation.

    You may also wish to consider treatment for the non-physical effects of debilitating chronic pain, such as depression.

    Talk with with your doctor today to determine if selective nerve root blocks can help assess your condition and work to provide relief. Selective nerve root blocks can assist your chronic pain specialist in determining the exact cause of your persistent pain.

    If you’ve experienced back pain for longer than three months, consult your physician today and find out how this procedure can work for you and what long-term treatment can help you lead a normal life.

    Spinal Cord Stimulation

    Spinal Cord Stimulation

    What is Spinal Cord Stimulation?

    Spinal Cord Stimulation (SCS) is a minimally invasive procedure that involves implanting a device that applies low currents of electrical stimulation to the spinal cord and/or its exiting nerves.

    Spinal cord stimulation is referred to by some pain experts as a “pacemaker for pain”. It works by sending small electrical impulses created by a compact generator through thin leads, or electrical cables, to the spinal cord, where they block pain signals traveling to the brain. Pain is replaced with a mild tingling or a massaging sensation, called paresthesias. A wireless remote control is used to adjust the location and degree of stimulation by selecting pre-programmed settings.

    The core technology that is used in today’s SCS systems was developed in the mid-1960s. Melzack and Wall developed the original theory for the mechanism of spinal cord stimulation in 1965 (1). This “gate-control theory” for pain proposes that simultaneously triggered touch and vibratory sensation inhibits pain stimuli sensation due to their shared location in the spinal cord, the dorsal horn nucleus. In essence this theory is the foundation for spinal cord stimulation. An everyday example of this theory is seen when one has a headache. Many people will rub their temples or another area of their head, stimulating the muscles of the head or sensory fibers of the skin. When these areas are stimulated, to some degree they block the sharp pain perceived from an active headache. This is also commonly seen when you accidently bump your knee, elbow, or finger and you rub the associated area inhibiting the acute painful stimuli to the brain.

    The first spinal cord stimulators were implanted directly on the dorsal column of the spinal cord of terminal cancer patients by Shealy et al. (2) in 1967. Shortly after, Shimogi et al. were the first to publish the successful implementation of epidural spinal cord stimulation (3), which is a percutaneous, less invasive technique. This avoids the complications of the original open surgery, which includes cerebrospinal fluid leakage, localized fibrosis, and arachnoiditis. Another initial challenge was a limited area covered by the single, or monopolar electrode. SCS leads today have evolved from monopolar (1 active electrode) to bipolar (2 active eletrodes), quadripolar (4 active electrodes), and octapolar (8 active elctrodes) leads.

    Since then, SCS has been used in the treatment of cervical and lumbar post-laminectomy syndrome (failed back or neck surgery syndrome), cervical and lumbar radiculitis (neck and back radiating pain), complex regional pain syndromes (CRPS or RSD), intractable pain due to peripheral vascular disease, phantom limb pain, intractable pain due to angina, peripheral neuropathy, post-thoracotomy syndrome, neuropathic extremity pain, chronic visceral pain syndromes, and other pain conditions.


    The spinal cord is a bundle of nervous tissue and supporting material that extends from the brain to innervate the rest of the body. The brain and the spinal cord together form the central nervous system (CNS), which sends and receives messages from the body through the peripheral nervous system (PNS).

    The spinal cord is contained in the spinal canal formed by the vertebral column. The meninges are a covering consisting of three layers that continues from the cranium to the sacrum and protects the spinal cord and its nerves. The innermost layer, or pia mater, wraps around the brain and spinal cord. The middle layer, or arachnoid mater, is a spider web-like layer. The outermost layer is called the tough dura mater. Between the arachnoid mater and the pia mater is ones cerebral spinal fluid (CSF) which protects and buffers the brain and spinal cord. Outside of the three-layered meninges is the epidural space. The epidural space is a potential space that lies outside of the dura and typically houses protective fatty tissue and blood vessels. The epidural space is where medications are placed for epidural blocks and where the leads are placed for spinal cord stimulation.

