Lesioning of Genicular Nerves for Intractable Knee Pain

Genicular Neurotomy (aka ablation) is an innovative option for treating knee pain without surgery. This highly advanced procedure is on the absolute cutting edge of medicine. By selectively applying a sophisticated type of radio wave to the nerves surrounding the knee (the genicular nerves), one can effectively relieve pain in the knee from any number of causes. The effects last until the nerve regrows which can be anywhere from 6 months to 2 years.

Many areas in the body, including the spine and knee, contain sensory nerves that are very active in certain pain conditions. These sensory nerves can be temporarily destroyed using a very precise thermal lesion delivered by a radiofrequency (RF) current through a special insulated needle. RF current is the safest form of delivering a heat lesion due to the fact that the lesion will remain the same size regardless of the heating duration. Using real-time X-ray guidance to define the location, a segment of the targeted nerve is cauterized with careful attention to avoid any nearby motor nerves or vascular structures. Once the sensory nerves have been taken out of commission there is often dramatic improvement in pain and blood flow. In addition, surrounding muscles begin to show improved function and loss of atrophy as the inhibitory pain sensations subside.

Injections and Lesioning of Ganglion of Impar for Coccydynia

This injection is a type of sympathetic block that can be used in the treatment of sympathetically-mediated pain, pain secondary to malignancy, neuropathic pain, and post-surgical pain. A ganglion of impar block is a minimally invasive procedure that is easy to perform and can be used to treat recalcitrant visceral, pelvic and genital pain. As a variety of pelvic structures have nerve fibers that travel through the ganglion of impar, a block performed here can treat multiple areas of pain simultaneously.

Coccydynia is often caused by an injury, but it may occur seemingly spontaneously. There are many causes of tailbone pain that can mimic coccydynia, including sciatica, infection, pilonidal cysts, sacroiliitis, and fractured bone (broken tailbone or tailbone fracture). The goal of coccydynia treatment is usually to reduce pain by keeping pressure off of the tailbone, easing inflammation or muscle tension that add to pain, or reducing pain signals to the brain using medication. Treatments and activity modification usually suffices to control or alleviate tailbone pain.

Intradiscal Electrothermal Annuloplasty (IDET) is a minimally invasive treatment for chronic low back pain that results from certain types of painful degenerative disc disease or contained disc herniation. Successful IDET treatment may allow some patients to experience good or excellent pain relief without having to undergo major spinal surgery for disc removal and spinal fusion, or disc replacement.

Common causes of disc herniation and associated disc pain are degenerative disc disease and traumatic injury, such as a fall.

What does it treat?

• Small tears in a vertebral disc (non-herniated)
• Mild complications from Degenerative Disc Disease
• Discogenic pain (pain stemming from the vertebral disc)

A lumbar sympathetic block is an injection of local anesthetic into or around the sympathetic nerves. These sympathetic nerves are a part of the sympathetic nervous system. The nerves are located on the either side of spine, in the lower back. Normally these nerves control basic functions like regulating blood flow.

A lumbar sympathetic block is performed to block the sympathetic nerves that go to the leg on the same side as the injection. It is done as a part of the treatment of Reflex Sympathetic Dystrophy (RSD), Sympathetic Maintained Pain, Complex Regional Pain Syndrome and Herpes Zoster (shingles) involving the legs. Certain patients with neuropathy or peripheral vascular disease may also benefit from lumbar sympathetic blocks.

The procedure is performed using an X-ray to guide the injection into the proper position along the outside of the spine. Once in place, a test dose of dye is used to confirm that the injected medication will spread in an appropriate area. Next, the injection takes place gradually over several minutes. The physician will use the X-Ray to evaluate the spread of the injected medication.

A lumbar micro-endoscopic discectomy is a minimally invasive procedure performed through a tubular device and designed to relieve pain caused by herniated discs pressing on nerve roots.

People who undergo a lumbar microendoscopic discectomy, or any other form of spinal disc removal, typically have herniated discs that produce pain, weakness or numbness that doesn’t respond to nonsurgical treatment; have progressively worsening numbness or weakness in their legs; have serious mobility issues resulting from their condition; or have pressure on a certain nerve cluster, called the cauda equina, that triggers leg weakness and loss of normal bowel or bladder control. Instead of a disc herniation, some people who undergo the procedure have a disc disorder called degenerative disc disease.

Piriformis Syndrome is a condition characterized by pain in the hip and buttock that can radiate up into the lower back and down the leg. It is caused by entrapment of the sciatic nerve as it passes through the piriformis muscle in the buttock. The pain is made worse by rotating the femur inward, which causes pressing of the sciatic nerve against the origin of the piriformis muscle.

