The most common pain complaints encountered are related to the spine. The sources of spinal pain are now well known through the research of the last few decades. The spinal canal is formed by individual bones called vertebra. These vertebra protect the spinal cord and the nerves that exit the spinal cord through openings between the vertebra. These vertebra articulate, or meet, eachother at three distinct joints which allow movement. The disc joints are found just in front of the spinal cord and the paired facet joints are found behind the spinal cord. It is these joints which are subjected to constant wear and tear, stress and strain, with daily living and which are effected by the normal aging changes associated with all joints (degenerative osteoarthritis). These are joints which can become injured or inflamed and which can cause chronic pain. Derangements of these joints can also cause pressure or inflammation of the spinal cord or exiting nerves causing extremity pain as well (often called sciatica in the leg).
The treatments which can alleviate spinal pain are directed at these joints or at the small nerves through which the pain travels from these joints back to the spinal cord on the way to the brain. Utilizing live x-ray, or fluoroscopy, pain management physicians are able to reduce pain from involved spinal joints through injections of minute amounts of steroids directly into or adjacent to the joints felt to be the source of pain. If these are ineffective or do not give prolonged relief, the pain can be reduced through injections of local anesthetic and steroid on the nerves through which the pain is travelling to the spinal cord.
If prolonged pain relief is not achieved in this manner, these injections, or nerve blocks, also serve to predict the ability of the pain physician to obtain long term relief utilizing methods which stop these nerves from functioning through the application of heat in a very safe and controlled manner.
All of these pain relieving treatments have the advantage of having excellent risk/benefit ratios (risk being minimal while the chance of benefit is excellent). Another distinct benefit of these treatments is the ability of the pain management physician to safely repeat the treatment in the future if prolonged relief is obtained.
The field of interventional pain management has evolved substantially over the past decade. This is primarily due to the increased ability of physicians who specialize in interventional pain management to pinpoint the cause of spinal pain through the use of MRI’s and the performance of diagnostic injections and nerve blocks. This has expanded the ability of interventional pain physicians to safely and effectively treat lower back and neck pain with minimally invasive procedures.
Minimally Invasive Procedures
Selective Nerve Blocks are performed near the spine to diagnose the specific spinal nerve that is the root source of chronic back and leg pain. This procedure also can reduce inflammation around the selected nerve root, which has the effect of decreasing or relieving pain.
During the procedure, the patient is usually given a local anesthetic. The physician then locates, under fluoroscopy, a specific spinal nerve root. A needle is introduced through the skin into the area adjacent to the nerve root, and medication is then injected into the area bathing the nerve root. The medications usually include an anesthetic and steroid. Selective Nerve Blocks are performed on an outpatient basis, and the procedure usually takes 30 to 45 minutes.
Caudal Adhesionolysis is a method of epidural injection that can alleviate pain by breaking up scar tissue to free entrapped nerves. This procedure entails accessing the spinal canal through the sacral hiatus (the triangular bone made up of five fused vertebrae and forming the posterior section of the pelvis) with a needle. Once the needle tip is confirmed to be in the caudal space utilizing radio-opaque dye, a catheter is inserted and directed under fluoroscopy. The dye is also used to look for “filling defects” which indicate the presence of epidural adhesions.
Medications such as hypertonic saline and/or local anesthetic and steroid are injected during the procedure to treat pain from epidural adhesions (which have been shown to be a cause of lower back pain). The insertion of the catheter can cause a mechanical disruption of the adhesions as well, which serves to lesson pain. Caudal Adhesionolysis can also be performed with a small scope in place of the catheter that may aid in the detection of epidural adhesions.
Intra-articular Facet Injections are fluoroscopically directed injections of local anesthetic and depot steroid into the facet joints suspected to be a source of spinal pain. In the lower back, this type of pain is most frequently related to degenerative disc disease which places increased stress on the facet joints. In the neck, it is the most common cause of pain following a whiplash type of injury. Pain secondary to the facets may also be a consequence of synovial tears, cysts, hematomas, subluxations, spinal instability, spondylolisthesis, and vertebral compression fractures. The purpose of the injection is two-fold. The relief of pain by the local anesthetic is important diagnostic information for the pain physician, allowing them to define and more effectively treat spinal pain. The steroid can provide long term relief of symptoms in many cases of pain related to disorders of the facet joint. Further treatment is guided by the response of the patient to both the local anesthetic and the steroid.
Radiofrequency Therapy is a form of pain management that requires the precise application of electricity to create pulsed or thermal energy, and it can also be used to treat a variety of diagnoses and symptoms. This pain management technique is proven safe and has a low rate of complication.
The procedure most commonly involves heating a small amount of nerve tissue to interrupt pain signals. Once the temperature of the nerve is heated from 140-185 degrees Fahrenheit, proteins are damaged and the cell membranes combine. The radiofrequency energy is distributed through a special type of probe that houses electrodes, which distributes energy into the tissue.
Although pain relief may begin immediately after the procedure, it can take up to one month for the full effects to become realized. Relief may be permanent; however, the treated nerves will regenerate after 9-18 months.
Alternately, the energy can be applied in a pulsed fashion, at two pulses per second and at a lower temperature of 104-108 degrees Fahrenheit to achieve similar relief. The physician will decide which technique will best suit the patient, based on anatomy and the type of pain being treated.
