SPINAL PROCEDURES & INJECTIONS

OCCIPITAL NERVE BLOCK

The greater occipital nerve arises from between the first and second cervical vertebrae, along with the lesser occipital nerve. It supplies sensation to the skin along the back of the scalp to the top of the head.

Sometimes, when the occipital nerve is irritated, the pain of this irritation is felt near the eye of the same side of the head. This is known as referred pain.

These nerves may also contribute to headaches. Sometimes blocking (numbing) the occipital nerve will reduce headache in the front of the head. This is known as Occipital Nerve Block

During an occipital nerve block, a local anesthetic and steroids are injected into the scalp where the trunk of the nerve is. The injection is done at the back of the head, just above the neck. The skin is numbed before the injection is done. A very fine needle is used for the nerve block.

If the injection has been well located, the scalp on that side of the head will go numb quickly. Pain relief can be felt sometimes within minutes. The doctor may ask what the patient is feeling in terms of his or her symptoms.

If there is a lot of swelling in the nerve, the steroids will relieve the pain of that. The full effect of the steroids may not be felt for two or three days. Their effect is more long lasting — sometimes weeks or months.

After an occipital nerve block, a patient can usually drive home and return to normal daily activities the following day. The effects of the local anesthetic may wear off in a few hours, but the effects of the steroid begin to increase over the next several days.

The best responses to an occipital nerve block usually come from patients whose pain is relatively recent rather than long-standing.

If the first occipital nerve block doesn’t relieve the patient’s symptoms in a week or two, it may be necessary to have a second injection. Additional nerve blocks may be done to keep the symptoms under control.

On the other hand, a lack of results may be a sign that the occipital nerves are not the source of the pain and further work should be done to diagnose the cause of the pain.

It is rare to do more than three occipital nerve blocks in a six-month period. The more injections of steroids that are given, the greater the chance of side effects. If more frequent injections are needed, another type of treatment will probably be considered.

STELLATE GANGLION BLOCKS

The stellate ganglion block is an injection procedure used to block or decrease pain located in the head, neck, chest, or arm. It also helps increase circulation. The stellate ganglion is a group of nerves located in the upper neck and is part of the sympathetic nervous system. After an injury, often auto injury or illness, the sympathetic nervous system may not function properly, causing pain. Some of the more common conditions are: complex regional pain syndrome (CRPS) also known as reflex sympathetic dystrophy (RSD), causalgia (nerve injury), and herpes zoster (shingles) of the head and face.

The stellate ganglion block is also used to treat intractable angina (severe pain caused by heart disease). If this treatment relieves your pain, the doctor will perform a series of blocks at another time in an attempt to break the pain cycle and provide long lasting pain relief. The number of blocks you will need depends on how long the pain relief lasted between injections. Usually you will get more and longer pain relief after each injection.

The procedure is performed with you lying on your back. After cleansing your neck with an antiseptic solution, Dr. Chowdhury will inject numbing medicine into the skin and tissue.

The doctor will also apply some pressure on your neck to determine exactly where to place the needle. It is very important that you do not talk, swallow, or cough. If you have to swallow or cough, raise your hand to let someone know. The doctor will insert a needle, and when satisfied with the needle position, the doctor will inject a numbing medicine (anesthetic). Although it takes about 10 to 20 minutes for the medication to take effect, you will remain at the Clinic until the doctor feels you are ready to leave. Ultrasound guidance may be used for needle localization.

You need to be aware of several potential side effects. These side effects, which usually disappear four to eight hours after the block may include: A droopy eyelid on the side of the block; Redness and blurred vision in the eye on the side of the block; A feeling like a lump in your throat; Difficulty swallowing; Hoarseness of your voice; Warmth and weakness of the arm on the side of the block. Do not eat solid food until you are comfortable swallowing. Do not drive for the remainder of the day. Please have an adult drive you home or accompany you in a taxi or other public transportation.

