WEBSITE EDUCATION INFORMATION

Neck

Neck pain can occur in the spinal column (axial) or refer outward or radiating as far downward as the fingers. The different types of pain give clues about the source of pain. Axial pain usually hurts as a broad ache, heaviness, tension that can spread (refer) up the back of the head causing tension headaches, down to the muscles between the shoulder blades (interscapular), and out to the shoulders. Axial pain tends to be worse in the morning and end of day after activity. Sources of Axial pain can be the interlocking facet joints on the back of the spine, the discs, and soft tissues like muscle spasms. Radiating (Radicular) pain shoots down the arms, sometimes as far as the hands. Radicular pain in the arms has been described as "Sciatica of the arms" and is frequently associated with tingling, numbness, and weakness. Radicular pain can be due to irritated nerve roots such as when they are inflammed by a disc that leaks acid, or swollen by the pressure from a herniation, or by a stabbing bone spur. These symptoms help your doctor advise you on the best treatment choices. Treatments: Cervical epidural, cervical facet medial branch block, EMG, occipital nerve block, trigger point injections, dystonia injections, discogram, neuromodulation (nerve stimulator), and surgical options.

Occipital Nerve Block

What is an occipital nerve block?

An occipital nerve block is an injection of a steroid around the greater and lesser occipital nerves that are located on the back of the head just above the neck area.

What is the purpose of an occipital nerve block?

The steroid injected reduces the inflammation and swelling of tissue around the occipital nerves. This may reduce pain, and other symptoms, caused by inflammation or irritation of the nerves and surrounding structures.

How long does the occipital nerve block take?

The actual injection takes only a few minutes.

What is actually injected?

The injection consists of a local anesthetic and a steroid medication.

Will I be "put out" for the occipital nerve block?

No. This procedure is done with a small thin needle, without any sedation. There is local anesthetic within the injection.

How is the occipital nerve block performed?

It is done with the patient seated or lying down. The skin and hair of the back of the head are cleaned with antiseptic solution and then the injection is carried out.

What should I expect after the occipital nerve block?

Immediately after the injection, you may feel that your pain may be gone or quite less due to the local anesthetic injected. This will last only for a few hours. Your pain may return and you may have a sore head for a day or two. You should start noticing a more lasting pain relief starting the third day or so.

What should I do after the occipital nerve block?

You will rest for a while in the office. Most patients can drive themselves home. You can perform any activity you can tolerate.

How long does the effect of the medication last?

The immediate effect is usually from the local anesthetic injected and wears off in a few hours. The steroid starts working in about 3 to 5 days and its effect can last for several days to a few months.

How many occipital nerve blocks do I need to have?

It varies. The injections are done about one week apart if needed. If the first injection does not relieve your symptoms in about a week to two weeks, you may be recommended to have a second injection.

Trigger point injections

Trigger points may irritate the nerves around them and cause referred pain, or pain that is felt in another part of the body. Trigger point injection (TPI) may be an option in treating pain for some patients. TPI is a procedure used to treat painful areas of muscle that contain trigger points and knots of muscle that form when muscles do not relax. The injections can relax the tension and show you how much of your symptoms are caused by the muscle.

Cervical epidural injection

What is the epidural space?

The membrane that covers the spine and nerve roots in the neck is called the dura membrane. The space surrounding the dura is the epidural space. Nerves travel through the epidural space to the neck, shoulder and arms. Inflammation of these nerve roots may cause pain in these regions due to irritation from a damaged disc or from contract with the bony structure of the spine in some way.

What is a cervical epidural and why is it helpful?

A cervical epidural injection places anti-inflammatory medicine into the epidural space to decrease inflammation of the nerve roots, hopefully reducing the pain in the neck, shoulders and arms. The epidural injection may help the injury to heal by reducing inflammation. It may provide permanent relief or provide a period of pain relief for several months while the injury/cause of pain is healing

What happens during the procedure?

In many cases, an IV is started so that relaxation medication can be given. The patient is placed prone on a table and positioned in such a way that the physician can best visualize the neck using fluoroscopic (x-ray) guidance. The skin on the back of the neck is scrubbed using a sterile scrub (soap). Next, the physician numbs a small area of skin with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, the physician directs a small needle, using x-ray guidance into epidural space. A small amount of contrast (dye) is injected to insure the needle is properly positioned in the epidural space. Then, a small mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) is injected.

What happens after the procedure?

Patients are then returned to the recovery area where they are monitored for 30-60 minutes. Patients are then asked to record the relief they experience during the next week. These injections are usually done in a series of three (3), spaced about two (2) weeks apart. The arms and hands may feel weak or numb for a few hours. This is to be expected, however it does not always happen.

General Pre/Post Instructions:

Approximately ten days prior to each injection, you must stop taking any blood thinners (aspirin, ibuprofens such as Aleve, Motrin, naproxen, ecotrin, etc.), as well as vitamin E and fish oiI. If you are on Coumadin/warfarin/Plavix (blood thinners) you will need to work with the physician who is prescribing that medication to determine how many days prior to the procedure the medication should be stopped (generally 5-7 days). You should not to eat or drink anything after midnight the night before the procedure. You may take your routine medications with a few sips of water in the morning. (i.e. high blood pressure and diabetic medications).

After the procedure you can resume all your medications and can eat a light breakfast. You should ice the area periodically throughout the first day (ie 20 minutes on, then 20 minutes off). Take it easy the first day - avoid activities that aggravate your pain, such as heavy lifting, repetitive motions, etc. Keep track of your pain levels for the week following the injection, as we will be asking you about the relief you get, and the activities that you can now do.

You may feel some tenderness at the injection site. This should last only a day or two. While not common, you may experience a headache following the procedure. Again, this should dissipate after two or three days. If you have any concerns following the injection, please give our office a call.

Cervical Facet Medial Branch Nerve Block

What is a Facet Joint?

Joints located on the back of the spine on each side where one vertebrae slightly overlaps the adjacent vertebrae. They guide and restrict movement of the spine. They can become a source of pain if they become inflamed.

What is a facet block?

A facet medial branch block that is performed to confirm whether a facet joint is the source of your pain. If you respond positively to the block, a second block may be performed with a corticosteroid to provide more extended pain relief and reduced inflammation in the facet joint or joints.

How is it done?

You will be given a local skin anesthetic first. Then a needle is then inserted into the facet joint or facet capsule under fluoroscopic (X-ray) guidance, and an anesthetic is injected by the physician. In subsequent injections, a corticosteroid may also be injected.

What happens after the procedure?

You are then returned to the recovery area where you are monitored for 30-60 minutes. You will be asked to record the relief you experience during the next four-twelve hours. The initial block has only short acting pain relieving medication so DO NOT go home and go to sleep. You should "try out" the injection, by performing activities that normally cause you pain (twisting, extension, walking, golfing, etc-whatever normally hurts). The following day (while it is still fresh in your mind), you should call our office to report on the results. If you have positive results, once your pain returns, you will be scheduled for a second block where the doctor will add a corticosteroid to provide more sustained relief. If necessary, your third procedure would be radiofrequency destruction of the nerves.

General Pre/Post Instructions:

Approximately ten days prior to each injection, you must stop taking any blood thinners (aspirin, ibuprofens such as Aleve, Motrin, naproxen, ecotrin, etc.), as well as vitamin E and fish oil. If you are on Coumadin/warfarin/Plavix (blood thinners) you will need to work with the physician who is prescribing that medication to determine how many days prior to the procedure the medication should be stopped (generally 5-7 days). You should not to eat or drink anything after midnight the night before the procedure. You may take your routine medications with a few sips of water in the morning. (i.e. high blood pressure and diabetic medications).

