Pain Conditions & Treatments Performed at Union Anesthesia & Pain Management

At UAPM we take your pain complaints seriously.  We will diagnose and treat the SOURCE of your pain!

Types of Pain:

The origin of some pain is neuropathic, while other pain is nociceptive. This is important to know because different treatments work better for each type of pain......

Neuropathic pain is caused by damage to nerve tissue. It is often described as a burning or stabbing pain.

Nociceptive pain is caused by an injury or disease outside the nervous system. This type of pain is sensed by special receptors that transmit the pain impulse through the nervous system to the brain.

Acute versus Chronic Pain

Acute pain is defined as pain which begins suddenly and lasts less than 6 weeks.

Chronic pain is usually defined as pain that persists greater than 3 to 6 months or pain that persists after healing has occurred.

SOME SPECIFIC PAIN CONDITIONS

HERNIATED DISCS

As part of the supporting structures of the axial (midline) skeleton, discs allow motion required by humans to walk, run, swim, and perform other regular movements. The discs also provide a space between the vertebrae to make room for the spinal nerves to exit the spinal cord on their way to their final destination. The discs also absorb impact and act as “shock absorbers” when the spine is compressed.

The discs are also a type of joint in the spine, and are bound together by flexible fibers in several circling bands, like a tough fire hose, that make up the outer portion of the disc. This outer tough part of the disc is called the “annulus”. The inner core of the disc is softer and is called the nucleus pulposus (nucleus). The nucleus is comprised of collagen, proteoglycans and consists of approximately 70-90% water at birth. This water content decreases with age making the disc less flexible and more prone to injury.

Symptoms of Herniated Discs

1) Radiculitis (sciatica)

Individuals suffering from radiculitis report pain that radiates along a nerve path because of pressure or inflammation of the nerve root where it connects to the spine. The location and type of pain depends on the area of the spine where the compression occurs. For instance, radiculitis in the cervical spine may cause pain in the neck or down the arm. If located in the thoracic spine, radiculitis may cause pain in the chest area.

The most common complaint, however, is in the lower or lumbar area, with pain in the hips, legs, and feet. This type of pain is often called sciatica, since it most usually originates from the lumbar region, where the nerves that make up the sciatic nerve enter the spinal canal. Sciatica is a common problem for those suffering from disc deterioration or injury involving the lower back.

Herniated Discs cause pain in the spine and/or down one or both arms or legs. Pain may or may not be present. Sometimes the symptoms of a herniated disc are numbness, tingling, electrical currents, shocks, or the sensation that water or bugs are running over the skin. Weakness may also be a symptom. Herniated discs cause physical irritation and/or chemical irritation of the spinal nerves that are in close proximity to the herniation which results in the above symptoms.

2.) Radiculopathy

Doctors use the term radiculopathy to specifically describe pain, and other symptoms like numbness, tingling, and weakness in your arms or legs that are caused by a problem with your nerve roots. The nerve roots are branches of the spinal cord that carry signals to the rest of the body at each level along the spine. Radiculopathy is a diagnosis made by EMG testing which shows a reduction in the speed or strength of the nerve impulse. It can also be diagnosed by clinical exam if neurologic deficits are apparent such as a depressed deep tendon reflex.

Diagnosis

There are several different causes of radiculopathy, but the correct diagnosis of the cause of your symptoms begins with a complete physical examination of the entire body, with special emphasis on the SPINE and extremities. Your doctor will examine your back for flexibility, range of motion, and the presence of certain signs that suggest that a particular nerve root is being affected. This often involves testing the strength of your muscles, sensation of your skin and checking your reflexes to make sure that they are still working normally. You will often be asked to fill out a diagram that asks you where your symptoms of pain, numbness, tingling and weakness are occurring. A routine set of x-rays is also usually ordered when a patient with back pain goes to see a doctor. An MRI scan or a CAT scan can also be part of the evaluation for the causes of radiculopathy. An MRI is very useful for determining where the nerve roots are being compressed because this type of a scan is designed to show the details of soft-tissue structures, like nerves and discs. A CT scan is often used to evaluate the bony anatomy in the lumbar spine, which can show how much space is available for the nerve roots. The nerve roots exit the spinal canal through a bony tunnel called the neuroforamen, and it is at this point that the nerve roots are especially vulnerable to compression.

