Evaluation and Management
"Since the patient is the expert of his/her pain we listen to our patients."

An Algorithmic Approach
In the changing paradigm of modern medicine, with its major focus on evidence-based medicine, interventional pain physicians are forced to learn and practice evidence-based interventional pain management. The necessary ingredients to provide evidence-based care include:

• Precise definition of the problem /diagnosis;

• Research of the best evidence;

• Critical appraisal of the evidence;

• Consideration of the evidence and its implications, in the context of the patient’s condition, circumstances and values.

Epidural Steroid Injection

Epidural refers to the area, which lies outside the spinal canal. An epidural injection is a procedure performed to reduce swelling, inflammation or irritation of the spinal nerve roots involved in causing your pain.

You will be taken to the fluoro room, which is a special room equipped with an x-ray machine for proper needle placement. You will then be asked to lie on your stomach. Your back will be cleaned with an antiseptic solution. The Doctor will then numb the area with a local anesthetic before inserting the needle. When the needle is in the proper area, the Doctor will inject the medication that is specifically used for your type of pain. It is usually a steroid and mild local anesthetic agent. You may feel pressure in your back during the procedure and slight burning during the injection of medication. After the medication is injected the needle is removed, your back is cleaned and a band-aid will be placed.

You will be taken to the recovery area where you will be observed for 10 to 30 minutes. The Doctor will be in to check on you and will discuss further plans of treatment. You will be given another appointment if necessary and discharge instructions before leaving the clinic.

You should be able to return to your usual level of activity from the following day. If you have any weakness or numbness it should subside in a few hours. You may notice a little more discomfort the first night after the procedure, but the steroid should begin to provide relief in 3 to 7 days. If your pain continues, please call the clinic.

Nucleoplasty
(A Minimally Invasive Procedure for the Treatment of Contained, Herniated discs)

“Minimally invasive percutaneous lumbar disc decompression: An alternative to major surgery”

Low back and/or leg pain secondary to spinal disorders affects 80% of individuals at some time during their lives. One in six will seek medical care for this affliction. This disorder represents the leading cause of disability in adults between the ages of 20 and 50. The total cost to our society is between 50 and 100 billion dollars per year. While the majority of the patients will improve with conservative care, there is a large population that will not.

There are number of treatment options available for an individual with back and leg pain secondary to a herniated disc. The majority of patients with radicular pain will improve within a matter of weeks following a conservative regimen. For those individuals who fail to experience significant relief, the next option could include fluoroscopically guided transforaminal selective nerve root block and 75% of patients will realize a successful outcome. If these fail, a minimally invasive percutaneous lumbar disc decompression will be an option. In the properly selected patients a significant number of the patients avoid an open surgical procedure to treat symptoms of herniated disc.

During percutaneous disc decompression with Nucleoplasty, RF energy is used to dissolve nuclear material through molecular dissociation. It is believed that this reduced volume of disc material results in reduced intradiscal pressure. Bipolar RF coagulation further denatures proteoglycans, changing the internal environment of the affected nucleus pulposus, which showed changes in intradiscal pressure following coblation. Percutaneous nucleoplasty achieved a significant reduction in intradiscal pressure in a disc that had less than 10% loss of disc height when compared to discs with more than 50% reduction. The effectiveness of PDD with nucleoplsty has recently been reported in two prospective trials. Both showed short-term and long-term relief. Retrospective evaluations were not included.

Nucleoplasty is performed on an outpatient basis under local anesthesia and light sedation. C-arm x-ray imaging is employed as an introducer needle is placed through the skin and into the intervertebral disc. The Spine Wand is introduced through the needle into the center of the disc, and then advanced using the ablation mode. Coagulation is then used while withdrawing the wand. The same technique is repeated in a sequential rotating manner 6 times within the disc. After the needle is removed, a bandage is placed on the skin and the patient is discharged. The procedure takes approximately 30 minutes. Patients normally experience a significant pain reduction or complete elimination of leg pain within the first week following the procedure. Relief of back pain may take longer to achieve, often 6-10 weeks.

Post Nucleoplasty Homegoing Instructions:

• Recovery period is 8-10 days

• No driving for 1-2 days

• Limit lifting to 5-10 pounds for two weeks

• Gentle exercise after 1 week

• May return to work after 1 week

• Follow-up in 1 week and 4-weeks

Inclusion criteria:

• Radicular pain associated with contained disc herniation less than or equal to 6mm.

• Clinical picture consistent with radiographic findings and exam(H&P).

• Duration of pain greater than 6 weeks.

• Patient must have failed conservative therapy treatments including; physical therapy, diagnostic and therapeutic injections and medical management, including oral oral analgesics and anti-inflammatory medications.

• Patient must have had good to excellent short-term(<2weeks) response to fluoroscopically guided transforaminal injection of local anesthetic and corticosteroid at symptomatic level(s).

• Confirmative Selective segmental spinal nerve block with .5-1.5 cc of anesthetic providing > 80% relief of radicular pain lasting at least the duration of local anesthetic.

• Preservation of disc height (less than 50% loss).

Exclusion criteria:

• Progressive neurological deficit

• More than 2 symptomatic levels

• Previous surgery (non minimally invasive) at proposed treatment level

• Spinal instability

• Spinal fracture or tumor

• Pain drawing inconsistent with clinical diagnosis

• Significant co-existing medical or psychological condition

Radiofrequency Neurolysis

Radiofrequency neurolysis is a technique where a controlled heat lesion is made along the nerves that have been shown to transmit pain. The most common applications are to denervate, or interrupt nerve transmission from the painful facet joints in the lumbar or cervical spines. Usually two or more joints are involved. Because up to three nerves provide sensation from each joint, at least 4-6 heat lesions must be made. These nerves have already identified by your physician by temporary blocks with local anesthetics under C-arm x-ray guidance.

The heating probe is placed under fluoroscopic guidance with local anesthesia and sedation. Because your participation is needed for both sensory and motor checks to ensure the heating probes are in correct position, you will not be heavily sedated. Once proper placement is ascertained, potent local anesthetic will be injected to avoid discomfort during the heating process. The entire process takes from 30 to 45 minutes to complete.

Around 70% of patients get good to excellent relief of pain. Therefore 30% do not get relief of pain, even after good results from test blocks with local anesthetics. Even in those patients who do respond, there will probably be some residual pain. This pain may be from a different source that may or may not be treatable. If you do achieve good relief to pain, the effect usually lasts at least 9 months, and many times much longer (3 to 5 years). These results are very encouraging, since most patients undergoing this procedure have not obtained relief from any other therapies prior to this.

Although it is very unlikely, you may develop increased pain, or even weakness or numbness as a result of the procedure. Skin burns are also possible, but precautions are taken to avoid this.

Patients with electrical implanted devices (pacemakers and spinal stimulators) may develop dysfunction of these. You will be monitored carefully during and after the procedure to ensure their proper functioning.

You may have temporary numbness or weakness after the radiofrequency neurotomy for 1 o 2 hours. This is due to the effect of local anesthetic on the nearby nerve roots. Most patients leave within 1 hour after their procedure.

After the procedure, you can expect one to two weeks of increased discomfort from the effect of the heat lesion itself. We will make sure you have enough pain medicine, but it should be easily manageable.