After the procedure you can resume all your medications and can eat a light breakfast. You should ice the area periodically throughout the first day (ie 20 minutes on, then 20 minutes off). As mentioned above, keep track of your pain levels following the injection, as we will be asking you about the relief you get, and the activities that you were able to do.

You may feel some tenderness at the injection site. This should last only a day or two. If you have any concerns following the injection, please give our office a call.

Cervical Selective Nerve Root block

A cervical selective nerve root block is an injection near the affected nerve (outside the epidural space) as it exits the spinal column. Selective nerve root blocks are used both for diagnostic purposes (to determine if a specific nerve root is the source of the problem) and to relieve radicular pain caused by irritation of a specific nerve root.

If a specific nerve is actually the cause of pain the local anesthetic in the injection will give immediate relief. The steroids in the injection will reduce inflammation over the next few days and possibly provide relief of pain that lasts for weeks to months. Herniated disk in the cervical spine causing neck pain with arm pain is a common condition treated by a selective nerve root block.

What happens during the procedure?

If you are anxious prior to the procedure, an IV will be started so that relaxation medication can be given. The patient is placed prone on a table and positioned in such a way that the physician can best visualize the back using fluoroscopic (x-ray) guidance. The skin on the neck area is scrubbed using a sterile scrub (soap). Next, the physician numbs a small area of skin with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, the physician directs a small needle, using x-ray guidance, next to the nerve root. A small amount of contrast (dye) is injected to insure the needle is properly positioned at the nerve root. Then, a small mixture of numbing medicine (anesthetic-lidocaine, marcaine) is injected.

What happens after the procedure?

Patients are then returned to the recovery area where they are monitored for 30-60 minutes. Patients are then asked to record the relief they experience during the next 4-12 hours. The initial injection is short acting but provides your physician with important information to assess which nerves are causing your pain. If significant pain relief is experienced with the initial block, subsequent injections will also include anti-inflammatory (cortisone/steroid) medication.

General Pre/Post Instructions:

Approximately ten days prior to each injection, you must stop taking any blood thinners (aspirin, ibuprofens such as Aleve, Motrin, naproxen, ecotrin, etc.), as well as vitamin E and fish oiI. If you are on Coumadin/warfarin/Plavix (blood thinners) you will need to work with the physician who is prescribing that medication to determine how many days prior to the procedure the medication should be stopped (generally 5-7 days). You should not to eat or drink anything after midnight the night before the procedure. You may take your routine medications with a few sips of water in the morning. (i.e. high blood pressure and diabetic medications).

After the procedure you can resume all your medications and can eat a light breakfast. You should ice the area periodically throughout the first day (ie 20 minutes on, then 20 minutes off). Take it easy the first day - avoid activities that aggravate your pain, such as heavy lifting, repetitive motions, etc. Keep track of your pain levels for the week following the injection, as we will be asking you about the relief you get, and the activities that you can now do.

You may feel some tenderness at the injection site. This should last only a day or two. While not common, you may experience a headache following the procedure. Again, this should dissipate after two or three days. If you have any concerns following the injection, please give our office a call.

Cervical Transforaminal Injection

During a cervical transforaminal injection, a small-gauge blunt needle is inserted into the epidural space through the bony opening of the exiting nerve root. The needle is smaller in size than that used during a conventional epidural approach. The procedure is performed with the patient lying on his/her stomach. The physician uses fluoroscopic (real-time x-ray) guidance, which helps to prevent damage to the nerve root. A radiopaque dye is injected to enhance the fluoroscopic images and to confirm that the needle is properly placed. This technique allows the cortico-steroid medicine to be placed closer to the irritated nerve root than using conventional interlaminar epidural approach. The exposure to radiation is minimal.

Spinal Conditions Treated and Outcomes :

Indications include large disc herniations, foraminal stenosis, and lateral disc herniations. Patients with disc herniations and arm pain in most of the studies attained maximal improvement in 6 weeks.

What happens during the procedure?

If you are anxious prior to the procedure, an IV will be started so that relaxation medication can be given. The patient is placed prone on a table and positioned in such a way that the physician can best visualize the back using fluoroscopic (x-ray) guidance. The skin on the neck/upper back area is scrubbed using a sterile scrub (soap). Next, the physician numbs a small area of skin with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, the physician directs a small needle, using x-ray guidance through the opening of the exiting nerve root into epidural space. A small amount of contrast (dye) is injected to insure the needle is properly positioned in the epidural space. Then, a small mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) is injected.

What happens after the procedure?

Patients are then returned to the recovery area where they are monitored for 30-60 minutes. Patients are then asked to record the relief they experience during the next week. These injections are usually done in a series of three (3), spaced about two (2) weeks apart. The arms and hands may feel weak or numb for a few hours. This is to be expected, however it does not always happen.

General Pre/Post Instructions:

Approximately ten days prior to each injection, you must stop taking any blood thinners (aspirin, ibuprofens such as Aleve, Motrin, naproxen, ecotrin, etc.), as well as vitamin E and fish oilI. If you are on Coumadin/warfarin/Plavix (blood thinners) you will need to work with the physician who is prescribing that medication to determine how many days prior to the procedure the medication should be stopped (generally 5-7 days). You should not to eat or drink anything after midnight the night before the procedure. You may take your routine medications with a few sips of water in the morning. (i.e. high blood pressure and diabetic medications).

After the procedure you can resume all your medications and can eat a light breakfast. You should ice the area periodically throughout the first day (ie 20 minutes on, then 20 minutes off). Take it easy the first day - avoid activities that aggravate your pain, such as heavy lifting, repetitive motions, etc. Keep track of your pain levels for the week following the injection, as we will be asking you about the relief you get, and the activities that you can now do.

You may feel some tenderness at the injection site. This should last only a day or two. While not common, you may experience a headache following the procedure. Again, this should dissipate after two or three days. If you have any concerns following the injection, please give our office a call.

Cervical discogram

What are the discs?

The discs are soft, cushion-like pads which separate the hard vertebral bones of your spine. A disc may be painful when it bulges, herniates, tears or degenerates and may cause pain in your neck, mid-back, low back and/or arms, chest wall, abdomen and legs. Other structures in your spine may also cause similar pain such as the muscles, joints and nerves. Usually, we have first determined that these other structures are not your sole pain source (through history and physical examination, review of x-rays, CT/MRI, and/or other diagnostic injection procedures such as facet and sacroiliac joint injections and nerve root blocks) before performing discography.

What is a discogram?

A discogram is a diagnostic test performed by your physician to view and assess the internal structure of a disc or discs and also to determine if/which disc is a source of your pain. Discography confirms or denies the disc(s) as a source of your pain. It is a relatively simple procedure that uses a small needle to inject contrast dye into your disc. MRI and CT scans only demonstrate anatomy and cannot absolutely prove your pain source. In many instances, the discs may be abnormal on MRI or CT scans, but not be a source of pain. Only discography, which is a functional test, can tell if the disc itself is a source of your pain. Therefore, discography is done to identify painful disc(s) and help the surgeon plan the correct surgery or avoid surgery that may not be beneficial. Discography is usually done only if you think your pain is significant enough for you to consider surgery or more advanced treatment options.

How is it done?

You will be given intravenous medication as a relaxant and pain reliever. A local anesthetic is injected into the skin in the area that is being examined. A needle is inserted through the skin and into each disc to be tested under fIuoroscopic (X-ray) guidance. A saline solution with radiopaque dye is injected into the disc or discs if more than one disc is being examined. Your physician looks at the disc through the fluoroscope of the painful disc after the dye is injected to obtain images of the dye distribution. This will demonstrate anular tears, scarring, disc bulges and changes in the nucleus of the disc. Your physician will ask you if you are having painful symptoms during the injection process. Your response will be a confirmation of a diagnosis and/or determination of which disc/discs is the source of your pain. After you provide your response, the physician will inject lidocaine or other pain relieving medications into the disc to take away the pain that you reported previously.