Treatment of this condition includes therapy and medication to relieve pressure and reduce muscle spasm and inflammation. An injection into the muscle using a local anesthetic and cortisone medication may be helpful in reducing inflammation and pain which may make it easier to participate in therapy to further reduce pressure, spasm, and inflammation. This procedure is usually done on an outpatient basis, meaning that you will be able to go home the same day as the surgery.

An epidural steroid injection (ESI) is a minimally invasive procedure that can help relieve neck, arm, back, and leg pain caused by inflamed spinal nerves.

ESI may be performed to relieve pain caused by spinal stenosis, spondylolysis, or disc herniation.
Cervical epidural steroid injection procedures are injections administered to relieve pain in the neck, shoulders and arms caused by a pinched nerve or inflamed nerve(s) in the cervical spine. Conditions such as herniated discs, spinal stenosis or arthritis can compress and pinch nerves, causing inflammation and pain.

Thoracic Epidural Steroid Injection (ESI) Pain Treatment. … Conditions such as herniated discs, spinal stenosis or arthritis can compress nerves causing inflammation and thoracic pain. The injection of medication into the surrounding area helps to decrease swelling of the inflamed nerve(s).

A caudal injection is actually an injection into the lowest portion of the epidural space. A caudal steroid injection can help reduce lower back and leg pain caused by sciatica, herniated discs, bone spurs or other back problems. You have nerves that run from your spinal cord out to your back and legs.

Several common conditions that cause severe acute or chronic low back pain and/or leg pain (sciatica) from nerve irritation can be treated with steroid injections.

These conditions include:

• A lumbar disc herniation, where the nucleus of the disc pushes through the outer ring (the annulus) and into the spinal canal where it pressures the spinal cord and nerves.
• Degenerative disc disease, where the collapse of the disc space may impinge on nerves in the lower back.
• Lumbar spinal stenosis, a narrowing of the spinal canal that literally chokes off nerves and the spinal cord, causing significant pain.
• Compression fractures in a vertebra.
• Cysts which are in the facet joint or the nerve root and can expand to squeeze spine structures.
• Annular tear, a painful condition where a tear is present in the outer layer of the disc.

Radiofrequency (RF) rhizotomy or neurotomy is a therapeutic procedure designed to decrease and/or eliminate nerve pain symptoms that have not responded to more conservative pain treatments. The procedure involves destroying the nerves causing the pain with highly localized heat generated with radiofrequency. By destroying these nerves, pain signals are prevented from being transmitted from the spine to the brain. A successful procedure reduces pain without reducing nerve function.

Sacroiliac joint injections are often used for treating patients that suffer from chronic, non-specific back pain that is the result of irritation, inflammation, or injury of the sacroiliac joint. Patients who suffer from sacroiliac pain often describe the pain as diffuse, lower back pain. Of concern when evaluating a patient with sacroiliac joint pain is their current level of impairment (strength, flexibility, balance, etc.). The level of impairment will help the patient’s’ physician determine whether the patient will be able to engage in a rehabilitation program without experiencing significant pain. Additionally, depending on the current level of impairment, the physician may recommend a trial of conservative treatment options before initiating this type of treatment.

A sacroiliac joint injection is an injection of local anesthetic and a steroid medication into the sacroiliac joint. Due to the numbing medicine used during this procedure, you may experience temporary pain relief afterwards that may last several hours.

A sacroiliac joint injection serves several purposes. First, by placing numbing medicine into the joint, the amount of immediate pain relief you experience will help confirm or deny the joint as a source of your pain. Time-release cortisone will also be injected into the joint to reduce any presumed inflammation, which on many occasions can provide long-term pain relief.

The selective nerve root block procedure is an injection of a small amount of steroid and numbing medication around a very specific nerve root/spinal nerve that exits out of the spinal cord. It can be done in the cervical (neck), thoracic (chest) and lumbar (low back) areas.

Conditions that are commonly treated with selective nerve root blocks include:

• Cervical radiculopathy: Pain and/or altered sensation that progresses into the upper extremities
• Lumbar radiculopathy: Pain and/or altered sensation that progresses into the lower extremities
• Failed back surgery syndrome (FBSS): Spinal pain that persists or develops following spinal surgery
• Spinal stenosis: Narrowing of the spinal canal
• Bulging intervertebral discs: Decreased structural integrity of the intervertebral discs outer layer, resulting in a bulge from the disc’s normal position
• Herniated disc: Rupture of the nucleus pulposus of an intervertebral disc through a tear in the outer layer of the disc
• Arthritis: Degeneration of the spinal joint cartilage

A spinal cord stimulator (SCS) is a device surgically placed under your skin to send a mild electric current to your spinal cord. A small wire carries the current from a pulse generator to the nerve fibers of the spinal cord. When turned on, the stimulation feels like a mild tingling in the area where pain is felt. Your pain is reduced because the electrical current interrupts the pain signal from reaching your brain.

