Opiate Detox Management
We offer a multitude of options for patients looking to change their opiate regimen or to be placed on a detoxification program. A comprehensive review of both past medications taken and the current regimen is done prior to making suggestions on how to improve pain. The best analogy to describe our approach would be to the process of making chicken soup. A tasty soup not only has chicken and water, but lots of vegetables and spices. Similarly, pain management requires medications working on multiple receptors and not just opiates in order to provide a satisfactory level of daily pain control. We frequently use bupredorphine [Suboxone] as a rapid alternative used to change opiate dependency. Prior to offering buprenorphine [Suboxone], we have a lengthy sit-down discussion in the office so the patient fully understands all expectations going forward. In my practice, the time spent educating the patient serves to improve the outcomes going forward.
Epidural Steroid Injections
By far the most common interventional pain procedure performed. Prior to doing an injection, we carefully go over all the information presented including acute vs. chronic pain, history of current symptoms, prior history of back pain symptoms, alternative methods that have been tried or that remain an option, and confirmation with MRI imaging which allows visualization of the anatomy. Epidurals work wonderfully for active inflammation type of conditions which may include radiculitis (sciatica) or acute disc bulging/herniation or extrusion. There is no generic type of injection, since we are able to visualize the anatomy and provide the medication with a variety of approaches including caudal, interlaminar and transforaminal techniques to ensure the most appropriate coverage of your pathology. After the injection, the follow up is done approximately one week. We never book multiple injections on your first visit and carefully review on your follow up appointment if you’re a candidate for a repeat injection. In our practice, we prefer for patients to, “get over the hump,” in order to tolerate participating in a course of physical therapy, Pilates and or acupuncture treatments.
Lumbar or Cervical Facet Injections/Medial Branch Nerve Blocks
The lumbar facet joints, also referred to as the zygopophyseal joints can commonly be a source of pain. We perform, “Medial Branch Nerve Blocks” in the office as a diagnostic block to determine whether or not the pain is actually derived from those joints. If the patient gets a positive response to the anesthetic, we consider going forward with radiofrequency ablation of those nerves which should relieve the painful symptoms for at least 6-9 months. Please note, the nerves do have the capacity to regenerate and therefore the procedure may be repeated.
Intraarticular Hip Injection under Fluoroscopic Guidance
For many patients suffering from acute hip pain, an injection within the capsule of the joint is appropriate for both diagnostic and therapeutic purposes. The injectate is a combination of both local anesthetic and steroids. Patients should receive immediate benefit after getting off the table and after 24-48 hours the steroid portion of the medication should mediate an inflammatory condition. This bypasses the patient having to take oral medications and is also very specific just for the hip joint. As you can see, the picture illustrates contrast material (black) surrounding the capsule enabling myself to know the medication is within the joint capsule.
Sacroiliac Joint Injections
A common area of pain localized around the buttock and may spread slightly down the leg to the hip. Usually the diagnosis of the condition is done based on a good history and physical examination with the exclusion of more common diagnosis. Positions such as a “FABER test,” Flexion Abduction and External Rotation will mimic patient’s usual pain complaints. In addition, our office will rule out any other common spinal condition before the diagnosis which may include MRI imaging. To confirm the diagnosis, an injection is done within the joint capsule and provides immediate relief with local anesthetic and hopefully longer term relief as the steroid dissipates the inflammation specific to the joint. The injection is very quick and done under fluoroscopic guidance and under sterile conditions. It is close to impossible to properly inject the Sacroiliac joint without the use of imaging.
Radiofrequency Ablation (RF)
A technique that provides the practitioner the option to either cauterize (destroy a nerve using heat) or change the mechanism of transmission using a pulsed radiofrequency function. This is often done in conjunction with Medial Branch Nerve Blocks for both the lumbar and cervical spines. In addition, RF has shown benefit in chronic Sacroiliac Joint Dysfunction.
Intercostal Nerve Blocks
Done for pain symptoms wrapping around the sternum from the back to the front side of the thoracic cage. Commonly performed to alleviate pain symptoms from trauma and or Shingles. We use fluoroscopic guidance to visualize the underside of the rib, in order to accurately flood the area with local anesthetic.
Trigger Point Injections
A very popular method of provided some pain relief for muscular “trigger points.” Trigger points are points of maximal tenderness felt on palpation (putting manual pressure on the musculature) that often contracts (tighten) under stress. The proper way of performing the injection is with a “dry needle.” This is passing the needle through the musculature to “break up” the contraction and allow relaxation. I like to place a touch of local anesthetic prior to removing the needle in order to provide a greater level of relief. However, it is the action of the dry needling that’s providing the crux of benefit.
In the pain management setting performed for chronic headaches, torticollis, cervical dystonia and generalized muscle spasm conditions that don’t remit under less invasive methods of treatment. Botox is a toxin that paralyzes muscles and allows relaxation to take place. I perform the procedure using electromyography to ensure proper needle placement. Botox is not permanent and may need to be repeated for long term results. In addition, chronic users of botox may develop tolerance to the medication and increasing doses may be necessary for treatment.
Places contrast dye in spinal disc space in order to determine the disc morphology and with pressure, is able to assess if patient’s pain symptoms are derived from the disc. This procedure is done under light conscious sedation and requires the cooperation of the patient during procedure. Usually done in a surgical center or hospital operating room setting and is effective in elucidating if pain symptoms are truly discogenic.
I.D.E.T. and Percutaneous Disc Decompression
Minimally invasive procedures to reduce size of disc herniation and cauterize (burn using heat) the nerves surrounding the disc that transmit pain signals based on pressures placed on the disc. Done under light conscious sedation in a surgical center or operating room environment, it is important for the patient to meet the strict criteria for these procedures to be performed in order to maximize potential benefit.
Usually performed on the Stellate Ganglion for the upper extremity or the Lumbar Sympathetic Chain for the lower extremity, as well as for conditions such as Reflex Sympathetic Dystrophy or Complex Regional Pain Syndromes. The sympathetic system in our bodies is thought to prolong pain symptoms caused by either a traumatic event such as surgery or non-traumatic sympathetic pain. It is important for me and my staff to evaluate whether the symptoms are truly sympathetically mediated in order to justify performing these types of blocks.
Platelet Rich Plasma (PRP)
A method in harnessing the body’s natural healing capacity by taking patient’s blood accessed with a common blood draw and using a centrifuge concentrating the platelets. This concentrated solution is then injected back into the patient over the area causing significant pain symptoms. Literature has reported fair-to-good results with the procedure for diagnosis specific to epicondylitis and other ligament/tendon related inflammatory conditions.
An excellent way of providing a whole body exercise as a complement to the primary diagnosis during your physical therapy visit. Pilates done in the office allows the patient to maintain specific limitations given their medical condition while working on multiple muscle groups. As an example, for our back pain patients that require core stabilizing exercises, Pilates on the Reformer is the perfect vehicle to accomplish the necessary goals.