General Pre/Post Instructions:

Approximately ten days prior to each injection, you must stop taking any blood thinners (aspirin, ibuprofens such as Aleve, Motrin, naproxen, ecotrin, etc.), as well as vitamin E and fish oil. If you are on Coumadin/warfarin/Plavix (blood thinners) you will need to work with the physician who is prescribing that medication to determine how many days prior to the procedure the medication should be stopped (generally 5-7 days). You should not to eat or drink anything after midnight the night before the procedure. You may take your routine medications with a few sips of water in the morning. (i.e. high blood pressure and diabetic medications).

After the procedure you can resume all your medications and can eat a light breakfast. You should ice the area periodically throughout the first day (ie 20 minutes on, then 20 minutes off). Take it easy the first day - avoid activities that aggravate your pain, such as heavy lifting, repetitive motions, etc. Keep track of your pain levels for the week following the injection, as we will be asking you about the relief you get, and the activities that you can now do.

You may feel some tenderness at the injection site. This should last only a day or two. You may also experience a flare up of your usual pain which could last for several days. In preparation for the procedure, you should be sure that you have at least a week's supply of your regular pain medications on hand, should you experience a flare up. If you have any questions or concerns following the injection, please give our office a call.

Shoulders

Shoulder pain is an extremely common complaint. There are many common causes of this problem. It is important to make an accurate diagnosis of the cause of your symptoms so that appropriate treatment can be directed at the cause. See a physician when you have; inability to carry objects or use the arm, injury that causes deformity of the joint, shoulder pain that occurs at night or while resting, shoulder pain that persists beyond a few days, inability to raise the arm, swelling or significant bruising around the joint or arm, signs of an infection, including fever, redness, warmth. Testing can determine whether the pain is coming from the shoulder, neck, or elsewhere. Treatments: Bursa injections, EMG, rehabilitation prescriptions.

Arms/hands

Fingers, hands, or wrists may burn, sting, hurt, feel tired, sore, stiff, numb, tingly, hot, or cold. They might be swollen and maybe you can't move them as well as usual. Your hands have turned a different color, such as red, pale, or blue. A lump or bump might have appeared on your wrist, palm, or fingers. Pain and other symptoms in the arm may be due to injury of the neck. Testing can determine whether the pain is coming from the arms, hands, neck, or elsewhere. Treatments: Trigger finger injections, ganglion cyst, De Quervains, Dupuytren’s, EMG, rehabilitation prescriptions.

Stellate Ganglion

What is a stellate ganglion block? A stellate ganglion block is performed under fluoroscopy to determine if there is damage to the sympathetic nerve chain and if it is the source of your arm/hand pain. The initial block is primarily a diagnostic block but it may provide pain relief in excess of the duration of the anesthetic. Subsequent blocks are done to help the nerves "re- learn" proper pain response.

How is it done?

A local skin anesthetic is given near the base of the neck on the affected side. A needle is inserted by your physician near the transverse process of the cervical spine (usually at the cervical-6 level). A sterile tubing is attached to the needle and anesthetic medication is slowly injected through the tubing.

How long does it last?

It takes less than thirty minutes for the procedure, followed by evaluation and recovery for several hours.

Expected Results:

You may note increased warmth and redness of the painful arm/hand during and after the injection. You can expect hoarseness of your voice, redness of the eye(s), drooping of the eyelid and pupillary constriction for four to eight hours after the injection. Pain relief may be noted immediately. Duration of relief is variable. You must assess your pain relief over the first three to four hours after the injection and report this to our office.

General Pre/Post Instructions:

Approximately ten days prior to each injection, you must stop taking any blood thinners (aspirin, ibuprofens such as Aleve, Motrin, naproxen, ecotrin, etc.), as well as vitamin E and fish oilI. If you are on Coumadin/warfarin/Plavix (blood thinners) you will need to work with the physician who is prescribing that medication to determine how many days prior to the procedure the medication should be stopped (generally 5-7 days) . You should not to eat or drink anything after midnight the night before the procedure. You may take your routine medications with a few sips of water in the morning. (i.e. high blood pressure and diabetic medications).

After the procedure you can resume all your medications and can eat a light breakfast. You should ice the area periodically throughout the first day (ie 20 minutes on, then 20 minutes off). Take it easy the first day - avoid activities that aggravate your pain, such as heavy lifting, repetitive motions, etc. Keep track of your pain levels for the week following the injection, as we will be asking you about the relief you get, and the activities that you can now do.

You may feel some tenderness at the injection site. This should last only a day or two. If you have any questions or concerns following the injection, please give our office a call.

Selective Nerve Root Block

What is a nerve root and why is a selective nerve root block helpful?

Nerve roots exit your spinal cord and form nerves that travel into your arms or legs. These nerves allow you to move your arms, chest wall, and legs. Inflammation of these nerve roots may cause pain in your arms or legs. These nerve roots may become inflamed and painful due to irritation, for example, from a damaged disc or a bone spur. A selective nerve root block provides important information to your physician and is not a primary treatment although sometimes it provides long term relief. It serves to prove which nerve is causing your pain by placing temporary numbing medicine over the nerve root of concern. If your main pain complaint improves after the injection that nerve is most likely causing your pain, If your pain remains unchanged, that nerve probably is not the cause of your pain.

By confirming or denying your exact source of pain, it provides information allowing for proper treatment, which may include limited surgery at a specific location.

What will happen to me during the procedure?

While lying on a table face down for lumbar and face up for cervical, the skin over your spine will be well cleaned. Dr. Johnson will numb a small area of skin with numbing medicine which stings for a few seconds. Next, Dr. Johnson will use x-ray guidance to direct a very small needle just next to the nerve root without injuring the nerve root. He will then inject contrast dye to confirm that the medicine flows around the nerve root. This may increase your usual pain for about 30 seconds. Lastly, numbing medicine will be injected along the nerve root to hopefully stop your pain, if that nerve is the source of your pain.

What should I do after the procedure?

20-30 minutes afterwards you will try to provoke your usual pain. Call the office in a week to report your percentage of pain relief. You may temporarily feel numb or weak from the anesthetic for several hours. You will wait 30-60 minutes before going home. Avoid driving for eight hours because you may experience temporary numbness or weakness.

General Pre/Post Instructions:

You should eat a light, but not a full meal at least 2 hours before the procedure. If you are an insulin dependent diabetic do not alter your normal food intake. Take your routine medications before the procedure (such as high blood pressure and diabetes medications) except stop aspirin and all anti-inflammatory medications (e.g. Motrin/Ibuprofen, Aleve, Relafen, Daypro) 10 days before the procedure. These medicines may be re-started the day after the procedure. You may take your regular pain medicine as needed before/after the procedure. If you are on coumadin, heparin, lovenex, plavix or ticlid you must notify my office so that the timing of stopping these medications can be explained. If you are on antibiotics please notify our office, we may wait to do the procedure. If you have an active infection or fever we will not do the procedure. You will be in the hospital as an out-patient for 2-3 hours even though you see the physician for 20 minutes. You will need to bring a driver with you. You may return to your current level of activities the next day including return to work.

Mid spine

The thoracic spine—the upper or mid-back region—does not move as much as the neck or low back, so there aren't as many injuries associated with overuse. Often patients with upper back pain also have neck pain. That's particularly true of patients whose upper back pain is caused by poor posture. Think of sitting hunched over as you work at your desk: your upper back is rounded and your neck is straining forward at an unusual angle. Poor posture can lead to muscle strain or muscle fatigue, both causes of upper back pain. Treatments: epidural injection, facet medial branch block, trigger point injections, dystonia injections, vertebroplasty, discography, surgical options.

Thoracic epidural injection

What is the epidural space?