Stimulation interferes with the signal to the brain, and so the amount of pain relief varies for each person. The goal for spinal cord stimulation is a 50-70% reduction in pain. However, even a small amount of pain reduction can be significant if it helps you to perform your daily activities with less pain and reduces the amount of pain medication you take. The most common use of SCS is failed back surgery syndrome (FBSS).

A stellate ganglion block is an injection of local anesthetic into or around the stellate ganglion (sympathetic nerve ganglion). The stellate ganglion is a bundle of nerves located in the neck between your jaw and collarbone. Stellate ganglion block is a short, minimally invasive procedure that can effectively treat a wide array of conditions that have failed optimal medical management. These include providing relief for sympathetic-related pain in face, chest, and upper extremities, improving circulation in upper extremities and face, decreasing perspiration in upper extremities and face, decreasing hot flashes and associated sleep disturbances, and showing promise as a novel treatment for PTSD.

Conditions Commonly Treated with Stellate Ganglion Block:

• Severe headaches
• Complex regional pain in the upper extremities (e.g., reflex sympathetic dystrophy or causalgia)
• Refractory angina
• Hyperhydrosis
• Phantom limb pain or discomfort
• Herpes zoster outbreak (i.e., shingles) within the upper chest, head, neck, or arm regions
• Postherpetic neuralgia
• Paget’s disease
• Postradiation neuritis

Arterial vascular insufficiency disorders include:

• Raynaud’s disease
• Intra-arterial embolism
• Vasospasm
• Scleroderma
• Insufficient lymphatic drainage and localized edema following mastectomy
• Neoplasm

Strip Rhizotomy of Sacral Nerves for Chronic Sacroiliitis

A rhizotomy is a term primarily referring to a neurosurgical procedure that selectively destroys problematic nerve roots in the spinal cord, most often to relieve the symptoms of neuromuscular conditions such as spastic diplegia and other forms of spastic cerebral palsy.

The sensory nerve roots, where spasticity is located, are first separated from the motor ones, and the nerve fibres to be cut are then identified via electromyographic stimulation. The ones producing spasticity are then selectively lesioned with tiny electrical pulses.

Such radiofrequency nerve lesioning results in five to eight or more months of pain relief before the nerve regenerates and another round of the procedure needs to be performed. A facet rhizotomy is just one of many different forms of radiofrequency ablation, and its use of the “rhizotomy” name should not be confused with the SDR procedure.

Lesioning of Suprascapular Nerve for Intractable Shoulder Pain

Suprascapular nerve blockade improves pain, range of motion, and disability in acute and chronic shoulder pain. A suprascapular nerve block may be performed if you are experiencing pain in the suprascapular and shoulder joint areas. This block may be used to help with acute pain emergencies, postoperative pain, pain from acute injury to the shoulder joint and girdle, cancer pain, chronic regional pain syndrome of the shoulder area, and adhesive capsulitis. Pain relief usually lasts several hours with local anesthetic. If steroids are added, the relief lasts several weeks. Each provided 4-5 months of pain relief and improvement in shoulder function, without deterioration in muscle strength.

Trigger point injection (TPI) may be an option for treating pain in some patients. TPI is a procedure used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax. Many times, such knots can be felt under the skin.

Trigger points are focal areas of spasm and inflammation in skeletal muscle. The rhomboid and trapezius back muscles, located in the upper back and behind the shoulder areas, are a common site of trigger points.

TPI is used to treat many muscle groups, especially those in the arms, legs, lower back, and neck. In addition, TPI can be used to treat fibromyalgia and tension headaches. The technique is also used to alleviate myofascial pain syndrome that does not respond to other treatments. In addition to the upper spine, trigger points can also occur in the low back or less commonly in the extremities.

In the TPI procedure, a healthcare professional inserts a small needle into the patient’s trigger point. The injection contains a local anesthetic or saline, and may include a corticosteroid. With the injection, the trigger point is made inactive and the pain is alleviated. Usually, a brief course of treatment will result in sustained relief. Several sites may be injected in one visit. If a patient has an allergy to a certain drug, a dry-needle technique (involving no medications) can be used.