Depending on how you feel, you may resume normal activities and return to work the following day. If the doctor prescribes physical therapy, it is very important that you continue with the physical therapy program. Although you may feel much better immediately after the injection (due to the numbing medicine), there is a possibility your pain may return within a few hours. It may take a few days for the steroid medication to start working.

TRIGGER POINT INJECTIONS

Trigger point injection (TPI) is used to treat extremely painful areas of muscle. Normal muscle contracts and relaxes when it is active. A trigger point is a knot or tight, ropy band of muscle that forms when muscle fails to relax. The knot often can be felt under the skin and may twitch involuntarily when touched (called a jump sign).

The trigger point can trap or irritate surrounding nerves and cause referred pain — pain felt in another part of the body. Scar tissue, loss of range of motion, and weakness may develop over time.

TPI is used to alleviate myofascial pain syndrome (chronic pain involving tissue that surrounds muscle) that does not respond to other treatment, although there is some debate over its effectiveness. Many muscle groups, especially those in the arms, legs, lower back, and neck, are treated by this method. TPI also can be used to treat Fibromyalgia and tension headaches.

Trigger Point Injections are limited to what is called the “soft tissue” of the body. They are not given into blood vessels, nerves, joints or the spinal canal.

You may be sitting or lying down in order to be comfortable. This allows Dr. Chowdhury and associates who are a leading specialists of administering Trigger Point Injections in particular for the treatment of auto accidents injuries to localize areas of maximum tenderness. These areas are cleansed with a sterile solution. The injection is then performed using local anesthetic and sometimes an anti-inflammatory steroid. You may experience some transient burning as the local anesthetic starts to take effect before it numbs the area. Injection of medication inactivates the trigger point and thus alleviates pain. Sustained relief usually is achieved with a brief course of treatment. Several sites may be injected in one visit.

Icing for 20 to 30 minutes several times later on the day of the injection may be helpful, along with easy stretching exercises. You may return immediately to work or regular activities after the injection. You may drive, although some people feel less nervous if they know they have someone along to drive them home. You should continue any physical therapy sessions already scheduled. At times, the physician will specifically want to perform the injection on a day when you are scheduled for physical therapy. You may be sore for the first 24 to 48 hours. If any unusual redness or swelling or warmth occurs at the injection site, notify the physician. You may continue taking all of your regular medications. The doctor may prescribe some new medications to enhance the effectiveness of the injections.

KNEE INJECTIONS

Cortisone is a type of steroid that is produced naturally by a gland in your body called the adrenal gland. Cortisone is released from the adrenal gland when your body is under stress. Natural cortisone is released into the bloodstream and is relatively short-acting.

Injectable cortisone is synthetically produced and has many different trade names (e.g. Celestone, Kenalog, etc.), but is a close derivative of your body’s own product. The most significant differences are that synthetic cortisone is not injected into the bloodstream, but into a particular area of inflammation. Also, the synthetic cortisone is designed to act more potently and for a longer period of time (days instead of minutes).

Cortisone knee injections can also be used in the treatment of auto accident injuries.

Articular cartilage is the smooth coating covering the surface of the bones inside the knee. It helps to lubricate and cushion the surfaces of the knee joint. In osteoarthritis, this coating is damaged leading to reduced lubrication and cushioning. This results in some of the pain, grinding, and other symptoms experienced by osteoarthritis-sufferers (see the osteoarthritis section for further information).

Viscosupplementation therapy involves injecting a clear gel-like substance directly into the knee joint. These injections help to restore some of the lubrication lost by damaged cartilage and thus improve symptoms. An injection is given as one shot into the knee joint each week for three weeks. Usually people who respond to this form of treatment will experience some improvement for six to ten months. An injection series can be repeated every six months as needed. This method of therapy is used for people who have not benefited from less invasive therapies such as lifestyle modification, physiotherapy, and oral medications. The injections do carry a small risk of infection or allergic reaction to the lubricant itself. Physicians can provide additional information about the risks and benefits of this procedure.