The membrane that covers the spine and nerve roots in the neck is called the dura membrane. The space surrounding the dura is the epidural space. Nerves travel through the epidural space to the neck, shoulder and arms. Inflammation of these nerve roots may cause pain in these regions due to irritation from a damaged disc or from contract with the bony structure of the spine in some way.

What is a thoracic epidural and why is it helpful?

A thoracic epidural injection places anti-inflammatory medicine into the epidural space to decrease inflammation of the nerve roots, hopefully reducing the pain in the neck/mid back and around the ribs. The epidural injection may help the injury to heal by reducing inflammation. It may provide permanent relief or provide a period of pain relief for several months while the injury/cause of pain is healing

What happens during the procedure?

If you are anxious prior to the procedure, an IV will be started so that relaxation medication can be given. The patient is placed prone on a table and positioned in such a way that the physician can best visualize the back using fluoroscopic (x-ray) guidance. The skin on the mid back area is scrubbed using a sterile scrub (soap). Next, the physician numbs a small area of skin with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, the physician directs a small needle, using x-ray guidance into epidural space. A small amount of contrast (dye) is injected to insure the needle is properly positioned in the epidural space. Then, a small mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) is injected.

What happens after the procedure?

Patients are then returned to the recovery area where they are monitored for 30-60 minutes. Patients are then asked to record the relief they experience during the next week. These injections are usually done in a series of three (3), spaced about two (2) weeks apart.

General Pre/Post Instructions:

Approximately ten days prior to each injection, you must stop taking any blood thinners (aspirin, ibuprofens such as Aleve, Motrin, naproxen, ecotrin, etc.), as well as vitamin E and fish oil. If you are on Coumadin/warfarin/Plavix (blood thinners) you will need to work with the physician who is prescribing that medication to determine how many days prior to the procedure the medication should be stopped (generally 5-7 days). You should not to eat or drink anything after midnight the night before the procedure. You may take your routine medications with a few sips of water in the morning. (i.e. high blood pressure and diabetic medications).

After the procedure you can resume all your medications and can eat a light breakfast. You should ice the area periodically throughout the first day (ie 20 minutes on, then 20 minutes off). Take it easy the first day - avoid activities that aggravate your pain, such as heavy lifting, repetitive motions, etc. Keep track of your pain levels for the week following the injection, as we will be asking you about the relief you get, and the activities that you can now do.

You may feel some tenderness at the injection site. This should last only a day or two. While not common, you may experience a headache following the procedure. Again, this should dissipate after two or three days. If you have any concerns following the injection, please give our office a call.

Thoracic Facet Medial Branch Nerve Block

What is a Facet Joint?

Joints located on the back of the spine on each side where one vertebrae slightly overlaps the adjacent vertebrae. They guide and restrict movement of the spine. They can become a source of pain if they become inflamed.

What is a facet block?

A facet medial branch nerve block that is performed to confirm whether a facet joint is the source of your pain. If you respond positively to the block, a second block may be performed with a corticosteroid to provide more extended pain relief and reduced inflammation in the facet joint or joints.

How is it done?

You will be given a local skin anesthetic first. Then a needle is then inserted into the facet joint or facet capsule under fluoroscopic (X-ray) guidance, and an anesthetic is injected by the physician. In subsequent injections, a corticosteroid may also be injected.

What happens after the procedure?

You are then returned to the recovery area where you are monitored for 30-60 minutes. You will be asked to record the relief you experience during the next four-twelve hours. The initial block has only short acting pain relieving medication so DO NOT go home and go to sleep. You should "try out" the injection, by performing activities that normally cause you pain (twisting, extension, walking, golfing, etc-whatever normally hurts). The following day (while it is still fresh in your mind), you should call our office to report on the results. If you have positive results, once your pain returns, you will be scheduled for a second block where the doctor will add a corticosteroid to provide more sustained relief. If necessary, your third procedure would be radiofrequency destruction of the nerves.

General Pre/Post Instructions:

Approximately ten days prior to each injection, you must stop taking any blood thinners (aspirin, ibuprofens such as Aleve, Motrin, naproxen, ecotrin, etc.), as well as vitamin E and fish oil. If you are on Coumadin/warfarin/Plavix (blood thinners) you will need to work with the physician who is prescribing that medication to determine how many days prior to the procedure the medication should be stopped (generally 5-7 days). You should not to eat or drink anything after midnight the night before the procedure. You may take your routine medications with a few sips of water in the morning. (i.e. high blood pressure and diabetic medications).

After the procedure you can resume all your medications and can eat a light breakfast. You should ice the area periodically throughout the first day (ie 20 minutes on, then 20 minutes off). As mentioned above, keep track of your pain levels following the injection, as we will be asking you about the relief you get, and the activities that you were able to do.

You may feel some tenderness at the injection site. This should last only a day or two. If you have any concerns following the injection, please give our office a call.

Thoracic Selective Nerve Root Block

A thoracic selective nerve root block is an injection near the affected nerve (outside the epidural space) as it exits the spinal column. Selective nerve root blocks are used both for diagnostic purposes (to determine if a specific nerve root is the source of the problem) and to relieve radicular pain caused by irritation of a specific nerve root.

If a specific nerve is actually the cause of pain the local anesthetic in the injection will give immediate relief. The steroids in the injection will reduce inflammation over the next few days and possibly provide relief of pain that lasts for weeks to months. Herniated disk in the thoracic spine causing pain with is a common condition treated by a selective nerve root block.

What happens during the procedure?

If you are anxious prior to the procedure, an IV will be started so that relaxation medication can be given. The patient is placed prone on a table and positioned in such a way that the physician can best visualize the back using fluoroscopic (x-ray) guidance. The skin on the mid back area is scrubbed using a sterile scrub (soap). Next, the physician numbs a small area of skin with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, the physician directs a small needle, using x-ray guidance, next to the nerve root. A small amount of contrast (dye) is injected to insure the needle is properly positioned at the nerve root. Then, a small mixture of numbing medicine (anesthetic-lidocaine, marcaine) is injected.

What happens after the procedure?

Patients are then returned to the recovery area where they are monitored for 30-60 minutes. Patients are then asked to record the relief they experience during the next 4-12 hours. The initial injection is short acting but provides your physician with important information to assess which nerves are causing your pain. If significant pain relief is experienced with the initial block, subsequent injections will also include anti- inflammatory (cortisone/steroid) medication.

General Pre/Post Instructions:

Approximately four days prior to each injection, you must stop taking any blood thinners (aspirin, ibuprofens such as Aleve, Motrin, naproxen, ecotrin, etc.), as well as vitamin E and fish oiI. If you are on Coumadin/warfarin/Plavix (blood thinners) you will need to work with the physician who is prescribing that medication to determine how many days prior to the procedure the medication should be stopped (generally 5-7 days). You should not to eat or drink anything after midnight the night before the procedure. You may take your routine medications with a few sips of water in the morning. (i.e. high blood pressure and diabetic medications).

After the procedure you can resume all your medications and can eat a light breakfast. You should ice the area periodically throughout the first day (ie 20 minutes on, then 20 minutes off). Take it easy the first day - avoid activities that aggravate your pain, such as heavy lifting, repetitive motions, etc. Keep track of your pain levels for the week following the injection, as we will be asking you about the relief you get, and the activities that you can now do.

You may feel some tenderness at the injection site. This should last only a day or two. While not common, you may experience a headache following the procedure. Again, this should dissipate after two or three days. If you have any concerns following the injection, please give our office a call.

Low back

Back pain may be acute, chronic, sudden and sharp, or dull. Acute pain lasts four to six weeks, but chronic pain is persistent, long-term pain—sometimes lasting throughout life. At times, people with chronic pain can have episodes of acute pain. Pain may occur with movement, and it may even occur with coughing and sneezing. You may also have numbness in your arms or legs. Treatments: epidural injection, nerve blocks, diagnostic injections, facet medial branch block, trigger point injections, MILD (Minimally Invasive lumbar Decompression) outpatient laminotomy, outpatient discectomy, discogram, EMG, vertebroplasty, neuromodulation (nerve stimulator), and surgical options.

