Procedures:

Bursa injections:  A bursa is  a small, fluid-filled sac that lubricates and cushion  your bones and the tendons and muscles near your joints. They allow  joints  to move with ease. Bursitis occurs when these  bursa becomes inflamed. You have more than 150 bursae in your body. When inflammation occurs, movement or pressure is painful.  At our clinic we can deliver medication into the bursa without a needle. This delivery system is known as Iontophoretic therapy. A patch will be placed over the affected area and medication delivered trough. Easy, fast and painless.

Celiac block: indicated in pain involving the pancreas, liver and stomach. This injection is also performed with the help of x-rays and some time CT-scan. It is widely used in the treatment of pancreatitis and pancreatic cancer. Initially performed with local anesthetic only (lidocaine, marcaine), if successful then a solution may be injected to stop the celiac nerves from causing  pain. This procedure is known as lytic block.

Continuous Epidural catheters: placed in the epidural space or intrathecally ( where spinal fluid lies) connected to a device that delivers constant or demand pain medications. Used  as test before intrathecal pumps,  to alleviate severe pain after surgery  and for severe cancer pain. Placed while admitted to the hospital, but available to take home, hospice or rehabilitation facility.

Epidural steroid injections: these injections are given for the treatment of several conditions that produce neck, thoracic or low back pain. You may have heard of  spinal stenosis, herniated discs, facet arthropathy, degenerative disc disease and  sciatica. We perform these injections with the help of fluoroscopy (x-rays). It is important to visualize the exact entry point and the spread of the medication injected. It also prevents us from  accidentally injecting into  the wrong target. Medications used include a local anesthetic (lidocaine, marcaine) and an anti-inflammatory compound (depomedrol, celestone). This combination is thought  to provide with quick and long lasting relief of pain. There are 3 possible approaches into the epidural space: at the center of the spine (most common), trough the tailbone (caudal) and transforaminal (from the side of the spine). You may receive up to 3 injections, using the  same approach or a combination of all. Epidural injections could be given in the neck, upper and lower back.

Facet blocks: also referred as medial branch nerve block or diagnostic blocks. Consists of injections into the small joints (facets) of your spine thought to be responsible for back pain. Another approach is to inject with local anesthetics (lidocaine, marcaine) the small nerves that supply these joints. If effective you  may be a candidate for radiofrequency ablation of the nerve. Used to treat inflammation of the facet (zigo-apophyseal) joints of the spine.

Ganglion impar block:  the last set of sympathetic nerves, locate around the coccyx. Indicated for vaginal, rectal and pelvic pain.  Performed with the help of x-rays.

Hypogastric block: fiber form these nerves go to the pelvic region. Conditions amenable to be treated include cancer of the uterus, cervix, testicle and anus. Pelvic, vaginal and rectal pain also can be treated. This block is performed with x-rays and the needle is placed in the low back.

Lumbar Sympathetic block: Injections performed to treat and diagnose sympathetic pain. Performed under x-rays (fluoroscopy), with a thin needle. Local anesthetics will "numb" this group of nerves decreasing pain. Changes in sweat and temperature may be observed. Performed as an outpatient, sedation is offered.

Nerve Injections: consist of an injection of local anesthetic (lidocaine, marcaine) near or into nerves or groups of nerves. These injections are performed to alleviate or diagnose pain thought to arise from nerves. Is a fast an easy procedure, most of the times performed in the office setting. Sometimes requires the help of x-rays and/or  a hospital setting.

Most important  nerves injected:

• Ankle nerves: for foot pain.
• Brachial plexus: for hand, shoulder and arm pain.
• Facial, supraorbital, supratrochlear, trigeminal and  mental nerves:  for headaches, eye and face pain.
• Femoral nerve: for leg pain
• Inguinal nerve: groin, testicle, vaginal pain.
• Intercostal nerve: ribcage pain after rib fractures, rib cancer and metastasis and shingle/herpes zoster. Also used to treat Post-thoracothomy pain syndrome.
• Lateral femoro-cutaneus nerve: treats leg pain, particularly a condition known as Meralgia Paresthetica.
• Median nerve:  for carpal tunnel.
• Occipital nerves: for headaches in the posterior aspect of the head. After whiplash injury.
• Peroneal and saphenous nerves: leg pain below the knee. Pain after knee surgery.
• Pudendal nerve: pelvic, groin and genital pain.
• Radial nerve: hand pain.
• Sciatic nerve:  leg pain below the knee.
• Superficial cervical plexus: shoulder and neck pain. Used particularly for pain after radical neck dissection surgery. Also for whiplash injury.
• Supraescapular nerve: shoulder pain.
• Ulnar: arm and hand pain.