This procedure is purely diagnostic. It entails the placement of needles into the disk at the spinal cord level to be studied. Under live fluoroscopy radio-opaque is then injected and the disk is studied. The Intradiscal pressure is monitored during the procedure. In most cases, a follow-up CT scan is obtained for further diagnostic information.
There are two components to the diagnosis. The patient’s response to the dye is the first element. The recreation of pain and the pressure at which that pain occurred in conjunction with the appearance of the disk, evidence of where the dye is seen and the follow-up CT scan make up the second part. Evidence of annular fissures or tears, the level of degeneration of the disk, diagnostic information, combined with the pain recreation, may guide further therapeutic interventions.
Another form of pain management treatment that utilizes heat, Intradiscal Electro Thermal Therapy (IDET) is used to treat lower back pain arising from painful discs identified by discography. In this particular treatment, a needle and thermo-coupled electrode are inserted into the painful disc(s). The electrode is heated to 90 Celsius (194 degrees Fahrenheit), over the course of 17 minutes. The heat destroys the pain causing nerve fibers in the disc, as well as thickens the collagen in the treated disc making it stiffer and less compressible. The thickening of the collagen also closes fissures (cracks in the disc), which in turn results in reduction of pain.
IDET is a minimally invasive outpatient treatment and offers an alternative to spinal fusion or disc replacement surgery. The effectiveness of this procedure has been proven in scientific studies which meet the highest levels of scientific validity.
Spinal Cord Stimulation (SCS) is a technique that treats pain by stimulating the sensory portions of the spinal cord with low amplitude electrical impulses. This technique has been proven to be very effective for patients diagnosed with neuropathic pain (e.g. RSD/CRPS, diabetic neuropathy, arachnoiditis, post-herpetic neuralgia, etc.). Candidates for this procedure usually have pain that has been unresponsive to other forms of treatment.
An implanted lead (a linearly aligned array of electrodes), powered by a battery or receiver, is implanted in the epidural space near the spinal cord. The system works by tricking the brain. By sending electrical impulses to the spinal cord, the brain experiences a tingling vibrating sensation as opposed to pain. The technique is typically performed in two stages; the first being the trial stage in which a lead is placed through the skin under local anesthesia into the epidural space. The lead is connected to the trial screening box that the patient takes home. After being taught how to operate this trial screener, the patient goes home for several days to determine if the electrical current provides pain relief. If the “test drive” is successful, a permanent system can be implanted, typically with all the components placed under the skin. This permanent implant usually involves a one to two day hospital stay.
Intraspinal Drug Therapy utilizes the latest in medical technological advancement to provide continuous, low doses of pain medication directly to the spinal cord. As part of this therapy, a small electronic pump is implanted under the skin of the abdominal wall. A catheter, also surgically placed, provides a small tube through which the medication is delivered from the pump into the spinal fluid. To maintain a supply of medication, the pump is periodically filled with pain medication through a needle that’s inserted into a port at the center of the pump face.
Because the drug is delivered directly to the spinal cord (where pain signals travel), Intraspinal Drug Therapy is typically very effective in controlling chronic pain. More importantly, this therapy works with a tiny fraction of the dose that would be required with pills, minimizing side effects. Since the pump is reletively small, the device also maintains a very inconspicuous profile.
Nucleoplasty is a minimally invasive procedure performed under a local anesthesia. This procedure enables us to combine tissue removal with thermal treatment to achieve disc decompression quickly and efficiently. Disc decompression has been shown to treat symptomatic patients with a contained herniated disc(s).
The atlanto-axial joint is the joint formed by the uppermost cervical vertebrae. It is a common cause of pain at the base of the scalp that can radiate all the way behind the eye. Treatment of pain from this joint with injection therapy can provide long term relief of these frequently under diagnosed or misdiagnosed headaches. The atlanto-occipital joint is the joint formed by the joining of the skull with the cervical spine. Although a more unusual cause of headaches, it can be a cause of upper neck pain and headaches that occur with rotation of the head.
Peripheral Nerve Stimulation (PNS) is an exciting new neuromodulatory technique to control pain in specific regions of the body. It has been used successfully to treat headaches and other pain syndromes which are debilitating and cannot be controlled with other treatments or medications. Electrical stimulation for pain is a remarkable advance in treatment for many reasons including unmatched relief as well as a lack of tolerance and unmatched safety.
Patient Art states he has suffered from neck pain since he was a child, the pain became worse when he was involved in a car accident years later. Art has tried every avenue to relieve the pain; it was not until he was referred to Dr. Glaser who worked hard to find a plan that worked specifically for him. Art is not pain free but does say his pain is manageable and will continue to follow Dr. Glaser’s treatment plan. We thank Art for sharing his story!
Dr. Goodman can be described as our hero and a miracle worker. He was very encouraging with my mother and gave her to x-ray guided injections in her hip. After the first one she was able to bear weight and he prescribed physical therapy for her to get her leg strength back. After several months of physical therapy she is now able to ambulate in her apartment and within the retirement community where she lives. She is able to leave the community easily and attend family functions again - even going up two steps. You can now see the wheelchair is being used as her desk! Dr. Goodman also provided his input in the care plan meeting at the community and was very insistent on pushing my mom as far as she could go by encouraging everyone to limit the use of the wheelchair whenever possible. He gave my mom the confidence she needed to improve.