    The spinal cord normally extends from the foramen magnum, a hole at the bottom of the cranium, to the L1 vertebra in adults. In children the spinal cord ends at L3 and travels upward as they grow older. Nerve roots exit from the back and front of the spinal cord and then join to form the spinal nerves from second cervical nerve root to the fifth sacral nerve root (C2 to S5). The spinal nerves then leave the spinal canal through openings between each vertebra called the intervertebral foramen.

    The main functions of the spinal cord are to relay signals from the brain to all muscles for movement, relay signals up from the body for sensory input, and to also coordinate reflexes. Each spinal nerve root supplies sensory innervations to a specific area of skin called a dermatome.

    Lesions of specific nerve roots result in predictable pattern of signs and symptoms. For instance, a lesion in a lumbar nerve root may cause radiating pain, muscle weakness, numbness, tingling, and/or reflex changes in the legs. This gives physicians a tool for localizing the lesion that is causing the symptoms. Imaging modalities such as MRIs and diagnostic tools like EMGs (electromyography) may be used to assist and confirm a diagnosis.


    SCS is a minimally invasive procedure that is done on an outpatient or short hospital stay basis. There are two steps to the procedure, a trial procedure and a permanent implant. The trial procedure is a brief procedure that is usually done under light sedation. The area where the leads are implanted is numbed with local anesthesia. One or more needles are directed under x-ray guidance into the epidural space, which is the area surrounding the spinal cord and/or nerve roots.

    The leads are then placed through the needles and are steered to the desired location. The leads are then connected to an external generator. Once the generator is turned on, the impulses are sent with varying intensities to different positions on the leads. The patient will sense paresthesias (tingling and/or buzzing) while a programmer adjusts the settings to provide the “optimal coverage” over the painful areas. These settings are then saved on the remote control so that the patient can adjust the stimulator to best fit their needs. The trial period usually lasts a few days to a week, depending on the effectiveness of the SCS. The goal is to test the stimulator’s effectiveness at relieving pain, increasing normal daily activities, and overall improving quality of life.

    If SCS trial period provides sufficient pain relief (usually 50% or greater), then the trial is deemed a success and a permanent implant may be scheduled if the patient desires. The permanent procedure is carried out in similar fashion to the trial procedure. The significant difference is that the generator is implanted, like a pacemaker, in a subcutaneous pocket. Usually the upper, outer quadrant of the buttock is chosen, which results in a largely unrecognizable and comfortable experience. A different type of lead may also be used if your physician believes this will give you better long-term relief. A few small bandages will be applied over the incisions. After the procedure, the patient can usually return home the same or the following day.

    Trigger Point Injections

    Trigger Point Injections

    What are Trigger Point Injections?

    Trigger points are specific places on the body where muscle fibers become tight due to stress or injury. This condition of the muscle fibers is sometimes referred to as a muscle knot, and can usually be felt under the skin as a raised bump or nodule.

    Typically these trigger points will be sensitive or tender to the touch or when pressure is placed upon them, and the tenderness or pain can even extend outward a certain distance from the trigger point. Sometimes pressure on the trigger point will elicit a muscle twitch in the related muscle fibers.

    Myofascial pain syndrome is characterized by chronic pain in which compression of a person’s trigger points leads to pain in seemingly unrelated areas of the body, called referred pain. Among the forms of treatment for this disorder are massage therapy, or manual therapy, topical sprays and trigger point injections.

    Trigger point injections have been shown to be one of the most effective treatments for inactivating trigger points and providing patients with pain relief.

    For a trigger point injection, the doctor will clean the area where the needle is to be inserted. Usually the patient will be asked to stop taking any medications that have blood-thinning effects; this is to prevent excessive bleeding at the injection site.

    The patient will be asked to sit or lie in a comfortable position to relax the muscles, and then the physician will insert the needle into the trigger point and release an anesthetic to alleviate pain.

    At the moment of injection, the patient may experience a sensation of pressure, a temporary sharp pain as the needle penetrates the tight muscle fibers, or muscle twitching.

    Often it will be necessary to administer a few injections in the same area during the same treatment to ensure all the tender areas have been relieved. Overall, the treatment lasts only a few minutes and recovery time is typically very short.