Lumbar epidural injection

What is the epidural space?

The membrane that covers the spine and nerve roots in the neck is called the dura membrane. The space surrounding the dura is the epidural space. Nerves travel through the epidural space to the neck, shoulder and arms. Inflammation of these nerve roots may cause pain in these regions due to irritation from a damaged disc or from contract with the bony structure of the spine in some way.

What is a lumbar epidural and why is it helpful?

A cervical epidural injection places anti- inflammatory medicine into the epidural space to decrease inflammation of the nerve roots, hopefully reducing the pain in the back and legs. The epidural injection may help the injury to heal by reducing inflammation. It may provide permanent relief or provide a period of pain relief for several months while the injury/cause of pain is healing

What happens during the procedure?

If you are anxious prior to the procedure, an IV will be started so that relaxation medication can be given. The patient is placed prone on a table and positioned in such a way that the physician can best visualize the back using fluoroscopic (x-ray) guidance. The skin on the low back area is scrubbed using a sterile scrub (soap). Next, the physician numbs a small area of skin with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, the physician directs a small needle, using x-ray guidance into epidural space. A small amount
of contrast (dye) is injected to insure the needle is properly positioned in the epidural space. Then, a small mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/ steroid) is injected.

What happens after the procedure?

Patients are then returned to the recovery area where they are monitored for 30-60 minutes. Patients are then asked to record the relief they experience during the next week. These injections are usually done in a series of three (3), spaced about two (2) weeks apart. The legs and feet may feel weak or numb for a few hours. This is to be expected, however it does not always happen.

General Pre/Post Instructions:

Approximately ten days prior to each injection, you must stop taking any blood thinners (aspirin, ibuprofens such as Aleve, Motrin, naproxen, ecotrin, etc.) , as well as vitamin E and fish oilI. If you are on Coumadin/warfarin/Plavix (blood thinners) you will need to work with the physician who is prescribing that medication to determine how many days prior to the procedure the medication should be stopped (generally 5-7 days). You should not to eat or drink anything after midnight the night before the procedure. You may take your routine medications with a few sips of water in the morning. (i.e. high blood pressure and diabetic medications).

After the procedure you can resume all your medications and can eat a light breakfast. You should ice the area periodically throughout the first day (ie 20 minutes on, then 20 minutes off). Take it easy the first day - avoid activities that aggravate your pain, such as heavy lifting, repetitive motions, etc. Keep track of your pain levels for the week following the injection, as we will be asking you about the relief you get, and the activities that you can now do.

You may feel some tenderness at the injection site. This should last only a day or two. While not common, you may experience a headache following the procedure. Again, this should dissipate after two or three days. If you have any concerns following the injection, please give our office a call.

Lumbar facet injections

What are the lumbar facet joints, and why are facet joint injections helpful?

Lumbar facet joints are small joints about the size of your thumb nails located in pairs on the back of your spine. They provide stability and guide motion in your back. When the joints become painful they may cause pain in your low back, abdomen, buttocks, groin, and legs.

A facet 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. Additionally, the temporary pain relief of the numbing medicine may better allow a physical therapist or chiropractor to treat that joint. Also, time release Celestone will serve to reduce any presumed inflammation within your joint and further assist the physical therapist or chiropractor, if necessary. It is possible to obtain relief from the injection alone without follow-up physical therapy or chiropractic care.

What will happen to me during the procedure?

After lying on a table face down, the skin over your back will be cleaned. For your comfort, Dr. Johnson will numb a small area of skin with numbing medicine which stings for a few seconds. Next, Dr. Johnson will use x-ray guidance to direct a very small needle into the joint, and then he will inject several drops of contrast dye to confirm that the medicine goes into the joint. Then, a small mixture of numbing medicine (anesthetic) and anti-inflammatory cortisone will be slowly injected.

What should I do after the procedure?

20-30 minutes after you will stand and walk and try to provoke your usual pain. Avoid driving for eight hours. On occasion, your leg may feel numb or weak for a few hours. Call the office one week after the procedure to report your percentage of pain relief. You may be referred to a physical therapist or chiropractor immediately afterwards while the numbing medicine is effective and over the next two weeks while the Celestone is working.

General Pre/Post Instructions:

You should eat a light, but not a full meal at least 2 hours before the procedure. If you are an insulin dependent diabetic do not alter your normal food intake. Take your routine medications before the procedure (such as high blood pressure and diabetes medications) except stop aspirin and all anti-inflammatory medications (e.g. Motrin/Ibuprofen, Aleve, Relafen, Daypro) 3 days before the procedure. These medicines may be re-started the day after the procedure. You may take your regular pain medicine as needed before/after the procedure. If you are on coumadin, heparin, lovenex, plavix or ticlid you must notify my office so that the timing of stopping these medications can be explained. If you are on antibiotics please notify our office, we may wait to do the procedure. If you have an active infection or fever we will not do the procedure. You will be in the hospital as an out-patient for 2-3 hours even though you see the physician for 20 minutes. You will need to bring a driver with you. You may return to your current level of activities the next day including return to work.

Lumbar Selective Nerve Root Block

A lumbar selective nerve root block is an injection near the affected nerve (outside the epidural space) as it exits the spinal column. Selective nerve root blocks are used both for diagnostic purposes (to determine if a specific nerve root is the source of the problem) and to relieve radicular pain caused by irritation of a specific nerve root.

If a specific nerve is actually the cause of pain the local anesthetic in the injection will give immediate relief. The steroids in the injection will reduce inflammation over the next few days and possibly provide relief of pain that lasts for weeks to months. Herniated disk in the lumbar spine causing low back pain with leg pain (sciatica) is a common condition treated by a selective nerve root block.

What happens during the procedure?

If you are anxious prior to the procedure, an IV will be started so that relaxation medication can be given. The patient is placed prone on a table and positioned in such a way that the physician can best visualize the back using fluoroscopic (x-ray) guidance. The skin on the low back area is scrubbed using a sterile scrub (soap). Next, the physician numbs a small area of skin with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, the physician directs a small needle, using x-ray guidance, next to the nerve root. A small amount of contrast (dye) is injected to insure the needle is properly positioned at the nerve root. Then, a small mixture of numbing medicine (anesthetic-lidocaine, marcaine) is injected.

What happens after the procedure?

Patients are then returned to the recovery area where they are monitored for 30-60 minutes. Patients are then asked to record the relief they experience during the next 4-12 hours. The initial injection is short acting but provides your physician with important information to assess which nerves are causing your pain. If significant pain relief is experienced with the initial block, subsequent injections will also include anti-inflammatory (cortisone/steroid) medication.

General Pre/Post Instructions:

Approximately four days prior to each injection, you must stop taking any blood thinners (aspirin, ibuprofens such as Aleve, Motrin, naproxen, ecotrin, etc.), as well as vitamin E and fish oil. If you are on Coumadin/warfarin/Plavix (blood thinners) you will need to work with the physician who is prescribing that medication to determine how many days prior to the procedure the medication should be stopped (generally 10 days). You should not to eat or drink anything after midnight the night before the procedure. You may take your routine medications with a few sips of water in the morning. (i.e. high blood pressure and diabetic medications).

After the procedure you can resume all your medications and can eat a light breakfast. You should ice the area periodically throughout the first day (ie 20 minutes on, then 20 minutes off). Take it easy the first day - avoid activities that aggravate your pain, such as heavy lifting, repetitive motions, etc. Keep track of your pain levels for the week following the injection, as we will be asking you about the relief you get, and the activities that you can now do.