Treatment of Herniated Discs

As with all injuries, treatment should begin with conservative measures. These include reducing activity without complete bed rest and using appropriate pain and anti-inflammatory medication. Usually pain will resolve within a few days to weeks. If pain continues, other forms of treatment such as chiropractic and physical therapy may be indicated. For persistent symptoms, interventional pain management therapy may be necessary. This treatment may include an injection of cortisone (steroid), which is a strong anti-inflammatory placed onto the effected nerve. This medicine is injected into the epidural space of the spine, see "epidural steroid injections" below. The treatment is very effective in most cases. The injection may need to be repeated if only partial relief is obtained. The procedure takes just a few minutes and is performed on an outpatient basis. Although low risk, very rarely complications can occur such as a headache.

Epidural Steroid Injections:

Epidural steroid injections (ESIs) are a common treatment option for many forms of low back pain and leg pain. They have been used for low back problems since 1952 and are still an integral part of the non-surgical management of sciatica and low back pain. The goal of the injection is pain relief; at times the injection alone is sufficient to provide relief, but commonly an epidural steroid injection is used in combination with a comprehensive rehabilitation program to provide additional benefit.

For patients who do not respond to the above, surgical options may be necessary. These options include percutaneous disc surgery, endoscopic/laser spine surgery, minimally invasive disc procedures or in rare cases more extensive spine surgery.

Patients need to realize that each patient is different and treatment options depend upon the severity of symptoms and neurologic function. Any signs of progressive deterioration of function, including sudden weakness, loss of bowel or bladder control may be an emergency situation and needs to be evaluated immediately.

Facet Joint Pain (Zygapophysial or Z-Joint)

Anatomy and Physiology of Facet Joints

The facet joint are a pair of small stabilizing joints located between and behind each adjacent vertebrae. These joints allow movement and provide support to the spine. The facet joints provide about 20% of the twisting stability in the neck and low back. Each joint has a smooth synovial lining just like other movable joints in your body. These joints are prone to arthritis as you age and injury from trauma. At each given spinal level the angle of the facets - relative to a plane running through the body from front to back - varies from more parallel to more perpendicular. Each facet joint is positioned at each level to provide the needed limits to motion, especially to rotation and to prevent forward slipping (spondylolisthesis) of that vertebra over the one below.

Each upper half of the paired facet joints are attached on both sides on the backside of each vertebra, near its side limits where they extend downward. They then project forward or towards the side. The other halves of the joints arise on the vertebra below then project upwards, facing backward or towards the midline to engage the downward faces of the upper facet halves. The facet joints do slide on each other and both sliding surfaces are normally coated by a very low friction, moist cartilage. A small sack or capsule surrounds each facet joint and provides a sticky lubricant for the joint. Each sack has a rich supply of tiny nerve fibers that provide a warning when irritated.

Symptoms of Facet Joint Pain

Facet joints are in almost constant motion with the spine and quite commonly simply wear out or become degenerated in many patients. When facet joints become worn and the cartilage becomes thin or disappears, there may be a reaction of the bone of the joint underneath producing overgrowth of bone spurs and an enlargement of the joints. The joint is then said be arthritic (literally, joint inflammation-degeneration), or osteoarthritis, that can produce considerable back pain on motion. This condition may also be referred to as “facet joint disease” or “facet joint syndrome”. Typical facet pain is worse in the morning, described as stiffness, aching, sometimes dull or sharp. The pain is also aggravated with changing positions, transitioning from sitting to standing, standing erect and using stairs. Usually facet pain does not go down the leg like “sciatica” but may radiate into the groin, hips, buttocks or upper thighs.

Diagonsis

Facet Joint Syndrome can only be conclusively diagnosed by injecting the joint and assessing the response. In most cases, x rays and MRI findings are normal. However, facet joint arthritis or enlargement of the joints may be cause to investigate them as a pain source.

Treatment Options for Facet Joint Pain

Initial treatment for facet joint pain is conservative. This means anti-inflammatory medication, exercise, and local treatments such as heat, ice, massage, etc. If the pain continues, treatment by a pain specialist may be necessary. This type of treatment may include a facet joint injection. A small amount of cortisone and local anesthetic is placed into the joint or on the nerve of the joint. This treatment will reduce inflammation that causes the pain.

