Patients presenting with isolated back pain and spinal stenosis often have an element of facet joint arthropathy contributing to their pain. Facet blocks are performed under fluoroscopic (i. e., digital x-ray video) guidance, and can be either intra-articular injections, or medial branch blocks.
The medial branch of the dorsal ramus supplies sensory innervation to the facet joint. Blockade of this nerve has been shown to be as effective as intra-articular infiltration. It is perfomed quicker and more easily, and it is more comfortable for the patient. Also, it serves as a diagnostic block for potential radiofrequency lesioning of the medial branch if the block does not afford long-term relief.
The procedure is performed with the patient in the prone position and under fluoroscopyic guidance. Cervical (neck) facet joint arthropathy is also frequently seen in a pain management practice, and a similar procedure can be performed for the neck as for the low back. The cervical procedure is somewhat more challenging, as the density of the cervical bony elements is lower than in the lumbar region, and is difficult to visualize.
Lysis Of Epidural Adhesions Utilizing The Racz Catheter
Bleeding into the epidural space following surgery, leakage of disc material following breakage, or a tearing of a disc most commonly causes epidural scarring. Presumably, inflammation and compression of nerve roots by the epidural scars (Adhesions) are the cause of persistent pain following back surgery, ruptured or herniated discs, or vertebral body fracture. Epidural scarring may also contribute to the pain of spinal column metastatic carcinoma, failed facet joint syndrome, and unexplained neck or low back pain.
The Racz catheter is a small caliber, flexible catheter that is introduced into the tailbone under X-Ray guidance. The tailbone has a small opening at the bottom of the vertebral column, known as the sacral hiatus, which allows entrance into the epidural space. The Racz catheter can be placed into the epidural space through the sacral hiatus and can break up adhesions that may have been caused by surgery as well as deliver steroid medication into the epidural space.
Patients that are candidates for this procedure have usually had back surgery or have severe degenerative processes affecting the lower back.
Peripheral Nerve Blocks
Various neuropathic pain syndromes involving injuries to peripheral nerves may be amenable to treatment and diagnosis with the use of peripheral nerve blocks.When a diagnostic dilemma exists as to the cause of a specific pain, the blockade of a particular nerve may rule out its involvement in the pain syndrome.
The use of steroids peripherally may decrease the inflammation and irritation to that nerve and may decrease pain. The use of local anesthetics may also break the cycle of pain and provide some relief of the patient’s pain complaints.
The use of these blocks for therapeutic purposes is based only on anecdotal reports in the literature. The frequency of these blocks for therapeutic purposes depends on their overall effectiveness.
Sacroiliac Joint Injection
A sacroiliac joint injection is an injection that can be performed under X-Ray guidance in which a small caliber needle is placed into the sacroiliac joint. The sacroiliac joint is the joint formed between the pelvis and spine and can often be a source of lower back pain. The injection can be performed with a small amount of local anesthetics and steroids.
Transforaminal Nerve Root/Epidural Injections
These injections are for the blocking of a specific nerve root. Commonly, these are performed as both a diagnostic and therapeutic intervention.
This procedure is a far superior technique to the traditional epidural injection, however, it is much more difficult to perform. Presumably, this intervention can be more effective if the inflammation is more prominent at the neural foramina.
Occasionally, the mechanical obstruction of a herniated disc may prevent the steroid from spreading to the irritated focus along the nerve root. Thus, by delivering the steroid along the nerve course outside the central canal, this blockade can be avoided.
A much lower dose of methylprednisolone is employed than with epidural steroid injections, thus lowering concerns of systemic steroid side effects. Compared to most other pain clinics, this is a very commonly performed procedure at Integrated Pain Management, due to the physician’s expertise in this technique.