You may feel some tenderness at the injection site. This should last only a day or two. While not common, you may experience a headache following the procedure. Again, this should dissipate after two or three days. If you have any concerns following the injection, please give our office a call.

Discography

What are the discs?

The discs are soft, cushion-like pads which separate the hard vertebral bones of your spine. A disc may be painful when it bulges, herniates, tears or degenerates and may cause pain in your neck, mid-back, low back and/or arms, chest wall, abdomen and legs. Other structures in your spine may also cause similar pain such as the muscles, joints and nerves. Usually, we have first determined that these other structures are not your sole pain source (through history and physical examination, review of x-rays, CT/MRI, and/or other diagnostic injection procedures such as facet and sacroiliac joint injections and nerve root blocks) before performing discography.

What is discography and why is it helpful?

Discography confirms or denies the disc(s) as a source of your pain. It is a relatively simple procedure that uses a small needle to inject contrast dye into your disc. MRI and CT scans only demonstrate anatomy and cannot absolutely prove your pain source. In many instances, the discs may be abnormal on MRI or CT scans but not be a source of pain. Only discography, which is a functional test, can tell if the disc itself is a source of your pain. Therefore, discography is done to identify painful disc(s) and help the surgeon plan the correct surgery or avoid surgery that may not be beneficial. Discography is usually done only if you think your pain is significant enough for you to consider surgery or more advanced treatment options.

What will happen to me during the procedure?

An IV will be started so that antibiotics (to prevent infection) and relaxation medicine can be given. You will lie on your back for cervical discography, on your belly for lumbar discography. Your skin will be well
cleaned. Next, the physician will numb a small area of skin which may sting for a few seconds. Next, the physician will use x-ray guidance to direct a small needle into your disc. You may feel temporary discomfort as the needle passes through the muscle or near a nerve root. The physician may repeat this at several adjoining disc levels. After the needles are in their proper locations, a small amount of contrast dye is injected into each disc. If a disc is the source of your usual pain the injection will temporarily reproduce your symptoms. If a disc is not the source of your pain than the injection will not reproduce your symptoms or cause any discomfort.

What should I do after the procedure?

Immediately afterwards you may be taken for a CT scan. No driving for eight hours. You will wait 30-45 minutes after your CT scan to go home. You will be given, if desired, a prescription for pain medication over the next 2-3 days when your muscles may be sore.

General Pre/Post Instructions:

You should eat a light, but not a full meal at least 2 hours before the procedure. If you are an insulin dependent diabetic do not alter your normal food intake. Take your routine medications before the procedure (such as high blood pressure and diabetes medications) except stop aspirin and all anti-inflammatory medications (e.g. Motrin/Ibuprofen, Aleve, Relafen, Daypro) 3 days before the procedure. These medicines may be re-started the day after the procedure. You may take your regular pain medicine as needed before/after the procedure. If you are on coumadin, heparin, lovenex, plavix or ticlid you must notify my office so that the timing of stopping these medications can be explained. If you are on antibiotics please notify our office, we may wait to do the procedure. If you have an active infection or fever we will not do the
procedure. You will be in the hospital as an out-patient for 2-3 hours even though you see the physician for 20 minutes. You will need to bring a driver with you. You may return to your current level of activities the next day including return to work.

Lumbar Sympathetic Block

Chronic pain conditions often involve malfunctions of the sympathetic nerves. These nerves regulate blood flow, sweating, and glandular function. Blocks of these sympathetic nerves can provide important diagnostic information, and can also lead to a reduction of the pain. The lumbar sympathetic nerves in front of the spine of the lower back can be blocked to help with pain conditions of the legs and feet.

How is it done?

A local skin anesthetic is given near the spine on the affected side. A needle is inserted by your physician and anesthetic medication is slowly injected.

How long does it last?

It takes less than thirty minutes for the procedure, followed by evaluation and recovery for several hours.

Expected Results:

Pain relief may be noted immediately. Duration of relief is variable. You must assess your pain relief over the first three to four hours after the injection and report this to our office.

General Pre/Post Instructions:

Approximately ten days prior to each injection, you must stop taking any blood thinners (aspirin, ibuprofens such as Aleve, Motrin, naproxen, ecotrin, etc.), as well as vitamin E and fish oil. If you are on Coumadin/warfarin/Plavix (blood thinners) you will need to work with the physician who is prescribing that medication to determine how many days prior to the procedure the medication should be stopped (generally 5-7 days). You should not to eat or drink anything after midnight the night before the procedure. You may take your routine medications with a few sips of water in the morning. (i.e. high blood pressure and diabetic medications).

After the procedure you can resume all your medications and can eat a light breakfast. You should ice the area periodically throughout the first day (ie 20 minutes on, then 20 minutes off). Take it easy the first day - avoid activities that aggravate your pain, such as heavy lifting, repetitive motions, etc. Keep track of your pain levels for the week following the injection, as we will be asking you about the relief you get, and the activities that you can now do.

You may feel some tenderness at the injection site. This should last only a day or two. If you have any questions or concerns following the injection, please give our office a call.

Lumbar Transforaminal Injection

During a lumbar transforaminal injection, a small-gauge blunt needle is inserted into the epidural space through the bony opening of the exiting nerve root. The needle is smaller in size than that used during a conventional epidural approach. The procedure is performed with the patient lying on his/her stomach. The physician uses fluoroscopic (real-time x-ray) guidance, which helps to prevent damage to the nerve root. A radiopaque dye is injected to enhance the fluoroscopic images and to confirm that the needle is properly placed. This technique allows the cortico-steroid medicine to be placed closer to the irritated nerve root than using conventional interlaminar epidural approach. The exposure to radiation is minimal.

Spinal Conditions Treated and Outcomes

Indications include large disc herniations, foraminal stenosis, and lateral disc herniations. Patients with disc herniations and leg pain in most of the studies attained maximal improvement in 6 weeks.

What happens during the procedure?

If you are anxious prior to the procedure, an IV will be started so that relaxation medication can be given. The patient is placed prone on a table and positioned in such a way that the physician can best visualize the back using fluoroscopic (x-ray) guidance. The skin on the low back area is scrubbed using a sterile scrub (soap). Next, the physician numbs a small area of skin with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, the physician directs a small needle, using x-ray guidance through the opening of the exiting nerve root into epidural space. A small amount of contrast (dye) is injected to insure the needle is properly positioned in the epidural space. Then, a small mixture of numbing medicine (anesthetic) and anti-inflammatory (cortisone/steroid) is injected.

What happens after the procedure?

Patients are then returned to the recovery area where they are monitored for 30-60 minutes. Patients are then asked to record the relief they experience during the next week. These injections are usually done in a series of three (3), spaced about two (2) weeks apart. The legs and feet may feel weak or numb for a few hours. This is to be expected, however it does not always happen.

General Pre/Post Instructions:

Approximately ten days prior to each injection, you must stop taking any blood thinners (aspirin, ibuprofens such as Aleve, Motrin, naproxen, ecotrin, etc.), as well as vitamin E and fish oil. If you are on Coumadin/warfarin/Plavix (blood thinners) you will need to work with the physician who is prescribing that medication to determine how many days prior to the procedure the medication should be stopped (generally 5-7 days). You should not to eat or drink anything after midnight the night before the procedure. You may take your routine medications with a few sips of water in the morning. (i.e. high blood pressure and diabetic medications).

After the procedure you can resume all your medications and can eat a light breakfast. You should ice the area periodically throughout the first day (ie 20 minutes on, then 20 minutes off). Take it easy the first day - avoid activities that aggravate your pain, such as heavy lifting, repetitive motions, etc. Keep track of your pain levels for the week following the injection, as we will be asking you about the relief you get, and the activities that you can now do.