RFA: Radiofrequency ablation, also known as rhizotomy.  A test is performed injecting the facet joint or the nerves supplying them. If after the injection, adequate relief of pain is achieved then RFA of the nerves is performed. It consists of heating the tip of a very small needle at  affected levels (Facet nerves) of your back and neck. Most patients obtain 6-12 months of relief of neck and back pain. This procedure takes less than 30 minute to complete and should no be incapacitating, allowing you to go home shortly after.

Sacro-iliac joint injections: large joint connecting the sacrum with the pelvis. Located at each side of the back, around the buttocks. Sacro-iliac joint pain may mimic back pain, groin pain and leg pain (sciatica).  Experienced pain physicians will recognize and treat this pain. Under x-rays, and with a small caliber needle, the joint is accessed and injected with local anesthetics (marcaine, lidocaine) and an anti-inflammatory medication (depomedrol).  Fast and safe procedure, may be perfomed alone, one or both sides or in combination with other injections.

Scar Injections: superficial infiltration of local anesthetics, sarapin and depomedrol into scars. At times surgical or traumatic scars can become extremely painful and be a source of pain. Injections and other modalities may contribute to decrease such pain.

Spheno-Palatine block: Sometimes blocking a nerve does not include a needle. This block is a great example. A local anesthetic Lidocaine, marcaine) is instilled via the nostrils, either directly or with the help of cotton swabs. This procedure is traditionally performed for Cluster Headaches and facial pain. Takes about 15 minutes and is commonly performed in the office.

Spinal cord stimulator : Spinal cord stimulators (SCS) are one  of the newest addition to pain management. A small catheter is inserted into the epidural space trough an epidural needle. It is then connected to a stimulator.  A very low current is generated by the stimulator, propagating to the areas of pain of the spine or extremities. This small current interferes with the transmission of pain. The procedure is performed in 2 steps, a trial and a permanent placement. During the trial period a catheter is placed as described above.  This procedure takes less than one hour. Patients may go home the same day. While at home, you will try different stimulation patterns and intensities. At the end of the trial (3-5 days) if you are comfortable, the stimulator will be placed under the skin (think:pacemaker). Nothing is left outside and the SCS is controlled by a remote. Multiple conditions can be treated with SCS’s. The most common  being post-laminectomy surgery pain. Some other conditions successfully treated include painful nerve damage, complex regional pain syndrome (RSD), headaches, face pain, ischemic ulcers and pain and  cardiac angina.

Link to www.controlyourpain.com for more information.

Spinal pumps: Different types of medications have been injected into the spine, mostly for pain conditions. Most commonly for intractable low back pain after surgery and cancer pain. A small catheter is inserted into the spine, then connected to a reservoir (about the size of a pacemaker). This reservoir is the placed under the skin trough a small incision. The pump is then programmed to deliver a specific amount of medication daily. Refills to the pumps are possible with a small needle trough the skin and into the reservoir. Opioids (morphine, hydromorphone), local anesthetics (marcaine) and muscle relaxants (baclofen) are commonly injected via  pumps. Several other medications have been tried successfully.

Stellate block: the stellate ganglia is located in the anterior neck. It supplies the face, arm and chest with sympathetic fiber. Pain originating from these fibers is consider of sympathetic origin. The injection is placed with the help of x-rays in your anterior neck. Your doctor may choose to perform this injection in cases of severe face, eye, arm or chest pain. Also helps with the diagnosis and therapy of conditions like complex regional pain syndrome and Raynaud’s syndrome.

Sympathetic blocks: stellate, celiac, lumbar, hypogastric and ganglion impar. See each one individually. Injection to block the sympathetic nerves. Treats and diagnosis various conditions including CRPS, sympathetic pain, cancer pain, pancreatitis and vascular ischemic  pain among others.

Trigger Point Injections: local anesthetic (lidocaine, marcaine) is injected alone or in combination with sarapin or depomedrol into affected muscles. A trigger point is a painful contracted band of muscle. Easily identifiable by pressing gently upon the muscle. The needles used for these procedures are smaller than insulin needles, which in turn are regarded as very small.

Vertebroplasty: compression fracture of the vertebrae could be very painful. This procedure aims to “cast” the vertebrae just as you would cast a broken leg or arm. A needle is placed by an experienced physician into the center of the vertebrae and under x-rays, a special cement is injected. The aim is to restore the normal anatomy. More than one level can be treated. Ideally is performed for new fractures. Occasionally, Your doctor may choose to inject an old fracture, when all other therapies have failed.  Cancer or traumatic fractures can be managed with this technique. This injections is performed as an outpatient, you will be home for dinner.