Depending upon the response, additional injections may be necessary or in cases of temporary relief, radiofrequency ablation (RFA) may be necessary. RFA is a pain management technique where the nerve supply of the joint, the Medial Branch Nerves, are coagulated using a special needle and an electrical current to heat the tissue and the nerve around the tip of the needle. This procedure provides pain relief for an extended period of time. The Medial Branch Nerves do regenerate over time. Therefore, repeating the procedure over time may be necessary. The procedure is done on an outpatient basis with intravenous sedation and takes about a half hour.

Other Treatment Procedures:

Selective Nerve Root Block

WHAT IS IT? A block that is performed to determine if a specific spinal nerve is the source of pain. An anesthetic and steroid is injected on the nerve for diagnostic and potentially therapeutic purposes.

EXPECTED RESULTS: Relief of back and leg pain.

HOW IS IT DONE? The patient is given a local anesthetic. The physician then locates, under fluoroscopy, a specific spinal nerve root. A needle is introduced through the skin into the area adjacent to the nerve root. Medication is then injected into the area bathing the nerve root. The medications include

HOW LONG DOES IT TAKE? The time varies depending upon how many nerves are evaluated. Usually 30 minutes or less.

Discogram

WHAT IS IT? A discogram is a diagnostic test performed to view and assess the internal structure of a disc and to determine if it is a source of pain.

HOW IS IT DONE? The patient is given intravenous medication as a relaxant and a local anesthetic is injected into the patient's skin in the area that is being examined. A needle is inserted through a previously placed needle in the skin and into the disc under fIouroscopy. A radiopaque dye is injected into the disc or discs if more than one disc is being examined. A CT scan is usually performed on the painful disc after the dye is injected to obtain images of the dye distribution. This will demonstrate annular tears, scarring, disc bulges and changes in the nucleus of the disc.

HOW LONG DOES IT TAKE? Thirty minutes plus an additional thirty minutes if a CT is indicated plus recovery time of several hours.

Interventional Pain Management Treatments:

For back pain sufferers, interventional pain management techniques can be particularly useful. In addition to a thorough medical history and physical examination, interventional pain management physicians have a wide array of treatments that can be used including the following:
Epidural injections (in all areas of the spine): the use of anesthetic and steroid medications injected into the epidural space to relieve pain or diagnose a specific condition.

Nerve, root, and medial branch blocks: injections done to determine if a specific spinal nerve root is the source of pain. Blocks also can be used to reduce inflammation and pain.

Pulsed Radiofrequency Neurotomy (PRFN): a minimally invasive procedure that disables spinal nerves and prevents them from transmitting pain signals to the brain.

Radiofrequency Ablation (Neurotomy): a procedure in which pain signals are "turned off" through the use of heated electrodes that are applied to specific nerves that carry pain signals to the brain.

Spinal cord stimulation: the use of electrical impulses that are used to block pain from being perceived in the brain.

Intrathecal pumps: a surgically implanted pump that delivers pain medications to the precise location in the spine where the pain is located.

Percutaneous Discectomy/Nucleoplasty: a procedure in which tissue is removed from the disc in order to decompress and relieve pressure.

Minimally Invasive Endoscopic/LASER Spinal Surgery

Endoscopic surgery refers to the use of specialized video cameras and instruments which are passed through small incisions (less than 2 cm) into the DAMAGED DISC to perform surgery.

The benefits of endoscopic surgery are threefold. Since the size of the incisions are smaller, the recovery from surgery is much quicker. There is also less pain and less damage to the surrounding tissues.

Endoscopic techniques have been used for several decades, but these were exclusively for diagnostic purposes. In the late 1970s and early 1980s, endoscopic techniques were advanced so that both a diagnosis could be made and the disease could be treated. These same endoscopic techniques used in other surgical disciplines have now been advanced to the treatment of spinal disorders. In certain cases of degenerative disc disease, scoliosis, kyphosis, spinal column tumors, infection, fractures and herniated discs, endoscopic techniques may speed recovery, minimize post-operative pain and improve the final outcome.

By using special scopes, instruments and implants, surgeons have been able to successfully treat some spinal column disorders with less injury to surrounding healthy tissue. Essentially the operations are being performed for the same conditions, however by using endoscopic techniques the recovery is more comfortable and quicker. What once required 3 to 6 months to recover from now only require a few weeks.

Not every patient, however, is a candidate for endoscopic spinal surgery. To see if you are a candidate for endoscopic treatment of your spine or discs schedule an appointment with UAPM who have the knowledge and experience in these techniques.

       !!!  Please review our "PATIENT EDUCATION" section of this web site for videos and explanations of the above and more  !!!