We offer a wide variety of pain management services and procedures at Interventional Pain Consultants. Our highly qualified team of experts are trained in treating everything from sciatica nerve pain to lower back pain to vertebroplasty.
Instructions Prior to Procedure
Blood Thinning medications
Please consult our office to determine if you need to stop your blood thinner prior to your procedure. Some procedures can be safely done with patients on some blood thinners.
If you currently have an infection and are being treated with an antibiotic, we will most likely postpone your procedure for you to complete your antibiotic.
If you are a diabetic and your morning blood sugar is above 200mg/dL we will postpone your procedure if it involves steroids as this will increase your blood sugar. We will ask you to work with your diabetes physician to optimize blood sugar control prior to doing a steroid related injection.
Epidural injections are done for many common pain problems. Epidural injections are done in the neck and the thoracic spine as well as the lumbar spine. There are multiple kinds of epidural injections. The primary kind of epidural injections in pain management are the epidural transforaminal injection otherwise called selective nerve root injection, or the midline epidural injection or translaminar injection. These injections historically are done in a series of 3. This practice has been called into question by studies as well as insurance payers. Epidural injections currently are done and subsequent evaluation follows to determine if significant benefit was achieved. If significant benefit was achieved, the injection may be repeated. If significant benefit was not achieved, an injection may be done at a different level or a different type of epidural may provide greater benefit. Epidural injections are typically done at least 2 weeks apart and contain some kind of steroid with or without a local anesthetic. The most common steroid utilized would be Decadron or dexamethasone.
Facet injection refers to an injection of local anesthetic plus steroid into the joint area involving the neck, thoracic spine or lumbar spine. These injections are sometimes beneficial when someone has had an injury involving the above body part. Facet injections are typically not repeated multiple times. Medial branch blocks are a specific block of a branch of the nerves of the cervical, thoracic or the lumbar nerves. This branch of nerves supplies the facet joint, also known as the zygapophyseal joint. Medial branch blocks are a test to determine if one is a candidate for radiofrequency ablation of the medial branch and subsequent long-term pain relief of 6 months to 2 years. Most insurance companies dictate that you have to have 2 separate medial branch blocks to qualify for radiofrequency ablation.
Interventional Pain Consultants utilizes radiofrequency ablation of the medial branches, genicular nerves, and sometimes peripheral nerves. Radiofrequency ablation, in general, has a duration of 6-12 months of pain relief following successful ablation. Radiofrequency is only performed on selected nerves because radiofrequency of a motor nerve would result in weakness of the affected muscle. Radiofrequency can be done on sensory nerves; however, this results in numbness. Most of the nerves that are subject to radiofrequency ablation do not have a skin sensory component or a motor component to minimize that complication.
SI Joint Injections
SI pain is a common cause of low back pain. It is difficult to differentiate from hip pain as well as L5 nerve root pain in many cases. SI injections can be beneficial to help determine diagnostically that pain is from the SI joint. SI joint injections should be done under x-ray guidance to assure adequate placement of the medication. SI pain is more common in female patients than male patients.
Joint injections done involve most of the joints in the human body. In some cases, these are performed under x-ray guidance; typically, the hip joint injection. Joint injections can be performed under ultrasound guidance or x-ray guidance; typical for the knees, shoulders, ankles, and elbows. Joint injections are normally received every 3-4 months and typically contain a local anesthetic and a steroid, such as triamcinolone. Knee injections can also be done with one of multiple hyaluronic acid base injections. These go by many names, including: Supartz, Orthovisc, Monovisc, Gelsyn and many others. These injections are done in a series for degenerative joint disease or arthritis of the knee.
Trigger Point Injections
Trigger point injections are done to break muscle spasms. They are typically done with a very small needle; 30-gauge or 27-gauge with a local anesthetic injected into the muscle. The goal of trigger point injections is to break acute muscle spasms so the patient can do stretching exercises and physical therapy or chiropractic therapy to improve function of the muscular group. Trigger point injections are not a long-term treatment but simply a modality to break muscle spasms.
The human body contains many bursas. The most common bursa injected is the greater trochanteric bursa. The greater trochanter is part of the hip-joint complex. Often times, patients develop trochanteric bursitis secondary to abnormal gait. Trochanteric bursa injections can be done with or without ultrasound and or x-ray guidance. Typically, the medication injected is a local anesthetic plus steroid. Usually part of an overall plan to rehabilitate the affected body part is utilizing exercises or chiropractic therapy.
Transforaminal epidural injection is an epidural steroid injection that is done through the nerve root opening in the cervical, thoracic, or lumbar spine. These injections are frequently used for problems such as sciatica or cervical, thoracic, or lumbar radiculopathy. These are frequently used when the nerve is being impinged where it leads to the spine through the foramina. The medication injected in a transforaminal epidural is typically dexamethasone with or without a local anesthetic. Transforaminal epidurals, like other epidural injections, are evaluated subsequent to the procedure being done for significant pain benefit. For instance, if someone does not benefit from a right L5 transforaminal injection, this might be repeated. However, if they do not benefit, the most appropriate treatment might be a right L4 transforaminal to inject a different nerve. Transforaminal injections are very location specific.
Selective Nerve Blocks
Selective nerve blocks are done to specifically try and diagnose the location of a painful problem. These might be called a diagnostic lumbar transforaminal. These typically contain a local anesthetic which will immediately relieve the pain if applied to the affected nerve causing the pain. The primary goal of a selective nerve root block is to block the nerve where it leads to the spine, not to get steroid into the epidural space. Selective nerve root blocks can be ordered by referring surgeons to help determine what operation might be most beneficial for an individual patient.