    Following the injection, patients are instructed to protect the injection site, and to keep it clean to prevent infection and bleeding. Doctors will also encourage patients to remain active (not strenuous activities) following the injection to stretch the affected muscle, to prevent it from becoming knotted again, and to maintain a healthy range of motion.

    Because the bands of muscle at the trigger point are often very taut or tense, often the insertion of the needle alone will ease the tension in the patient’s muscles and the injection of a substance will not be necessary. This is called “dry needling.”

    While dry needling and trigger point injections have been found to be nearly identical in effectiveness when it comes to relieving patients with symptomatic active trigger points and patterns of referred pain, the post-injection recovery may be different. Some patients have found that the soreness following dry needling was longer lasting than that associated with the injection of an anesthetic.

    Acupuncture, a practice that includes the insertion of very thin needles into certain points in the body, seems similar in practice, but is a different method of treatment and does not include any injections. Acupuncture, whose origins are in traditional Chinese medicine, has been used in western medicine to treat pain, disease, disorders and other conditions, including to improve the symptoms of patients suffering from myofascial pain syndrome.

    Trochanteral Bursa Injections

    Trochanteral Bursa Injections

    Bursitis is the inflammation of a fluid-filled sac called a bursa, which acts to cushion and lubricate the areas between tendons and bones. Trochanteral bursitis is inflammation of the bursa located at the outside point of the hip bone known as the greater trochanter. This particular bursa separates the greater trochanter from the muscles and tendons of the thighs and buttock.

    When this bursa becomes irritated or inflamed, it causes pain in the hip, which is often aggravated by lying on the outside of the hip or the affected area. The pain can also be caused by certain types of activity, such as attempting to stand up from a deep chair or getting out of a car, or while walking up stairs. Bursitis is more common in women and in middle-aged or elderly people.

    Trochanteral bursitis can result from any number of events, including injury to the hip from a fall, bumping into something or lying on one side for extended periods of time. Certain repetitive activities can also cause or aggravate this pain, such as running up stairs, climbing or standing for long periods of time with the weight unevenly distributed on the hips.

    Incorrect posture, from such things as scoliosis or arthritis, or other conditions as such as gout, psoriasis or thyroid disease, can also cause trochanteral bursitis. Previous surgery around the hip or hip replacements, bone spurs, calcium deposits, or in rare cases, infections, can also lead to bursitis. Unfortunately, in many instances it can be quite difficult to identify the specific cause of bursitis.

    Most cases of bursitis improve without any treatment over a few weeks, but you should see your health care provider if your pain interferes with your normal day-to-day activities or if you experience soreness that doesn’t improve despite self-care measures, such as rest, ice and over-the-counter pain relievers, such as non-steroidal anti-inflammatory drugs like ibuprofen or naproxen. The overall goal is to reduce pain and inflammation, as well as prevent disability and recurrence of the problem.
    You should seek medical attention if you have recurring episodes of bursitis, or if you also have a fever or the area affected appears red, swollen or warm. Finally, you should seek medical attention if you have any other conditions that may increase your risk of an infection, or if you take medications that increase your risk of infection, such as corticosteroids or immunosuppressants.

    If at-home care fails to provide sufficient relief, your health care provider may suggest trochanteral bursa injections, which are injections of corticosteroids directly into the bursa. Steroids or corticosteroids are medications designed to mimic natural hormones produced by the body to reduce inflammation. An injection of corticosteroids works quickly to decrease the inflammation and pain in the hip.

    Following the trochanteral bursa injection procedure, it is often helpful to ice the area, as the injection itself may cause some pain and swelling. Treatment with ice and analgesics will usually be sufficient to treat this pain.

    Because most cases of bursitis are caused by overuse, the best treatment is prevention. It is important to avoid or modify the activities that cause the problem and to identify any underlying conditions - such as leg length differences, improper posture, or poor technique in sports or work - so that they can be corrected.

    Regenerative Medicine

    Regenerative Medicine

    Stem cell therapy is a form of regenerative medicine that utilizes the body’s natural healing mechanism to treat various conditions.