SHOULDER INJECTIONS

Cortisone is a type of steroid that is produced naturally by a gland in your body called the adrenal gland. Cortisone is released from the adrenal gland when your body is under stress. Natural cortisone is released into the bloodstream and is relatively short-acting.Injectable cortisone is synthetically produced and has many different trade names (e.g. Celestone, Kenalog, etc.), but is a close derivative of your body’s own product. The most significant differences are that synthetic cortisone is not injected into the bloodstream, but into a particular area of inflammation. Also, the synthetic cortisone is designed to act more potently and for a longer period of time (days instead of minutes).Cortisone shoulder injections can also be used in the treatment of auto accident injuries.

A corticosteroid injection is sometimes recommended when pain is caused by inflammation in the joints such as bursitis, tendonitis, and arthritis. A corticosteroid injection can also help reduce inflammation and pain when rotator cuff is affected.

SACROILIAC JOINT INJECTIONS

Sacroiliac joint injections are performed for diagnostic and therapeutic intentions for lower back pain associated with sacroiliac (SI) joint dysfunction and auto injuries. The sacroiliac joint is located between the sacrum (bottom of the spine) and the pelvis (hip).

Sacroiliac joint pain maybe difficult to diagnosis due to lack of accurate imaging study, physical examination, as well as similarity to pain caused by disc herniation and lumbar spinal nerve compression.

The sacroiliac joint is the cause of your low back pain if dramatic reduction of pain is derived after deposition of local anesthetic into the joint itself. Sacroiliac Joint Injury is common after auto accidents as a result of pressure from the seat belt during impact.

After an initial consultation with Dr. Chowdhury and your questions answered satisfactorily, you will be escorted to a procedure suite and positioned prone on the fluoroscopic table. The target site is cleansed with antiseptic solution. The skin over the injection site is numbed with a local anesthetic. A thin needle is then inserted into the sacroiliac joint under X-ray guidance. Once needle placement is confirmed, a combination of a long-lasting steroid and a local anesthetic (bupivicaine) are deposited. The whole process takes approximately 15-20 minutes with the actual procedure taking between 2-3 minutes.

HIP INJECTIONS

The hip joint is a large joint where the leg joins the pelvis. If this joint experiences arthritis, injury or mechanical stress, one may experience hip, buttock, leg or low back pain. A hip joint injection may be considered for patients with these symptoms. The injection can help relieve the pain, as well as help diagnose the direct cause of pain.

Hip joint injections involve injecting medicine directly into the joint. These injections can help diagnose the source of pain, as well as alleviate the discomfort:

Diagnostic function: By placing numbing medicine into the joint, the amount of immediate pain relief experienced will help confirm or deny the joint as a source of pain. If complete pain relief is achieved while the hip joint is numb it means this joint is likely to be the source of pain.
Pain relief function: Along with the numbing medication, time-release cortisone is also injected into these joints to reduce inflammation, which can often provide long term pain relief.

Hip Injections can also be used in the treatment of auto accident injuries.

On the day of the injection, patients are advised to avoid driving and doing any strenuous activities.

The hip joint injection procedure includes the following steps:

The patient lies face down on an x-ray table and the skin over the hip is well cleaned.
Dr. Chowdhury numbs a small area of skin with an anesthetic (a numbing medicine). The patient may feel a sting that will last for a few seconds.
The doctor uses x-ray guidance (fluoroscopy) to direct a very small needle into the joint.
A small mixture of anesthetic and anti-inflammatory cortisone is then slowly injected into the joint.

The whole process takes approximately 15-20 minutes, with the actual procedure only taking 3-5 minutes. After the hip joint injection procedure, the patient is asked to move the area of usual discomfort to try to provoke the usual pain. Patients may or may not obtain pain relief in the first few hours after the injection, depending upon whether or not the joint that was injected is the main source of the patient’s pain. On occasion, the patient may feel numb or experience a slightly weak or odd.