You may feel some tenderness at the injection site. This should last only a day or two. While not common, you may experience a headache following the procedure. Again, this should dissipate after two or three days. If you have any concerns following the injection, please give our office a call.

Minimally Invasive Fluoroscopically Guided Lumbar Laminotomy – mild

What is Spinal Stenosis?

Your spine provides support for your back and body. It also protects the spinal cord, the bundle of nerve tissues that runs from your brain to your lower body. The bony channel that encloses the spinal cord is called the spinal canal. Usually, there is enough space between the spinal cord and the spinal canal so that the nerves that flow through and exit the spinal canal are free of obstruction.

As your body ages, however, the ligaments and bones outside the spinal canal may thicken and begin to press on the spinal canal, causing it to narrow. The narrowing of the spinal canal is called spinal stenosis. When that occurs in the lower part of the spine, it is called lumbar spinal stenosis. This narrowing can cause the nerve tissues to become compressed or pinched, resulting in pain, numbness and disability.

What is Minimally invasive laminotomy?

The process involves removing the bone or tissue that is causing the pressure on the nerves through a minimally invasive approach (a small puncture of the skin, about the diameter of a pencil). The minimally invasive nature of the procedure enables shorter out-patient recovery compared to other open surgical treatment options such as Surgical Laminotomy, Laminectomy and Spinal Fusion. Patients who undergo fluoroscopically guided laminotomy are typically discharged the day of the procedure.

What happens during the procedure?

Prior to the procedure, an IV will be started so that relaxation medication can be given. The patient is placed prone on a table and positioned in such a way that the physician can best visualize the back using fluoroscopic (x-ray) guidance. The skin on the low back area is scrubbed using a sterile scrub (soap). Next, the physician numbs a small area of skin with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, your physician performs epidurography to reconfirm the areas to be treated. A Trocar instrument is advanced under fluoroscopic guidance to the intended treatment area. The Trocar is removed leaving the Portal in place, creating a working channel for advancement of a Tissue Sculpter Device and a Bone Sculpter. Under fluoroscopy the mild Tissue Sculpter is advanced to the target treatment area. The Tissue Sculpter excises (removes) excess tissue (ligamentum flavum). This step is repeated several times until sufficient tissue is removed. As an accessory, the Bone Sculpter is used to remove portions of the boney lamina to open the interlaminar space. This step is also repeated several times until sufficient bone fragments have been removed. After removal of excess tissue and bone fragments, your physician performs epidurography again, to confirm that enough tissue and bone has been removed to allow free flow through the spinal canal.

What happens after the procedure?

Patients are then returned to the recovery area where they are monitored for 1-2 hours, and can then be released.

General Pre/Post Instructions:

During the two weeks prior to the procedure, you will be asked to have several pre-op tests done. These include blood tests (Chemistry panel and CBC), as well as a chest X-ray and ECG test. In some cases we may require pre-operative clearance from your primary physician, and or cardiac clearance from your cardiologist. Once all of this is received, your appointment for the procedure is confirmed.

Approximately ten days prior you must stop taking any blood thinners (aspirin, ibuprofens such as Aleve, Motrin, naproxen, ecotrin, etc.), as well as vitamin E and fish oil. If you are on Coumadin/warfarin/Plavix (blood thinners) you will need to work with the physician who is prescribing that medication to determine how many days prior to the procedure the medication should be stopped (generally 5-7 days). You should not to eat or drink anything after midnight the night before the procedure. You may take your routine medications with a few sips of water in the morning. (i.e. high blood pressure and diabetic medications).

After the procedure you can resume all your medications and can eat a light breakfast. Take it easy the first week - avoid activities that aggravate your pain, such as heavy lifting, repetitive motions, etc. The second day after your procedure you can remove the bandage and can take a bath.

You may feel some tenderness at the injection site. This should last only a day or two. While not common, you may experience a headache following the procedure. Again, this should dissipate after two or three days. If you have any concerns following the injection, please give our office a call.

You should follow up in the clinic two weeks after your laminotomy for evaluation.

Lumbar Spinal Cord Stimulator trial

What is neurostimulation?

The use of electrical stimulation to relieve pain began in ancient times with the placement of torpedo fish directly onto painful body parts. Since then, the application of electrical stimulation to the body for pain relief has become much better and more sophisticated. In 1989, spinal cord stimulation (SCS) was approved by the Food and Drug Administration (FDA) as a treatment for chronic pain. Since that time, SCS has become a standard of care for patients with neuropathic chronic back and limb pain (nerve injury with abnormal nerve function producing pain). New technology has allowed for the development of neurostimulators that can allow patients with chronic back pain to reduce or eliminate their need for pain medications and return to comfortable, productive lives.

How does stimulation work?

In spinal cord stimulation, a tiny programmable generator and electrical leads are implanted beneath the skin. Small electrical currents are applied to the areas of the spinal cord involved in pain. For reasons that are not completely understood, these electrical impulses interfere with the transmission of pain signals to the brain and relieve pain without causing the side effects that medications can cause.

A pleasant tingling sensation is substituted for the pain and blocks the brain's ability to sense pain in the stimulated areas. This is similar to the relief felt by rubbing an area after getting an injury. The electrical impulses can be targeted to specific locations and, as pain changes or improves, stimulation can be adjusted as necessary.

What is the goal of spinal cord stimulation?

The goal of neurostimulation with SCS is to achieve significant or total relief from back pain and to be able to return to a happy productive lifestyle. While this therapy does not work for everyone, most patients with SCS are able to report a 50-70% reduction in their overall pain and are able to decrease or completely taper off narcotic painkiller medications. With successful SCS, patients can function during normal activities, return to work, and fully participate in family and community life.

How is this done?

What will happen to me? In spinal cord stimulation, the physician first numbs the skin using a local anesthetic. Soft, thin wires with electrical leads at the tip are placed through a needle (without any incision) into the back near the spinal column. The physician, either an interventional pain specialist or spine surgeon, determines the best location based on the individual patient's pain. The leads are then connected to a special programming device that can be used to program the electrical current in a pattern to exactly target the painful areas for the best relief possible.

What is the SCS trial?

Why not implant the permanent system immediately? To make sure the patient will benefit from SCS, a temporary system is implanted and tried for a few days to a week. For the SCS trial, leads are placed beneath the skin and attached to a small generator the patient carries. The generator is similar to a pager or cell phone. You will be asked to keep a "pain" diary to document your pain relief during the trial period. You should work closely with a representative from the device manufacturer to "try out" a number of different programs to see which is the most beneficial to you.

If the SCS trial is successful, a complete permanent system with a generator is implanted at another time. The leads for the permanent system can be inserted the same way as in the trial. A small generator is surgically implanted beneath the skin in the upper buttock or abdomen. The wires are then connected and the entire system is implanted beneath the skin. Nothing is visible on the body.

Using a programming device outside the body, the system can be programmed in a way similar to using a remote control to adjust a television. The area or intensity of stimulation can be changed, and the system can be turned on and off or adjusted to provide the best pain relief. Programming is initially done at the physician's office, and patients can learn how to control the stimulation on their own at home to adjust it to their pain.

Many systems today have rechargeable batteries that can easily be recharged at home. To recharge the batteries, the patient places the recharging unit over the skin where the generator is implanted. Batteries may require recharging several times a month.

The latest technology provides coverage of different pain types (sensations) simultaneously (i.e. burning, aching, stinging). It is referred to as multiple independent constant current technology (MICC). Using this technology, each electrode lying over the spinal cord can be controlled independently. Currently, this technology is available with an added feature; the patient can program the stimulator with user-friendly software.