    Stem cells are being used in regenerative medicine to renew and repair diseased or damaged tissues, and have shown promising results in treatments of various orthopedic, cardiovascular, neuromuscular and autoimmune conditions.

    Stem cells are present in all of us acting like a repair system for the body. However, with increased age sometimes the optimum amounts of stem cells are not delivered to the injured area. The goal of stem cell therapy is to amplify the natural repair system of the patient’s body.

    Types of Stem Cells

    There are two major types of stem cells embryonic stem cells and adult stem cells. Embryonic stem cells (ESCs) are stem cells derived from human embryos. They are pluripotent, which means they have the ability to develop into almost any of the various cell types of the body.

    As the embryo develops and forms a baby, stem cells are distributed throughout the body where they reside in specific pockets of each tissue, such as the bone marrow and blood. As we age, these cells function to renew old and worn out tissue cells. These are called adult stem cells or somatic stem cells. Like embryonic stem cells, adult stem cells can also replicate into more than one cell type, but their replication is restricted to a limited number of cell types.

    Use of Stem Cells in Orthopedics

    The unique self-regeneration and differentiating ability of embryonic stem cells can be used in regenerative medicine. These stem cells can be derived from eggs collected during IVF procedures with informed consent from the patient. However, many questions have been raised on the ethics of destroying a potential human life for the treatment of another.

    Adult stem cells are most commonly obtained from the bone marrow, specifically the mesenchymal stem cells, which have the ability to replicate into cells that form the musculoskeletal system such as tendons, ligaments, and articular cartilage. They can be obtained from the iliac crest of the pelvic bone by inserting a needle and extracting the stem cells from the bone marrow.

    Currently, stem cell therapy is used to treat various degenerative conditions of the shoulder, knees, hips, and spine. They are also being used in the treatment of various soft tissue (muscle, ligaments and tendons) as well as bone-related injuries.

    Who is a Good Candidate for a Stem Cell Procedure?

    You may be a good candidate for stem cell therapy if you have been suffering from joint pain and want to improve your quality of life while avoiding complications related to invasive surgical procedures.

    Preparing for the Procedure

    • It is important that you stop taking any non-steroidal anti-inflammatory drugs (NSAIDs) at least two weeks before your procedure.
    • Preparing for a stem cell procedure is relatively easy and your doctor will give you specific instructions depending on your condition.

    Stem Cell procedure

    The procedure begins with your doctor extracting stem cells from your own bone marrow. Bone marrow is usually aspirated from your hip region. Your doctor will first clean and numb your hip area. A needle is then introduced into an area of your pelvic bone known as the iliac crest. Bone marrow is then aspirated using a special syringe and the sample obtained is sent to the laboratory. In the laboratory, the aspirate is spun in a machine for 10 to 15 minutes and a concentrated stem cell sample is separated.

    Your doctor then cleans and numbs your affected area to be treated and then, under the guidance of special x-rays, injects the stem cells into the diseased region. The whole procedure usually takes less than one hour and you may return home on the same day of the procedure.

    Post-Operative Care

    • You will most likely be able to return to work the next day following your procedure.
    • You will need to take it easy and avoid any load bearing activities for at least two weeks following your procedure.
    • You will need to refrain from taking non-steroidal, anti-inflammatory medications (NSAIDS) for a while as this can affect the healing process of your body.

    Advantages & Disadvantages

    • Stem cell therapy is a relatively simple procedure that avoids the complications associated with invasive surgical procedures.
    • As stem cell therapy uses the cells derived from your own body it reduces the chances of an immune rejection.

    The disadvantage of adult stem cell therapy is lack of data about its long-term effects as it is a newer evolving therapy.

    Risks and Complications

    Stem cell therapy is generally considered a safe procedure with minimal complications, however, as with any medical procedure, complications can occur.

    Some risks factors related to stem cell therapy include infection as the stem cells may become contaminated with bacteria, viruses or other pathogens that may cause disease during the preparation process.

    The procedure to either remove or inject the cells also has the risk of introducing an infection to the damaged tissue into which they are injected. Rarely, an immune reaction may occur from injected stem cells.

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