Patients may notice a slight increase in pain lasting for several days as the numbing medicine wears off and the cortisone is just starting to take effect. If the area is uncomfortable in the first two to three days after the injection, applying ice or a cold pack to the general area of the injection site will typically provide pain relief and appear more beneficial than applying heat.

If the hip joint that was treated is the source of the pain, the patient may begin to notice pain relief starting two to five days after the injection. If no improvement occurs within ten days after the injection, then the patient is unlikely to gain any pain relief from the injection and further diagnostic tests may be needed to accurately diagnose the patient’s pain.

Patients may continue to take their regular medicines after the procedure, with the exception of limiting pain medicine within the first four to six hours after the injection, so that the diagnostic information obtained is accurate. Patients may be referred for physical therapy or manual therapy after the injection while the numbing medicine is effective and/or over the next several weeks while the cortisone is working.

On the day after the procedure, patients may return to their regular activities. When the pain has improved, it is advisable to start regular exercise and activities in moderation. Even if the pain relief is significant, it is still important to increase activities gradually over one to two weeks to avoid recurrence of pain.

FACET BLOCKS

Facet joints are part of your spine. They are small joints that connect adjacent vertebral bones in the back where they come together.

Facets can cause pain if they break, become arthritic, or injured.

A facet block can be done for two reasons. It can be used to see if a particular joint is causing one’s pain. A small amount of a Novocain like drug is used to numb the joint. If the pain goes away, it is assumed that the joint is the problem. Facet blocks can also be done for treatment. Injecting steroids can get rid of pain long term.

After an initial consultation with Dr. Chowdhury and your questions answered satisfactorily, you will be escorted to a procedure suite and positioned prone on the fluoroscopic table. The doctor watches on a fluoroscope as he inserts the thin needle to make sure it goes into the correct facet joint (a fluoroscope is a special X-ray TV that allows the doctor to see your spine and the needle). Once the needle is in the facet joint, he will inject a steroid into the joint.

Patients are able to leave the clinic upon completion of the procedure. If your pain goes away after the injection, it can be inferred that the targeted facet joint(s) is your pain generator. Although facet injections may provide long lasting relief, many do not. If relief lasts longer than several months, injections may certainly be repeated. However, if dramatic but brief relief is obtained, more diagnostic injections such as Medial Branch Blocks may be more appropriate. Potential side effects from steroid administration may include transient flushing, restlessness and elevation of blood sugar. You should follow up with your referring physician’s office in ten to fourteen days, unless instructed otherwise, accompanied with your questionnaire for evaluation.

EPIDURAL STEROID INJECTIONS

Epidural Steroid Injection (ESI) is an non-surgical treatment that may alleviate neck/back and arm/leg pain caused by conditions such as spinal stenosis, disc herniation and degenerative disc disease.

Medicines are delivered into the epidural space which lies between the protective covering of the spinal cord (dura mater) and the bony vertebral wall.

The goal is to reduce pain by diminishing inflammation of the spinal nerves so you may improve your daily function and continue with your rehabilitative exercises.

After an initial consultation with Dr. Chowdhury and your questions answered satisfactorily, you will be escorted to a procedure suite and positioned prone on the fluoroscopic table. The target site is cleansed with antiseptic solution and sterilely draped. The skin over the injection site is numbed with a local anesthetic. A thin needle is then inserted into the epidural space under X-ray guidance. Once needle placement is confirmed, depomedrol is injected into the epidural space. The whole process takes approximately 15-20 minutes, with the actual procedure only taking 2-3 minutes.

Most patients are able to leave the clinic upon completion of the procedure. Avoid strenuous activities over the next 24 to 48 hours. Application of ice and oral intake of mild analgesics usually will alleviate potential soreness over the injection site although flair-ups are possible. Potential side effects from steroid administration may include transient flushing, restlessness and elevation of blood sugar. You should follow up with your referring physician’s office in 10 to 14 days and report overall treatment response. There are no consensus in the medical community regarding the frequency of epidural steroid injections, the most prudent recommendation suggests evaluation of each and every injection prior to further treatments are planned.