DORSAL ROOT STIMULATION
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. Additionally, 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.
DURABLE MEDICAL EQUIPMENT
Neck, back, and knee braces are available to our patients, as needed, for pain.
KYPHOPLASTY
Kyphoplasty is a minimally invasive surgery that helps correct bone deformities. It also relieves pain associated with collapsed or broken bones in the spine. A cement mixture is injected into the bone to give it strength.
OCCIPITAL NERVE BLOCKS
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. Typically, occipital nerve blocks are not x-ray guided or ultrasound-guided. Occipital nerve blocks are frequently done for patients who have headaches in the back of their head and 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.
PAIN PUMPS
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.
RADIOFREQUENCY ABLATION (RFA)
Interventional Pain Consultants utilizes radiofrequency ablation of the medial branches, genicular nerves, and sometimes peripheral nerves. Radiofrequency ablation generally has a duration of 6-12 months of pain relief following successful ablation. This procedure 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.
SELECTIVE NERVE BLOCKS
Selective nerve blocks are done to specifically 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, rather than get steroids 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.
SPINAL CORD STIMULATORS
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 a requirement 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.
SYMPATHETIC NERVE BLOCKS
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. Such 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.
THE MILDⓇ PROCEDURE
The MildⓇ Procedure is a safe, outpatient procedure for individuals diagnosed with lumbar spinal stenosis (LSS). It will help them stand longer and walk farther with less pain. Only certified doctors, like our own Dr. Buenger, can perform the MildⓇ Procedure. A tiny incision, about the size of a baby aspirin, is made in the back to remove small pieces of bone and excess ligament tissue. The MildⓇProcedure requires no general anesthesia, no implants, and no stitches.
VERTEBROPLASTY
Vertebroplasty is a minimally invasive surgery that treats collapsed or broken bones in the spine. A cement mixture is injected into the bone to hold it in place and keep it from collapsing or breaking anymore.
SPRINT PNS
The SPRINT Peripheral Nerve Stimulation (PNS) System has been studied extensively for low back pain, shoulder pain, post-amputation pain, and post-operative knee pain, and is cleared for use up to 60 days.
This breakthrough treatment is designed to provide significant and sustained pain relief and is the only stimulation device cleared that does not require incisions or a permanent implant.