Hips

Pain can arise in the hip joint or from structures surrounding the hip. The hip joint is a potential space, meaning that there is a minimal amount of fluid inside it to allow the femoral head to glide in the socket of the acetabulum. Any illness or injury that causes inflammation will cause this space to fill with fluid or blood, which stretches the hip capsule and results in pain. The prominent attachment point on the femur bone is called the Greater Trochanter and has a bursa (lubricating sack) that can get inflamed due to excess friction tendonitis. Treatments: Bursa injection, trigger point blocks, joint block, rehabilitation prescription.

Buttocks

There are a number of structures that can hurt in the buttock including sacroiliac joints, muscles, ligaments, and the pelvis. Sitting, trying to stand up, and walking may be painful and difficult. Testing can help determine where the pain is coming from. Treatments: sacroiliac injection, coccyx injection, ablation-neurotomy, fusion. Coccyx Injection

Coccxydinia is the medical term for tailbone pain. People often experience this pain when they fall and land squarely on the tailbone and sacrum. Sometimes the pain continues past the normal healing time, especially when sitting for long periods of time or going from sitting to standing. To treat this pain, the physician will perform a coccyx injection, which consists of an injection of local anesthetic and corticosteroid around the tailbone under fluoroscopic guidance.

Who is it for?

This injection is for people with tailbone pain.

What are the risks?

As with all injections, there is some risk of bleeding, nerve damage and injection. Because the tailbone is a sensitive area, this injection can be painful and sometimes the patient is sedated to deal with this pain.

What happens during the procedure?

If you are anxious prior to the procedure, an IV will be started so that relaxation medication can be given. The patient is placed prone on a table and positioned in such a way that the physician can best visualize the back using fluoroscopic (x-ray) guidance. The skin on the low back/buttock area is scrubbed using a sterile scrub (soap). Next, the physician numbs a small area of skin with numbing medicine. This medicine stings for several seconds. After the numbing medicine has been given time to be effective, the physician directs a small needle, using x-ray guidance at the coccyx. A small amount of contrast (dye) is injected to insure the needle is properly positioned in the epidural space. Then, a small mixture of numbing medicine (anesthetic-lidocaine/marcaine) is injected. The first injection provides significant pain relief, subsequent injections will also include an anti-inflammatory (cortico-steroid).

What happens after the procedure?

Patients are then returned to the recovery area where they are monitored for 30-60 minutes. Patients are then asked to record the relief they experience during the next 6-12 hours, to give the physician important diagnostic information.

General Pre/Post Instructions:

Approximately ten days prior to each injection, you must stoptaking any blood thinners (aspirin, ibuprofens such as Aleve, Motrin, naproxen, ecotrin, etc.), as well as vitamin E and fish oil. If you are on Coumadin/warfarin/Plavix (blood thinners) you will need to work with the physician who is prescribing that medication to determine how many days prior to the procedure the medication should be stopped (generally 5-7 days). You should not to eat or drink anything after midnight the night before the procedure. You may take your routine medications with a few sips of water in the morning. (i.e. high blood pressure and diabetic medications).

After the procedure you can resume all your medications and can eat a light breakfast. You should ice the area periodically throughout the first day (ie 20 minutes on, then 20 minutes off). Keep track of your pain levels for the week following the injection, as we will be asking you about the relief you get, and the activities that you can now do.

You may feel some tenderness at the injection site. This should last only a day or two. If you have any concerns following the injection, please give our office a call.

Sacroiliac injection

What is the sacroiliac joint and why is a sacroiliac joint injection helpful?

The sacroiliac joint is a large joint in the region of your low back and buttocks. When the joint becomes painful it can cause pain in its immediate region or it can refer pain into your groin, abdomen, or leg.

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. Additionally, the temporary pain relief of the numbing medicine may better allow a physical therapist or chiropractor to treat the joint. Also, time release Celestone will serve to reduce any presumed inflammation within your joint and further assist the physical therapist or chiropractor, if necessary. It is possible to obtain relief from the injection alone without follow-up physical therapy or chiropractic care.

What will happen to me during the procedure?

After lying on your stomach, the skin over your buttocks will be well cleaned. For your comfort, Dr. Johnson will numb a small area of skin which stings for a few seconds. Next, Dr. Johnson will use x-ray guidance to direct a very small needle into the joint, and then he will inject several drops of contrast dye to confirm that the medicine goes into the joint. Then, a small amount of numbing medicine and anti-inflammatory celestone will be slowly injected.

What should I do after the procedure?

20-30 minutes afterwards you will walk and try to provoke your usual pain. You will call the office in one week to report your percentage of pain relief. On rare occasion, your leg may feel temporarily numb or weak for several hours. If this happens do not walk without assistance. Your physician may refer you to a physical therapist or chiropractor immediately afterwards while the numbing medicine is effective and over the next two weeks while the celestone is working.

General Pre/Post Instructions:

You should eat a light, but not a full meal at least 2 hours before the procedure. If you are an insulin dependent diabetic do not alter your normal food intake. Take your routine medications before the procedure (such as high blood pressure and diabetes medications) except stop aspirin and all anti-inflammatory medications (e.g. Motrin/Ibuprofen, Aleve, Relafen, Daypro) 3 days before the procedure. These medicines may be re-started the day after the procedure. You may take your regular pain medicine as needed before/after the procedure. If you are on coumadin, heparin, lovenex, plavix or ticlid you must notify my office so that the timing of stopping these medications can be explained. If you are on antibiotics please notify our office, we may wait to do the procedure. If you have an active infection or fever we will not do the procedure. You will be in the hospital as an out-patient for 2-3 hours even though you see the physician for 20 minutes. You will need to bring a driver with you. You may return to your current level of activities the next day including return to work.

Legs

Leg pain can range from a mild nuisance that comes and goes, to debilitating pain that makes it difficult to sleep, walk, or engage in simple everyday activities. The pain can take many different forms. Some patients describe the pain as aching, searing, throbbing, or burning, and it can be accompanied by other symptoms, such as a pins-and-needles sensation, and/or leg or foot numbness or weakness. Testing can help determine where the pain is coming from. Treatments: epidural injections, nerve blocks, EMG, MILD (Minimally Invasive lumbar
Decompression), nerve stimulator, surgery.

Knees

Symptoms of knee injury can include pain, swelling, and stiffness. It can be caused by a sudden injury, an overuse injury, or by an underlying condition, such as arthritis. Testing can help determine where the pain is coming from. Treatments: knee injections, bracing, taping, rehabilitation programs.

Feet

Foot pain may be caused by many different conditions or injuries. Trauma is a result of forces outside of the body either directly impacting the body and result in damage to the structures of the body. Poor biomechanical alignment may lead to foot pain. Wearing high heeled shoes or shoes that are too tight can cause pain around the balls of the feet and the bones in that area. Testing can help determine where the pain is coming from. Treatments: Peripheral nerve blocks, peroneal nerve blocks, EMG.

EMG

Electromyography and Nerve Conduction Tests are ordered to learn more about the health of peripheral nerves. These tests can establish if a nerve is damaged, and give a numeric value to how severely it is injured and where. The test can last from a half an hour to an hour. During the Nerve Conduction portion of the test, electrodes much like EKG patches are placed along the known course of the nerve. The nerve it stimulated with tiny electrical current at one point. The nerve must then transmit the signal along its course, and an electrode placed further down the arm or leg captures the signal as it passes. Your doctor will measure how fast it traveled and how much got through. A healthy nerve will transmit the signal faster and stronger than a sick nerve. The EMG portion of the test measures the electrical activity in muscles. Muscles normally receive constant electrical signals from health nerves, and in return, “broadcast” their own healthy electrical signals. During the EMG portion of the test, the doctor places an acupuncture like needle into the muscles to record their electrical signals. If a muscle doesn’t receive adequate signals from a sick nerve, it broadcasts signals which show the muscle is confused. The data can be used to find which nerves are pinched and the seriousness of the condition. This information can then be used to help formulate further treatment plans.