Occipital Nerve Block
Occipital nerve blocks are done of the greater occipital nerve, lesser occipital nerve, and third occipital nerve. They are done with a steroid and local anesthetic. They are typically not x-ray guided or ultrasound-guided. Occipital nerve blocks are frequently done for patients who have headaches in the back of their head. Occipital nerve block can sometimes alleviate this headache. If the headache continues to return and occipital nerve blocks are not helpful, the patient may be considered for surgical referral for decompression of the occipital nerve or for spinal cord stimulation.
Sympathetic Nerve Block
Sympathetic blocks consist of multiple types of blocks such as stellate, celiac plexus, lumbar sympathetic, and hypogastric plexus. These injections are done for different pain states. The stellate ganglion block is typically done for complex regional pain syndrome involving an upper extremity. These injections are most typically x-ray or ultrasound-guided and patients have intravenous lines started for all the sympathetic blocks. Celiac plexus blocks are done for diffuse abdominal pain or pancreatic cancer pain. Lumbar sympathetic blocks are typically done for complex regional pain syndrome involving the lower extremity. Hypogastric plexus blocks are frequently done for patients who have interstitial cystitis or chronic pelvic pain. The hope of the sympathetic block is that you can get the central nervous system to reset, like rebooting the computer, and see if the pain will diminish. In some patients, a series of these blocks can diminish the for a long period of time. These blocks are typically not done more than once per week. Patient who fail sympathetic blocks for certain pain conditions subsequently go on to be considered for spinal cord stimulation.
Interventional Pain Consultants has extensive experience with spinal cord stimulation. We utilize several different brands, including: Saint Jude / Abbott burst DR spinal cord stimulation as well as Dorsal Root Ganglion stimulation, Nevro high frequency or 10 K spinal cord stimulation, Medtronic HD spinal cord stimulation, and Boston scientific Waverider. We perform trials for spinal cord stimulators in the office and trials for dorsal root ganglion stimulation in the hospital setting. Interventional Pain Consultants has extensive experience with trialing spinal cord stimulators in the cervical, thoracic, and lumbar spine as well as dorsal root ganglion stimulation. We are highly skilled with both the trial phase and the permanent implantation phase. Permanent spinal cord stimulation implantation is always done in a Surgery Center or hospital-based setting. Spinal cord stimulation is a technique where wires or a paddle is placed in the back of the spinal cord somewhere between the cervical and the sacral spine. Electrical stimulation of the dorsal columns has multiple effects to eliminate pain. Specific mechanism is not discussed here because different stimulators have different mechanisms. The goal of spinal cord stimulation is improvement in function of activities of daily living and a pain reduction greater than 50% of baseline. When doing a spinal cord stimulator evaluation, patients are first sent to a psychologist who will help interpret the degree the patient has been educated regarding the stimulator. This is required by insurance carriers as part of the overall evaluation. The referral to the psychologist is not to determine whether the patient is being considered to have psychological or psychogenic pain. The patient being evaluated for a spinal cord stimulator by definition is felt to have pain of a nociceptive or neuropathic origin and not psychogenic pain. Patients may sometimes misinterpret this referral to the psychologist as their doctor or provider not believing their pain is valid. It is our goal to reassure them otherwise.
Pain pumps, otherwise known as morphine pumps, are utilized by Interventional Pain Consultants. We typically utilize the Medtronics SynchroMed 2 infusion device. Most of our patients have a patient therapy manager (PTM) where they can give themselves extra doses of medication. The advantage of pain pumps is the medication is applied directly to the area of the spine where the pain is entering the central nervous system. The intrathecal catheter portion of the pump infuses medication directly into the patient’s spinal fluid. If the patient has neck pain, then the intrathecal catheter would be placed in the cervical spine area. If the patient has low back pain, intrathecal catheter placement would be at approximately the T9 area. A patient who has metastatic cancer or locally invasive cancer in the pelvis may have an intrathecal catheter tip at the L1 area. The FDA approved medications for the intrathecal pump include morphine, ziconotide (Prialt), and baclofen. Many intrathecal pumps contain Dilaudid or hydromorphone, which is not FDA approved. Hydromorphone, however, is considered a class I drug by the poly-analgesic conference and recommended for use. Many intrathecal pumps have medications such as bupivacaine or clonidine added; however, these are an off-label use and not FDA approved. These are tier 2 drugs from the poly-analgesic conference and recommended for use. IT pumps offer better pain relief with fewer side effects and are frequently programed to give intermittent boluses to control pain. Psychological evaluation is usually done before IT pumps. This is done to review patient education. Patient who are on narcotic therapy will be weaned off the narcotic medication prior to
placement of an IT pump. This is done to get the patient receptors normalized to get the best long-term outcome for the patient. IT pumps has a trial phase to see if the medication is helpful and then a permanent phase if the trial phase is determined to be helpful. The trials are typically done in the office and permanent phase operation is done in the hospital.
Dorsal root ganglion stimulation is indicated for complex regional pain syndrome involving the lower extremity. This can frequently occur after an injury to the foot, ankle or fracture. This can occur after ankle surgery or knee surgery. We perform a complete evaluation on the patient to determine if they have complex regional pain syndrome. This is done by a sympathetic block. To attempt to get rid of the pain, we work with the patient’s surgeon to try and correct any underlying pathology. If the patient continues to have significant pain, a dorsal root ganglion stimulator trial would be recommended. This trial would have a duration of proximally 7-14 days and would be placed in the patient at a Surgery Center or Hospital. If the patient has a successful trial, we would then undergo permanent implantation of a dorsal root ganglion stimulator and battery.